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RESPONSE: Effect of a nurse coordinated prevention program on cardiovascular risk after an acute coronary syndrome: Main results of the RESPONSE trial

Risk Factors, Epidemiology, Rehabilitation and Sports Cardiology

Ron J G Peters
Presenter | see Discussant report | read press release Play presentation webcast
Peters, Ron J G
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List of Authors:  

RJG Peters, HT Jorstad, AMW. Alings, JGP. Tijssen, AH Liem, JM van Dantzig, W Jaarsma, DJA Lok, JA Kragten, CJ de Vries, PAR de Miliano, AJAM Withagen, C von Birgelen.


A considerable gap exists between guidelines on secondary prevention of cardiovascular disease and their implementation. In the RESPONSE study we quantified the impact of a hospital based nurse coordinated prevention program on the risk of future complications in patients with established coronary artery disease.

Methods : RESPONSE was a randomized clinical trial in 11 centres in The Netherlands. Patients aged 18-80 years were eligible if they had been admitted for an acute clinical coronary complication within 8 weeks prior to inclusion. Patients were randomized to either the nurse coordinated prevention program in addition to usual care (intervention group) or usual care alone (control group). The intervention included up to 4 outpatient visits to a nurse during the first six months after inclusion. The nurse protocol was based on current guidelines and focused on healthy lifestyles (smoking cessation, adequate physical exercise and healthy weight/fat distribution), biometric risk factors (blood pressure control, lipid control, screening for diabetes, and glycemic control in diabetics) and medication adherence. Data were independently collected at baseline, at 6- and 12-months after entry.
The primary outcome of the study was the SCORE 10 year cardiovascular risk estimation at 12-months (6 months after the last visit). SCORE includes age, gender, total cholesterol, systolic blood pressure, and smoking status.
A secondary outcome was the proportion of patients classified as having good control of risk factors, defined as at least 7 of 9 risk factors at target level. The trial is registered with, number TC1290.

Findingsl: 754 participants were randomly assigned to the intervention group (n=377) or the control group (n=377). At 12 months, SCORE was 4•5% in the intervention group and 5•4% in the control group, representing a 16•9 relative risk reduction (p=0•029). In 35% of patients in the intervention group compared to 25% in the control group, risk factor control at 12 months was classified as good (37% increase, p=0•006). Adherence to medication was excellent in both groups and was not significantly different..

Conclusion of the abstract: Interpretation. A 6-month nursing intervention leads to significant and sustained reductions in cardiovascular risk due to improved control of risk factors. These programs can readily be implemented in clinical practice.

M Christi Deaton, FESC
Discussant | see Presenter abstract Play presentation webcast
Deaton, M Christi
(United Kingdom)
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The RESPONSE trial was a multi-centre randomised trial of a nurse-coordinated intervention for secondary prevention. Other studies have shown that interventions that include nurse-coordinated programmes or nurse case-management, are more effective than usual care in managing patient risk factors. Previous randomised trials such as EUROACTION, the Stanford Coronary Risk Intervention Programme (SCRIP) and a study in the Kaiser Permanente healthcare system demonstrated that nurse-led interventions led to significant improvement in individual risk factors compared to usual care.1-3 In the SCRIP trial nurse case management also decreased progression of CHD by angiography, and achieved a 45% reduction in cardiovascular events over a 4-year period.2 Nurse-led secondary prevention clinics in primary care in the UK showed a 20% relative risk reduction in mortality and cardiovascular events compared to usual care over a mean 4.7 year follow-up.4

Within this context, the RESPONSE trial tested a relatively modest hospital-based intervention of up to 4 visits to specialist nurses over the first 6 months post acute coronary syndrome (ACS) in addition to usual care. According to an earlier paper on the design of the study, the nurses were experienced and received only a few days of additional training (including motivational interviewing) for the role.
5 Patients (n = 754) were recruited and randomised within 8 weeks of an ACS event, and were primarily young (mean age less than 60) and 80% male. Recruitment soon after the event could potentially catch patients at a time when they were feeling vulnerable and would be eager to decrease their risk of subsequent ACS. It is unfortunate that more women were not recruited, as other authors have noted the overall under-representation of women in cardiovascular prevention trials.6 Attendance at the clinics was 93.3%, which would indicate a high degree of acceptance and satisfaction by participants. Patients were assessed at baseline, 6 and 12 months, with a follow-up rate at 12 months of 93%.

The investigators used the Systematic Coronary Risk Evaluation (SCORE) charts to quantify change in patient risk profiles rather than only measuring individual risk factors.
The use of SCORE is controversial as the charts are intended for assessment of cardiovascular risk in primary prevention, and absolute scores will be inaccurate for patients with coronary heart disease (CHD).
However, it does provide a means of quantifying the relative change in risk for cardiovascular events as a result of changes in risk factors in the two groups. The intervention group showed a relative risk reduction of 17% in predicted 10 year mortality compared to the usual care group. Comparison of individual risk factor management between the two groups generally favoured the intervention, with a greater percentage of intervention patients meeting risk factor targets for systolic blood pressure, LDL, physical activity, and consumption of fruits and vegetables at 12 months than usual care alone. Improvement in blood pressure and LDL targets occurred in the intervention group, while the proportion of patients who met those goals declined in the control group.
Both groups showed a robust decrease in patients who were smoking (by self-report), but neither was successful in increasing the proportion of people with body mass index (BMI) and waist circumference within recommended parameters. At 12 months a higher proportion of the intervention patients had control of 7 – 9 risk factors than the control group (35.6% versus 25.9%, p = .006). Medication use was high for both groups, with the intervention patients having higher rates of diuretic and angiotensin converting enzyme medication use than usual care.

Better control of multiple risk factors and decreased mortality risk occurred with the addition to usual care of a modest intervention of up to 4 visits to a nurse-coordinated prevention programme during the first 6 months after an ACS event. Although there are few details at this point regarding the intervention, the nurses were experienced and received some additional training. Most nurse coordinated models of prevention include individualised assessment, education, counselling, and support to change unhealthy behaviours, and make different lifestyle choices. Other successful trials have used longer training programmes for the nurses, more extensive interaction with patients, inclusion of family members, group classes and multi-disciplinary teams.1-3
The lack of success in improving BMI and waist circumference in the RESPONSE trial may be due to the need for more specific intervention or skills, and a longer duration of intervention (as well as the need for societal approaches to address obesity). Due to the sample characteristics, the likely success of the programme in patients who are older with multiple co-morbid conditions is unknown. The most appropriate ‘dose’ of this type of intervention in terms of intensity and duration, and the most effective components for sustained effect in different patient groups still need to be elucidated.

Nonetheless the RESPONSE trial provides further evidence that nurse-coordinated prevention programmes are an effective means of improving secondary prevention in Europe. The RESPONSE trial, along with the EUROACTION programme, has demonstrated the feasibility of nurse-coordinated prevention programmes within European health care systems. Nurses are well-suited to this type of role, given that their educational preparation commonly includes behavioural change, counselling, communication and support to patients and families as well as medical and nursing content. The public considers nurses a credible source of information, and nursing roles typically involve coordination of care, and collaboration with physicians and other providers. This does not preclude other providers from coordinating this type of programme, but does indicate the suitability of nurses to take on this responsibility.
There is heterogeneity in nursing education and roles across Europe, but with appropriate standards, training and support nurse-coordinated prevention programmes could be an integral component in reducing the burden of cardiovascular disease in Europe.


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The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.