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Preventive Cardiology in Hospital

From knowledge to expertise and responsibility

The EACPR Cardiac Rehabilitation section comments on: 

Recent years have witnessed extraordinary advances in the ability to prevent cardiovascular diseases (CVD). We have an unprecedented arsenal of weapons, including many potent medications and non-pharmacological strategies (1-2), however, power is not enough, and, in fact, in some cases, it has led us to ignore some very simple effective and executive measures.

In a recent work published in Circulation, Chow et al (3) examined the association of risk factor modification with the occurrence of early cardiovascular events after acute coronary syndrome (ACS). On the basis of a patient questionnaire, 18 809 patients from the OASIS 5 (Fifth Organization to Assess Strategies in acute Ischemic Syndromes) randomized clinical trial (fondaparinux versus enoxaparin in unstable angina or non–ST-elevation myocardial infarction -MI) were followed up for adherence to diet, physical activity, and smoking cessation at 30 days after ACS: 64.8% of patients reported smoking cessation, while 29.9% demonstrated adherence to both diet and exercise modification.

At 6 months risk-adjusted analysis, including adjustment for percutaneous coronary intervention or coronary artery bypass grafting before 30 days and secondary preventive medication use at 30 days, revealed a significant decrease in risk for MI with smoking cessation (OR 0.57) and in risk for overall cardiovascular events with the combination of diet and exercise (OR 0.46). On the contrary, a 3.8-fold (95% CI 2.5 to 5.9) increased risk of cardiovascular events was noted in patients with persistent smoking and non-adherence to diet and exercise. In short, on one hand the marked reductions in cardiovascular morbidity and mortality with lifestyle intervention in ACS patients call for a timely initiation of behavioral advice, on the other the low rates of smoking cessation and diet/exercise adherence recalls the ineffectiveness of current healthcare system. Hence, expertise and organization in preventive cardiology in hospital are decisive issues.

Secondary prevention interventions are endorsed through the formulation of guidelines (1-2), and these recommendations generally include: 1) smoking cessation; 2) blood pressure control (to a goal of less than 140/90 mm Hg or lower with co-morbidity); 3) management of dyslipidemia to a target LDL cholesterol level less than 100 mg/dl using dietary measures and lipid-lowering therapy; 4) regular physical activity (at least 30 min, possibly every day) ; 5) weight management; 6) diabetes control; 7) angiotensin-converting enzyme inhibitor therapy, especially for those with depressed ventricular function; 8) antiplatelet therapy; and 9) beta-blocker therapy. Most of the interventions are associated with reductions of 20% to 30% in total mortality, similar reductions in recurrent CVD (4). Unfortunately, secondary prevention therapies and strategies are not fully implemented. Cardiologists, in particular, often view their role as managers of the acute event only and prefer to defer the prevention issues to primary care providers or other health-care professionals.

The modern cardiac rehabilitation program has evolved tremendously from a simple exercise training prescription and is now considered an essential component of a secondary prevention plan (2, 5-6), an integral component of the continuum of care for patients with CVD. It has become central to bridging the gap from successful acute care to life-long sustained behavioral change (5). In-hospital cardiac rehabilitation consists traditionally of early mobilization and education, however, since both the shorter hospital stay, and time consuming comprehensive investigations make extremely difficult to conduct a formal inpatient education plan.

According to Chow’s findings, the secondary prevention plan with behavioral advice should be provided immediately during hospital stay. There is no better time for the educational process toward lifestyle change than to begin than the days immediately after the acute before hospital discharge. The patients are more aware and focused on their current condition, have access to health care professionals for education, and have a strengthened perception of their responsibility to prevent future cardiac events (7-8). The duration of the intervention is inevitably short, but the intensity of the intervention is important (7), and behavioral advice should be delivered by the acute care physicians/cardiologists (the interventionists and cardiac surgeon) in collaboration with other health care professionals and not as an ‘add-on (9-10).

The process of delivering information should be just as important as the information itself (11). A discharge plan usually incorporates a discharge letter to the general practitioner and/or cardiologist or cardiac surgeon and assurance that the patient is aware of the need for continued medication and proper life-style actions. Discharge letter and discharge information should cover as a minimum: 1) physical activity plan, 2) smoking cessation plan and support (if appropriate), 3) angina action plan, 4) medication (dosage and possible side effects), 5) feelings and relationships, 6) work, 7) driving, 8) nutrition habits and recommendations, 9) alcohol use. Generally, appointments are made for follow-up review and, ideally, referral to a formal outpatient cardiac rehabilitation program are provided as well.

Since guidelines do not implement themselves (12) and approaches designed solely to bring information to practitioners do not produce significant changes in performance (13), it is our task to promote active interventions directed to changing and implementing systems of preventive care during hospital stay.

Secondary prevention through cardiac rehabilitation services and their flexible application on individual basis of multi-factorial programs, integrated with a designed discharge plan are the key elements to scale-up of cardiovascular risk assessment and management.

Hence, it’s time and our responsibility to develop new organizational models for cardiac care in different settings to support the delivery of the “preventive weapons” with appropriate expertise and strategies.


1.      Graham I et al, Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice. Eur J Cardiovasc Prev Rehabil. 2007 ;14 Suppl 2:S1-113.

2.      Piepoli MF et al, Secondary prevention through cardiac rehabilitation - from knowledge to implementation. A Position Paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2010; 17(1):1-17.

3.      Chow CK et al, Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010; 121:750 –758.

4.      Jolliffe JA et al,  Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2000:CD001800.

5.      Balady GJ et al,  Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115:2675–2682.

6.      Wenger,  NK. Current Status of Cardiac Rehabilitation. J Am Coll Cardiol 2008;51:1619–31.

7.      LaBresh KA, et al. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med. 2004;164:203–209.

8.      Fonarow GC, Ballantyne CM. In-hospital initiation of lipid-lowering therapy for patients with coronary heart disease: the time is now. Circulation. 2001;103: 2768-2770.

9.      Di Mario C, Piepoli MF. “Rehabilitation" after PCI: nonsense or the only way to achieve lasting results? EuroIntervention. 2010 J;5(6):655-8.

10.  Ades P, Balady G, Berra K, Transforming exercise based cardiac rehabilitation programmes into secondary prevention centres: A national imperative. J Cardipulmonary Rehabilitation, 2001, 21(5): 263-272.

11.  Peterson ED, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006; 295:1912–1920.

12.  Field MJ, Lohr KM. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990.

13.  Davis D, O’Brien MAT et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874.