Paris, 28 August 2011: A nurse led family centred preventive cardiology programme for high CVD risk smokers and their partners, with intensive smoking cessation support and optional use of varenicline in general practices, can improve smoking cessation in this group of smokers in routine clinical practice. Such a programme reduces total cardiovascular risk for both vascular patients and patients without symptoms but at high risk of developing a heart attack or stroke. These are the conclusions of researchers from Imperial College London who conducted the study in four European countries between January 2010 and July 2011. The study was presented at the European Society of Cardiology’s ESC Congress 2011, today by Prof David Wood from Imperial College, London, UK.
Scientific evidence for smoking cessation and CVD prevention is compelling. Following smoking cessation there is a rapid decline in risk of CHD. In those with CHD, the risk falls within 2 – 3 years to the level of those with CHD who never smoked. In asymptomatic people, up to 10 years are needed to reach risk level of an individual who has never smoked. On average, smokers die 10 years younger than non-smokers6. Stopping at 50 halves the hazard, but if a smoker stops before they reach 30 years, the hazard may be eliminated completely. Stopping at 60, 50, 40, 30 gains respectively 3, 6, 9 or 10 years of life expectancy. There is also a 36% risk reduction of all cause mortality in those who stop smoking following myocardial infarction7. After one year, the excess risk of coronary heart disease caused by smoking is reduced by half. After 15 years of abstinence, the risk is similar to a non-smoker8.
In addition a more comprehensive lifestyle intervention, risk factor management, and cardioprotective drugs can further reduce morbidity and mortality and increase life expectancy in these patients. However, the most recent EUROASPIRE survey showed that smoking cessation support in routine clinical practice is inadequate.
More than a half of coronary patients who were smoking at the time of their event are still smoking one year later1. In people at high risk of developing cardiovascular disease identified in general practice, the situation is worse with nearly 90% still smoking after they have been started on therapies to reduce their cardiovascular risk2. The same EUROASPIRE survey also showed that, whilst a large proportion of patients report being advised to stop smoking by their doctor, very few actually access specialist support to stop [5% coronary patients and 3% high risk individuals].
The EUROACTION PLUS model was developed by Professor David Wood’s team at the International Centre for Circulatory Health at Imperial College London to help high risk patients (atherosclerotic disease, or at high multifactorial risk of developing the disease, or with diabetes) identified in general practice, and their partners, to achieve the lifestyle, risk factor, and therapeutic targets defined in the prevention guidelines. Professor Wood and colleagues undertook a randomised trial in 4 countries* in general practice**, to test whether the EUROACTION PLUS model was effective in everyday clinical practice. Led by nurses trained to deliver a comprehensive lifestyle and risk factor management programme, it focused on the family. As well as smoking cessation, it also addressed dietary and physical activity habits, overweight and obesity and other risk factors such as blood pressure, cholesterol and use of cardioprotective drugs
A total of 696 patients, 137 with vascular disease and 559 at high risk of developing cardiovascular disease, were randomised with their informed consent by the end of recruitment on March 31st this year. 350 were assigned to the intervention arm (EA+), and 346 to the usual care (UC) arm. 109 partners were also recruited. 16 week follow-up was completed on July 31st 2011 in 299 patients (85.4%) in EA+ and 288 patients (83.2%) in UC.
For the primary endpoint, smoking abstinence for the last seven days confirmed with breath carbon monoxide less than 10 parts per million, 51.2% of patients in the EA+ programme were abstinent compared to 18.8% in UC at 16 weeks, a highly statistically significant result (odds ratio 4.52; 95% CI 3.20 to 6.39, p<0.0001). Encouragingly, in those partners who also smoked at the time of recruitment, 73.1% were abstinent in the EA+ arm compared to 36.7% in UC, also highly statistically significant (odds ratio 4.67: 95% CI 1.92 to 11.48, p<0.001).
Dietary and physical activity habits were also improved by the EUROACTION PLUS programme. 52.3% of patients in EA+ achieved a Mediterranean diet score ≥ 9, compared to 37.3% in UC (p<0.001). 16.2% in EA+ achieved the physical activity target compared to 7.2% in UC (P=0.002) with a corresponding improvement in fitness as demonstrated by a significantly higher proportion achieving the METSmax target (Chester Step test): 37.8% in EA+ versus 27.3% in UC (p=0.04).
The programme may also have limited weight gain normally associated with smoking cessation as there was no significant difference in body weight between EA+ and UC at the 16 week follow-up.
Blood pressure management was improved in the EA+ group compared with UC. 52.4% achieved the target (140/90 mm Hg in patients and high risk of developing CVD or 130/80 mm Hg in vascular patients or those with diabetes) compared with 42.9%% UC (p=0,03); but there were no differences in lipid or glucose levels. Better blood pressure control was achieved without the use of additional anti-hypertensive drug therapies as prescribing of cardioprotective drugs was similar in both arms of the trial. Quality of life measured according to the EQ-VAS instrument was significantly higher in EA+ patients in comparison to UC patients.
The investigators say:
‘Nurses have demonstrated that they can coordinate a complex intervention and reduce total cardiovascular risk in a particularly challenging group - high CVD risk smokers’
‘The original EUROACTION study in general practice showed no effect on smoking. Now nurses have demonstrated that with the help of effective pharmacotherapy, varenicline, we can achieve real gains in smoking cessation in dependent high CVD risk smokers’
‘Partners of patients who were also smoking had a much higher success rate in stopping smoking in this family based programme compared to the partners of patients who had no access to specialist support. In addition the partners efforts to stop smoking may have also contributed to the better result seen in patients.’
They conclude: “The nurse-led EUROACTION preventive cardiology model has successfully demonstrated that it is possible to help persistent smokers to stop, and as importantly to reduce their total cardiovascular risk by achieving a healthier lifestyle and more effective risk factor management. Just addressing smoking cessation alone is not enough – we need a more comprehensive family based approach which addresses all risk factors. ”
*The four countries involved in the study were UK, Italy, Netherlands and Spain
**Patients were referred from 20 general practices to the study nurses in each country