Efficacy of a nurse-led lipid-lowering secondary prevention intervention in patients hospitalized for ischemic heart disease: A pilot randomized controlled trial

Abstract

Background and aims:

Lack of achievement of secondary prevention objectives in patients with ischaemic heart disease remains an unmet need in this patient population. We aimed at evaluating the six-month efficacy of an intensive lipid-lowering intervention, coordinated by nurses and implemented after hospital discharge, in patients hospitalized for an ischaemic heart disease event.

Methods:

Randomized controlled trial, in which a nurse-led intervention including periodic follow-up, serial lipid level controls, and subsequent optimization of lipid-lowering therapy, if appropriate, was compared with standard of care alone in terms of serum lipid-level control at six months after discharge.

Results:

The nurse-led intervention was associated with an improved management of low-density lipoprotein (LDL) cholesterol levels compared with standard of care alone: LDL cholesterol levels ⩽100 mg/dL were achieved in 97% participants in the intervention arm as compared with 67% in the usual care arm (p value <0.001), the LDL cholesterol ⩽70 mg/dL target recommended by the 2016 European Society of Cardiology guidelines was achieved in 62% vs. 37% participants (p value 0.047) and the LDL cholesterol reduction of ⩾50% recommended by the American College of Cardiology/American Heart Association in 2013 was achieved in 25.6% of participants in the intervention arm as compared with 2.6% in the usual care arm (p value 0.007). The intervention was also associated with improved blood pressure control among individuals with hypertension.

Conclusions:

Our findings highlight the opportunity that nurse-led, intensive, post-discharge follow-up plans may represent for achieving LDL cholesterol guideline-recommended management objectives in patients with ischaemic heart disease. These findings should be replicated in larger cohorts.

Keywords

Nurse-led intervention acute coronary syndrome cholesterol ischaemic heart disease lipids secondary prevention statins

Introduction

Despite landmark primordial and primary preventive efforts,^1,2 as well as dramatic improvements in the acute-phase care of ischaemic heart disease (IHD) patients attained in the last three decades,^3–5 IHD remains one of the leading causes of death worldwide.⁵

Among the prevailing unmet needs in the care of these patients, lack of achievement of secondary prevention targets after an acute IHD event is currently considered a key issue.^6,7 Specifically, although the guidelines of the European Society of Cardiology (ESC) recommend that patients with overt IHD should be treated aggressively to achieve low-density lipoprotein (LDL) cholesterol levels ⩽70 mg/dL,^6,8 this treatment goal is often not achieved.^6,7 Poor adherence to lifestyle recommendations and pharmacological therapies by patients, as well as time constrains, limited follow-up and medication titration by healthcare providers are considered important participating factors.^9–12

Studies suggest that specialized post-discharge follow-up by trained nurses represents an opportunity to improve the care and outcomes of patients with cardiovascular diseases.^13–15 Nurses may have more availability than physicians to conduct close follow-up, and may communicate with patients more effectively, particularly in terms of health education. Specifically, periodic follow-up by specialized nurses has become a key component of chronic disease management programmes for patients with chronic diseases, such as heart failure.¹³ However, whether this approach may also be beneficial for patients with IHD is less understood.

Our aim was thus to evaluate the six-month efficacy of an intensive lipid-lowering intervention, coordinated by a nurse and implemented after hospital discharge, in patients hospitalized for an IHD event. For this purpose, we conducted a randomized, controlled trial in which this intervention was compared with the standard of care, in terms of use of lipid-lowering therapies and lipid-level control at six months after discharge.

Materials and methods

Study context

Since 2007, a multi-disciplinary cardiac rehabilitation programme (CRP) has been in place in our centre. The CRP is coordinated by specialized nurses, and includes interventions performed by cardiologists, nurses, rehabilitation physicians, physiotherapists and professionals specialized in the management of anxiety and other mental health disorders. All patients discharged from our centre after a hospitalization for an acute IHD event and with no severe cognitive impairment are invited to the CRP; of them, those willing to participate are included in the programme.

As part of the programme activities, nurses educate patients in healthy habits during the in-hospital stage, as well as in follow-up visits at three and 12 months after discharge; provide and monitor quality of life, anxiety and depression symptoms using validated tests; and coordinate the follow-up plan and visits. Rehabilitation physicians and physiotherapists assess the functional status of the patient, promote and supervise the early mobilization and deambulation of patients during the hospital stay, and indicate and supervise physical activity during follow-up. All professionals involved in the CRP participate in monthly group sessions aimed at reinforcing the health education of the patients, with a special focus on increasing the patients’ understanding of the pathophysiology of IHD, on the role of cardiovascular risk factors and on the importance of optimal risk factor management, particularly through physical activity, management of anxiety and adherence to guideline-recommended pharmacotherapies.

Because of its characteristics and infrastructure, the CRP provides thus an excellent platform to implement additional secondary prevention interventions.

Trial design and study participants

The Estudio de UTilización del chronic care model en pacientes isquémicos de Elevado Riesgo mediante un Proceso basado en Enfermería (EUTERPE, Spanish acronym) study was a single-centre, unblinded, randomized controlled pilot trial assessing the efficacy and safety of a specialized, nurse-guided, lipid-lowering intervention aimed at improving the management of LDL cholesterol levels and other cardiovascular risk factors in patients hospitalized for IHD.

Between 1 April 2012 and 28 February 2013, all patients hospitalized for IHD in our centre meeting inclusion criteria in the local CRP and willing to participate in the programme were screened for inclusion in this study. This included patients hospitalized for ST-segment elevation and non ST-segment elevation myocardial infarction, unstable angina and stable angina. Of them, all patients providing written informed consent were included in the EUTERPE. The study was approved by the Ethics Committee of the Hospital del Mar and was conducted in accordance with the Declaration of Helsinki.

Interventions

Participants were randomized in a 1:1 ratio to two management arms (Figure 1). The ‘standard care arm’ involved usual post-discharge follow-up, which in our healthcare area typically involves follow-up by the patient’s primary care general physician, plus follow-up by a primary care cardiologist for a limited period of time; and inclusion in the standard CRP (see Study context above for more details).

On the other hand, the ‘intervention arm’ involved usual post-discharge follow-up, inclusion in the standard CRP, plus the following additional interventions: 1) periodic follow-up by a CRP nurse, who coordinated all ‘intervention arm’ actions; 2) conduct of serum lipid level controls at months 3 and 6 after discharge; 3) evaluation of laboratory test results using a pre-specified algorithm based on clinical practice guidelines and developed ad-hoc for this study (Supplementary Material Figure S1 online); 4) prescription and dispensing of any additional/alternative lipid lowering treatment, if indicated according to the algorithm, by a cardiologist involved in the CRP; and 5) permanent communication with the patient and with the patient’s primary care physician (phone, email) regarding any laboratory test results and therapeutic changes during the intervention.

Randomization to the two study arms was performed using a computer-generated randomization scheme. Study participants and personnel were aware of, that is, not blinded to, the study intervention.

Study endpoints

The primary study endpoint was the proportion of patients with serum LDL cholesterol levels ⩽70 mg/dL at six months of follow-up in each study arm, which is the treatment goal supported by current ESC guidelines.^6,8 Other variables related to lipid management assessed at six months included lipid-lowering medication use at six months, changes in lipid-lowering medication, changes in lipid levels as compared with hospital discharge, and proportion of individuals with a reduction in LDL cholesterol of ⩾50%, among others. Specifically, the atorvastatin equivalent daily dose was calculated using an equivalence chart generated by clinical pharmacy specialists.

As other secondary study endpoints, we also assessed the impact of the intervention in terms of control of other cardiovascular risk factors: proportion of patients with systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg at six months; proportion of patients in which blood-pressure medication had changed at six months compared with discharge; levels of glycosylated haemoglobin (HbA1c); and proportion of active smokers (all after six months of follow-up). As tertiary study endpoints, we also assessed the frequency of urgent hospitalization and of all-cause death after six months of follow-up.

Because the safety of achieving LDL cholesterol levels <70 mg/dL and of aggressive LDL cholesterol management has been largely described in the literature,^2,16,17 no safety endpoints were evaluated in this pilot analysis.

Sample size

Although initially, based on sample size calculations, we aimed at recruiting 118 study participants (59 in each study arm), due to funding limitations the study population finally had to be restricted to 78 participants (39 in each study arm).

Statistical analyses

Baseline characteristics of the study participants were described using number and proportion for categorical variables, and median (interquartile range) for continuous variables. Differences between the two study arms were compared using chi-square statistics or Fisher’s exact test for categorical variables, as needed, and non-parametric tests for continuous variables in order to account for the small sample size.

The same tests were used to compare the two study arms after six months of follow-up. For this comparison, an intention-to-treat analysis was performed. There were no losses to follow-up during the study period, and no cross-overs between study arms happened either.

The absolute atorvastatin dose change at six months and the absolute change in LDL cholesterol levels at six months was described graphically, for both study arms.

All statistical analyses were performed using Stata Version 15.0.¹⁸ A p value of <0.05 was used to define statistical significance.

Results

Study participants

Between 1 April 2012 and 28 February 2013, 96 IHD patients discharged after an IHD-related hospitalization met the inclusion criteria of the CRP, and were therefore screened for inclusion in the study. Of them, 78 provided written informed consent, while 18 refused participation in the study. The 78 patients included in the study were randomized in a 1:1 ratio either to the standard care arm or to the study intervention arm (n = 39 each). Figure 1 displays the flow of the patients included in the study.

Baseline characteristics

The baseline characteristics of the study participants (i.e. at hospital discharge) are summarized in Table 1. Overall, the median age of the study population was 61 years, and 83% were male. There were no statistically significant differences between the two study groups in terms of baseline sociodemographic characteristics and other cardiovascular risk factors in the reason for hospitalization or in laboratory test results at admission. This included identical median baseline LDL cholesterol levels (103 mg/dL in both arms). There was a trend towards a higher median HbA1c in the intervention arm (6.1% as compared with 5.7% in the standard care arm) although this was not statistically significant.

Table 1.

Baseline characteristics of the study participants.

	OverallN = 78	Standard caren = 39	Interventionn = 39	p value
Sociodemographic characteristics and cardiovascular risk factors
Age, years	61 (54, 71)	60 (53, 70)	62 (55, 73)	0.382
Male sex	65 (83.3)	33 (84.6)	32 (82.1)	0.761
Active smoker	18 (23.1)	8 (20.5)	10 (25.6)	0.591
Diabetes mellitus	24 (30.8)	9 (23.1)	15 (38.5)	0.141
Hypertension	59 (75.6)	27 (69.2)	32 (82.1)	0.187
Dyslipidaemia	51 (65.4)	25 (64.1)	26 (66.7)	0.812
Clinical variables at discharge
Systolic blood pressure, mmHg	116 (108, 129)	115 (107, 128)	118 (109, 137)	0.385
Diastolic blood pressure, mmHg	71 (64, 77)	71 (64, 80)	70 (62, 76)	0.418
LVEF, %	60 (55, 66)	60 (49, 65)	60 (53, 66)	0.572
Reason for hospitalization
STEMI	35 (44.9)	19 (48.7)	16 (41)	0.679^a
NSTEMI	30 (38.5)	13 (33.3)	17 (43.6)
Unstable angina	12 (15.4)	6 (15.4)	6 (15.4)
Stable angina	1 (1.3)	1 (2.6)	0 (0)
Laboratory test results at admission
Glucose, mg/dL	109 (98, 127)	109 (98, 136)	108 (98, 123)	0.642
Creatinine, mg/dL	0.80 (0.70, 1.00)	0.80 (0.70, 1.00)	0.90 (0.80, 1.00)	0.223
Urea, mg/dL	38 (28, 47)	34 (26, 45)	41 (30, 49)	0.053
Haemoglobin, g/dL	14.1 (13.2, 15.1)	14.2 (13.3, 15.1)	14.0 (12.8, 15.1)	0.549
HbA1c, %	5.8 (5.5, 6.6)	5.7 (5.4, 6.3)	6.1 (5.5, 7.0)	0.084
Total cholesterol, mg/dL	176 (150, 215)	178 (162, 216)	166 (136, 214)	0.393
LDL cholesterol, mg/dL	103 (84, 142)	103 (93, 140)	103 (79, 142)	0.566
HDL cholesterol, mg/dL	41 (32, 49)	44 (33, 55)	40 (28, 48)	0.193
Triglycerides, mg/dL	124 (99, 179)	119 (98, 179)	130 (104, 174)	0.693
Lipid-lowering medication use at discharge
Statin use at discharge	77 (98.7)	38 (97.4)	39 (100)	1.000^a
Atorvastatin	65 (83.3)	31 (81.6)	34 (87.2)	0.755^a
Simvastatin	2 (2.6)	1 (2.6)	1 (2.6)
Rosuvastatin	10 (12.8)	6 (15.8)	4 (10.3)
Equivalent daily dose of atorvastatin	40 (40, 40)	40 (40, 40)	40 (40, 40)	0.877

Data presented as median (interquartile range) or n (%). Percentages may not sum 100% due to rounding.

p value calculated using Fisher’s exact test.

HbA1c: glycosylated haemoglobin; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LVEF: left ventricle ejection fraction; NSTEMI: non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction.

At hospital discharge, 100% of patients in the intervention arm and 97.4% patients in the control arm received statins, with atorvastatin being the most frequently used option. The median equivalent daily dose of atorvastatin was identical in the two groups (40 mg per day).

Lipid-lowering management and lipid level endpoints at six months of follow-up

Table 2 summarizes the study results in terms of lipid management at six months after discharge. Briefly, although statin use remained very high in both study arms, the equivalent daily dose of atorvastatin was higher in the intervention group (Figure 2(a)), and use of ezetimibe was more frequent among the patients in the intervention arm. Median total and LDL cholesterol levels were lower in the intervention arm, and the relative change in LDL cholesterol levels at six months was larger in the intervention arm than in the standard care arm (–36% reduction vs. –26% reduction, p 0.025). The distribution of absolute changes in LDL levels by study arm is presented in Figure 2(b).

Table 2.

Lipid-lowering medication use and serum lipid levels at six months of follow-up.

	Standard care n = 39	Intervention n = 39	p value
Lipid-lowering medication use
Any statin, %	37 (94.9)	39 (100.0)	0.494^a
Ezetimibe, %	1 (2.6)	11 (28.2)	0.003^a
Lipid-lowering medication changed, %	8 (20.5)	19 (48.7)	0.009
Equivalent daily dose of atorvastatin, mg	40 (40, 40)	40 (40, 80)	0.045
Absolute change in daily dose of atorvastatin, mg	0 (0, 0)	0 (0, +40)	0.036
Relative change in daily dose of atorvastatin, %	0 (0, 0)	0 (0, +100)	0.036
Laboratory test results
Total cholesterol, mg/dL	151 (129, 176)	130 (115, 147)	<0.001
Absolute change in total cholesterol, mg/dL	−45 (–63, –3)	−43 (–70, –14)	0.635
Relative change in total cholesterol, %	−24 (–33, –1)	−25 (–37, –9)	0.389
LDL cholesterol, mg/dL	82 (63, 108)	67 (60, 78)	0.006
Absolute change in LDL cholesterol, mg/dL	−35 (–42, +4)	−34 (–69, –16)	0.062
Relative change in LDL cholesterol, %	−26 (–38, +5)	−36 (–54, –19)	0.025
HDL cholesterol, mg/dL	48 (41, 55)	43 (37, 50)	0.051
Absolute change in HDL cholesterol, mg/dL	+6 (–6, +11)	+5 (–4, +9)	0.581
Relative change in HDL cholesterol, %	+13 (–11, +30)	+11 (–8, +33)	0.964
Triglycerides, mg/dL	99 (77, 132)	95 (69, 114)	0.246
Absolute change in triglycerides, mg/dL	−41 (–60, +13)	−30 (–88, –6)	0.995
Relative change in triglycerides, mg/dL	−28 (–43, +18)	−27 (–51, –5)	0.686
LDL cholesterol clinical management endpoints
LDL cholesterol ⩽100 mg/dL	18 (66.7)	36 (97.3)	0.001^a
LDL cholesterol ⩽70 mg/dL	10 (37.0)	23 (62.2)	0.047
LDL reduction at six months ⩾50%	1 (2.6)	10 (25.6)	0.007^a

Data presented as median (interquartile range) or n (%). Percentages may not sum 100% due to rounding.

p value calculated using Fisher’s exact test.

HDL: high-density lipoprotein; LDL: low-density lipoprotein.

In this context, the primary study endpoint (proportion of patients with LDL ⩽70 mg/dL at six months of follow-up) was achieved more frequently in the intervention arm (62%) than in the standard care arm (37%, p value 0.047). The less strict target of LDL cholesterol <100 mg/dL was achieved by 97.3% and 66.7% of participants, respectively (p<0.001). Also, a LDL cholesterol reduction of ⩾50% was more frequently attained in the intervention arm compared with the standard care arm (26% vs. 3%, p value 0.007).

Management of other cardiovascular risk factors

Table 3 summarizes the management of other relevant cardiovascular risk factors at six months of follow-up. Compared with the standard care arm, there was a trend towards a better management of blood pressure levels in the intensive care arm compared with the standard care arm. These differences were statistically significant when only individuals with a prior diagnosis of hypertension were compared. On the other hand, no differences were observed between study arms with regard to tobacco use at six months or HbA1c levels.

Table 3.

Management of other cardiovascular risk factors, and clinical events at six months of follow-up.

	Standard care n = 39	Intervention n = 39	p value
Management of other cardiovascular risk factors at six months
Systolic blood pressure, mmHg	130 (120, 140)	126 (119, 134)	0.270
Diastolic blood pressure, mmHg	76 (66, 82)	72 (62, 79)	0.038
SBP <140 and DBP <90 mmHg	26 (66.7)	33 (84.6)	0.065
Change in blood pressure-lowering medication	0 (0)	5 (12.8)	0.055^a
HbA1c, %	5.8 (5.5, 6.3)	6.1 (5.9, 6.4)	0.123
Active smoker	4 (10.3)	3 (7.7)	1.000*
Management of blood pressure in individuals with hypertension
Systolic blood pressure, mmHg	132 (123, 144)	127 (120, 135)	0.114
Diastolic blood pressure, mmHg	76 (66, 85)	72 (64, 76)	0.044
SBP <140 and DBP <90 mmHg	17 (63.0)	28 (87.5)	0.035^a
Change in blood pressure-lowering medication	0 (0.0)	4 (12.5)	0.118^a
Management of HbA1c in individuals with diabetes
HbA1c, %	6.2 (5.8, 7.3)	6.4 (6.0, 7.2)	0.380
HbA1c <7.0%	5 (71.4)	7 (70.0)	1.000^a
Clinical events during follow-up
Urgent hospitalization	4 (10.3)	0 (0.0)	0.115^a
All-cause death	0 (0.0)	0 (0.0)	–

Data presented as median (interquartile range) or n (%).

p value calculated using Fisher’s exact test.

HbA1c: glycosylated haemoglobin; DBP: diastolic blood pressure; SBP: systolic blood pressure.

Clinical events

Table 3 also presents the results regarding urgent hospitalizations and all-cause death at six months of follow-up. During the study period, the number of hospitalizations was very few, and there were no deaths in any of the study arms. In this context, no statistically significant differences between the two study arms were identified.

Discussion

In this pilot, randomized, controlled trial conducted in a single centre in which a comprehensive CRP was in place, a nurse-led intervention including periodic follow-up, serial lipid level controls and subsequent optimization of lipid-lowering therapy, if appropriate, was associated with an improved management of LDL cholesterol levels compared with standard care alone. Also, the intervention was associated with improved blood pressure control among individuals with a diagnosis of hypertension. If replicated in larger studies, the present findings may have important implications for the chronic management of patients with IHD, in many of whom the treatment goals recommended by clinical practice guidelines are currently not achieved.

In our study, despite being included in a comprehensive, multidisciplinary CRP, only 37% of the individuals in the standard care arm achieved the LDL target of ⩽70 mg/dL six months after discharge. This observation, which is consistent with the poor results published in the literature,^6,7 highlights the need for additional efforts aimed at improving adherence to and treatment titration of lipid-lowering medications in patients with IHD. Of note, despite the additional interventions included in the intervention arm, 38% of participants in this group still did not achieve the LDL ⩽70 mg/dL target, which stresses the complexity of the issue and the difficulty of achieving full success in this patient population.

Our results are consistent with those from prior studies assessing the efficacy of nurse-led cardiovascular risk reduction programmes in patients with IHD. In the Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists (RESPONSE) trial,^19,20 which included 754 patients from The Netherlands admitted for an acute coronary syndrome and exposed to a nurse-coordinated secondary prevention intervention (comprising four outpatient clinic visits to a cardiovascular nurse focused on healthy lifestyle recommendations, improvement of biometric risk factors and of medication adherence, and in which medication adjustment was conducted when necessary), there was a significant improvement in overall cardiovascular risk factor control, in 10-year estimated cardiovascular disease death risk after 12 months, and in re-hospitalizations among individuals exposed to the intervention as compared with those in the usual care arm. Specifically regarding LDL cholesterol, although study nurses had been trained and were highly confident about their ability to achieve drug-related treatment targets,²¹ differences between the two study arms were smaller than in our study, with a target of LDL cholesterol <2.5 mmol/L (≈100 mg/dL) being achieved in 80% of patients in the intervention arm compared with 69% in the usual care arm (as compared with 97% and 67%, respectively, in our study). Our results are also consistent with those from observational studies evaluating similar nurse-led programmes,^22,23 as well as with experimental evaluations conducted in other groups of cardiovascular patients.¹⁵ In this context, to our knowledge our analysis is the first to assess the efficacy of a nurse-based intervention in terms of achieving the LDL target recommended in the 2016 ESC guidelines,⁶ as well as in terms of achieving the LDL reduction recommended in the 2013 American College of Cardiology/American Heart Association cholesterol treatment guidelines.²⁴

Our findings have important clinical implications. The intervention, which could be easily incorporated into a standard CRP, resulted not only in clear benefits in terms of lipid level management, but also in improved management of blood pressure levels among individuals with hypertension. Because the intervention did not include any actions aimed at modifying the patient’s blood pressure lowering pharmacologic treatment, the latter was likely the consequence of the increased contact between the healthcare personnel and patients leading to greater adherence to healthy lifestyle recommendations. Our study identifies thus an invaluable opportunity to improve the secondary prevention management of patients with IHD.

Study limitations

Some study limitations must be acknowledged. First, patients were recruited from a single medical centre, therefore, generalizability of our findings to other patient populations and healthcare environments may be limited. Nevertheless, the benefits of closer follow-up observed in our study are likely to apply to other environments. Second, the small sample size may have impacted statistical power and our ability to identify statistically significant differences between the groups. This, however, did not prevent observing significant differences between the study arms in several endpoints, including the pre-specified primary study endpoint, which supports the efficacy of the intervention. On the other hand, our analysis was clearly underpowered to identify differences in clinical events, or in other study endpoints such as differences in tobacco use during follow-up.

Third, the small sample size also prevented conducting detailed evaluations of different lipid-lowering pharmacologic management strategies. For the same reason, subgroup analyses in clinically relevant subgroups of patients were not feasible either. Finally, because the study was conducted before 2015, this prevented gaining insights on the effectiveness specifically of PCSK9 inhibitors²⁵ in patients with IHD. These limitations stress the pilot nature of the present analysis, and the need to replicate our findings in larger, multi-centre, contemporary cohorts.

Conclusions

In this small experimental study, a nurse-led intervention added to a standard CRP including periodic follow-up, serial lipid level checks and subsequent optimization of lipid-lowering therapy was associated with a markedly improved management of LDL cholesterol levels compared with a standard CRP programme alone. Our findings highlight the opportunity that nurse-led, intensive, post-discharge follow-up plans represent for the optimization of risk factor control and specifically of LDL cholesterol in patients with IHD.

Supplemental Material

Supplementary_Material – Supplemental material for Efficacy of a nurse-led lipid-lowering secondary prevention intervention in patients hospitalized for ischemic heart disease: A pilot randomized controlled trial

Supplemental material, Supplementary_Material for Efficacy of a nurse-led lipid-lowering secondary prevention intervention in patients hospitalized for ischemic heart disease: A pilot randomized controlled trial by Sonia Ruiz-Bustillo, Consol Ivern, Neus Badosa, Nuria Farre, Esther Marco, Jordi Bruguera, Mercè Cladellas, Cristina Enjuanes, Miguel Cainzos-Achirica, Julio Marti-Almor and Josep Comin-Colet in European Journal of Cardiovascular Nursing

Footnotes

Acknowledgements

SR and CI contributed equally as co-first authors. The authors thank the other investigators, the staff, and the participants of the EUTERPE study for their valuable contributions. All authors have contributed to and approved the content of this manuscript. Supplementary Material for this article is available online.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

This work was financially supported by an unrestricted grant from the Hospital del Mar Quality of Care Improvement Program (2012/4727/I).

Implications for practice

Strategies are needed to optimize secondary prevention in post-myocardial infarction patients;

A nurse-led intervention improved low-density lipoprotein cholesterol control at six months;

Other risk factor-control benefits were also observed at six months;

Easily incorporable to a standard rehabilitation programme.

References

Fichtenberg

Glantz

SA.

Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. N Engl J Med 2000; 343: 1772-1777.

Cholesterol Treatment Trialists’ (CTT) Collaboration, Fulcher

O’Connell

et al . Efficacy and safety of LDL-lowering therapy among men and women: Meta-analysis of individual data from 174,000 participants in 27 randomised trials. Lancet 2015; 385: 1397-1405.

Le May

Dionne

et al . A citywide protocol for primary PCI in ST segment elevation myocardial infarction. N Engl J Med 2008; 358: 231–240.

Boersma

; Primary Coronary Angioplasty vs. Thrombolysis Group. Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J 2006; 27: 779–788.

Benjamin

Blaha

Chiuve

et al .; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2017 update: A report from the American Heart Association. Circulation 2017; 135: e146-e603.

Piepoli

Hoes

Agewall

et al .; ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315-2381.

Kotseva

Wood

De Backer

et al .; EUROASPIRE Study Group. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil 2009; 16: 121-37.

Ibanez

James

Agewall

et al .; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39: 119-177.

Naderi

Bestwick

Wald

DS.

Adherence to drugs that prevent cardiovascular disease: Meta-analysis on 376,162 patients. Am J Med 2012; 125: 882–887 e1.

10.

Reiner

Sonicki

Tedeschi-Reiner

Physicians’ perception, knowledge and awareness of cardiovascular risk factors and adherence to prevention guidelines: The PERCRO-DOC survey. Atherosclerosis 2010; 213: 598–603.

11.

Dallongeville

Banegas

Tubach

et al . Survey of physicians’ practices in the control of cardiovascular risk factors: The EURIKA study. Eur J Prev Cardiol 2012; 19: 541–550.

12.

Byrne

O’Connor

Jennings

et al . A survey of GPs awareness and use of risk assessment tools and cardiovascular disease prevention guidelines. Irish Med J 2015; 108: 204–207.

13.

Phillips

Singa

Rubin

et al . Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis. Eur J Heart Fail 2005; 7: 333-341.

14.

Qvist

Hendriks

Møller

et al . Effectiveness of structured, hospital-based, nurse-led atrial fibrillation clinics: A comparison between a real-world population and a clinical trial population. Open Heart 2016; 3: e000335.

15.

Cicolini

Simonetti

Comparcini

et al . Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: A randomized controlled trial. Int J Nurs Stud 2014; 51: 833-843.

16.

Robinson

Rosenson

Farnier

et al . Safety of very low low-density lipoprotein cholesterol levels with alirocumab: Pooled data from randomized trials. J Am Coll Cardiol 2017; 69: 471-482.

17.

Benn

Nordestgaard

Frikke-Schmidt

et al . Low LDL cholesterol, PCSK9 and HMGCR genetic variation, and risk of Alzheimer’s disease and Parkinson’s disease: Mendelian randomisation study. BMJ 2017; 357: j1648.

18.

Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC.

19.

Harald

von Birgelen

Alings

et al . Effect of a nurse-coordinated prevention programme on cardiovascular risk after an acute coronary syndrome: Main results of the RESPONSE randomised trial. Heart 2013; 99: 1421–1430.

20.

Snaterse

Jorstad

Heiligenberg

et al . Nurse-coordinated care improves the achievement of LDL cholesterol targets through more intensive medication titration. Open Heart 2017; 4: e000607.

21.

Jorstad

Chan

Scholte

Reimer

WJM

et al . Nurses’ perspectives on nurse-coordinated prevention programmes in secondary prevention of cardiovascular disease: A pilot survey. Contemp Nurse 2015; 51: 96–106.

22.

Harbman

The development and testing of a nurse practitioner secondary prevention intervention for patients after acute myocardial infarction: A prospective cohort study. Int J Nurs Stud 2014; 51: 1542-1556.

23.

Wong

Chua

SJT

Gao

et al . The effect of a nurse-led telephone-based care coordination program on the follow-up and control of cardiovascular risk factors in patients with coronary artery disease. Int J Qual Health Care 2016; 28: 758-763.

24.

Stone

Robinson

Lichtenstein

et al .; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63: 2889-2934.

25.

Cainzos-Achirica

Martin

Cornell

et al . PCSK9 Inhibitors: A new era in lipid-lowering treatment? Ann Intern Med 2015; 163: 64-65.

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