What is the best way of organizing the follow-up of patients with cardiovascular disease?

The follow-up of patients with cardiovascular disease is one of the gaps in both the current European Society of Cardiology guidelines for myocardial revascularization ¹ and in the European guidelines for the diagnosis and treatment of peripheral arterial disease (PAD). ² By contrast, the American guidelines for lower extremity PAD highlight the importance of longitudinal follow-up. They recommend yearly return visits for a physical examination, including the assessment of cardiovascular risk factors, limb symptoms and functional status. ³ Therefore it is important that the position paper of Venermo et al. ⁴ tries to fill this guidance gap in Europe and gives some recommendations about the long-term follow-up of patients with vascular disease. Multiple studies have shown that secondary prevention after PAD is as crucial as after an acute coronary syndrome (ACS). Steg et al. ⁵ showed that the one-year incidence of major cardiovascular events was higher among patients with PAD than among those with coronary heart disease. Shalaeva et al. ⁶ showed a tenfold decrease in Major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus who were compliant versus non-compliant to secondary prevention measures after high limb amputation.

This shows that secondary prevention after PAD is not only important for preventing recurrent PAD events, but also in preventing ischaemic strokes and ACS. It is well established that rehabilitation and secondary prevention are associated with an improved prognosis^7,8 in both ACS and PAD. ⁹ However, the adherence to guideline recommendations remains disappointingly low. The EuroAspire V surveys show disappointing results that underline the challenges remaining in the secondary prevention of recurrence. ¹⁰

We may ask whether early screening for ischaemia is necessary for every vascular disease because early revascularization does not always give a prognostic advantage. In stable coronary artery disease, for example, multiple studies have shown that percutaneous coronary intervention does not reduce the risk of death, myocardial infarction or other major cardiovascular event when added to optimum medical treatment, except in a few specific situations. ¹¹ The ORBITA trial showed no significant difference in exercise time at 12 weeks between optimum medical treatment and a sham procedure versus percutaneous coronary intervention. ¹² Even in patients with substantial anatomical atherosclerotic stenosis in at least one renal artery, endovascular revascularization plus medical treatment carries a substantially higher risk than medical treatment only without any proved benefit with respect to renal function, blood pressure, renal or cardiovascular events, or mortality. ¹³

The CLEVER study showed that supervised exercise and stent revascularization in patients with claudication due to aorto-iliac PAD gave a comparable durable improvement in functional status and quality of life up to 18 months. ¹⁴ This evidence raises the question of whether organizing an effective secondary prevention programme with exercise, optimum treatment and education is more important than providing a follow-up programme after revascularization.

Secondary prevention is traditionally divided into three phases: inpatient, outpatient and long-term intervention. The greatest problem is often the lifelong maintenance of healthy changes in lifestyle. ¹⁵ Secondary prevention will always be a joint lifelong effort among patients, primary care physicians, nurses, therapists and cardiologists. ¹⁵ An important question is, who should be in charge of secondary prevention? It is important for patients to be guided by health professionals because many studies have shown that regular follow-up and interaction with health professionals ensures long-term adherence to changes in health behaviour.^16–18

For example, a number of studies have concluded that delayed outpatient follow-up beyond the first six weeks after an acute myocardial infarction is associated with poorer short- and long-term adherence to medication. ¹⁶ Patients with inpatient and follow-up cardiology care have a lower mortality risk after ACS. ¹⁷ The GOSPEL trial showed that a multifactorial, continued reinforced intervention with telephone calls and education is effective in decreasing the risk of several important cardiovascular outcomes. ¹⁸ Another study also confirmed that a nurse-led, telephone-based secondary prevention programme was significantly more efficient at improving low-density lipoprotein cholesterol levels and diastolic blood pressure than usual care. ¹⁹ Marcos-Forniol et al. ²⁰ showed that the implementation of a secondary prevention programme in elderly patients was effective in achieving risk factor control goals in patients older than 70 years of age. ²⁰

We conclude that secondary prevention is crucial in patients with cardiovascular disease. Therefore it is important that the paper of Venermo et al. ⁴ sets a framework for the long-term follow-up of patients with vascular disease. However, it is important to note that these recommendations are as yet not based on much scientific evidence. The focus must be on the long-term maintenance of a healthy lifestyle and compliance with medication, nutritional and exercise recommendations.

To follow-up secondary prevention programmes in patients with cardiovascular disease in the long term, digital health might be a significant help in vascular disease. It can be used to promote secondary prevention by monitoring cardiovascular risk factors, giving feedback and education, and by motivating patients towards long-term behavioural changes, which is more important than the timely diagnosis of recurrent disease.