National Heart & Lung Institute (NHLI)

Cardiovascular Medicine

The Cardiovascular Medicine research group, at the International Centre for Circulatory Health on St. Mary's campus, focuses on the prevention of cardiovascular disease through research, teaching and patient care:

Research

Clinical trials of cardiovascular disease

We are undertaking trials of effectiveness and cost effectiveness in the delivery of preventive cardiology care. The EUROACTION trials are evaluating the delivery of preventive cardiology care in hospital and general practice in Europe. EuroactionThe original EUROACTION trial was set up as a European demonstration project in preventive cardiology in 8 countries funded by the European Society of Cardiology. The aim was to demonstrate whether a nurse-led, multidisciplinary, programme for coronary patients in hospital, and those at high risk of developing cardiovascular disease in general practice, could raise standards of preventive cardiology care as defined by the Joint European Societies guidelines on CVD prevention in terms of achieving the lifestyle, risk factor and therapeutic goals.

This 8 country, 24 centre, 8,657 person matched-pair cluster randomised controlled trial showed that the EUROACTION programme was able to achieve healthier lifestyles, in terms of diet and physical activity, for both coronary and high risk patients compared to usual care at one year. In addition blood pressure control was significantly better in the EUROACTION arm and this was largely achieved through lifestyle changes. The principal results were published in the Lancet. Wood DA, Kotseva K, Connolly S, Jennings C, Mead A, Jones J, Holden A, De Bacquer D, Collier T, De Backer G, Faergeman O. EUROACTION Study Group. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008; 371:1999-2012

Euroaction PlusThe second EUROACTION trial is evaluating the effectiveness and cost effectiveness of the same nurse-led programme but in high risk smokers at risk of developing or having recurrent CVD. The object is to determine if this preventive cardiology programme, which also includes the optional use of Varenicline, can help more patients to stop smoking and reduce their total cardiovascular risk compared to usual care.

This parallel group randomised controlled trial is being conducted in 16 general practices across 4 countries in cigarette smokers. They have either established vascular disease, or are at high risk (hypertension / dyslipidaemia / diabetes) of developing cardiovascular disease, and are willing to make a quit attempt. Pharmacological support in the form of Varenicline is offered. The first short term results were presented at a Highlights session at the ESC Congress in Paris in 2011 and showed that the EUROACTION programme achieved 51.2% abstinence at 16 weeks compared to 18.8% in usual care. As importantly these patients achieved healthier diets and became more physically active and blood pressure control was also significantly better compared to usual care. So total cardiovascular risk was reduced. Patients are being followed up for one year outcomes.

 

Clinical surveys of cardiovascular diseases


Euroapire

The ASPIRE survey, conducted under the auspices of the British Cardiac Society in the early nineties, was the first national study to describe risk factor management in coronary patients. It led to a series of EUROASPIRE surveys, monitoring the delivery of preventive cardiology care across 25 European countries in both hospital and general practice, for the European Society of Cardiology. The first EUROASPIRE survey of coronary patients was conducted in nine countries in 1995/96, and the second (EUROASPIRE II) survey in 15 countries in 1999/2000 also studied coronary patients together with the relatives of patients with premature CHD. EUROASPIRE III in 1996/1998 took place in 22 countries and included all those who had participated in the previous surveys and, for the first time, the management of high risk individuals in general practice from 12 countries.

Lifestyle and risk factor time trends across the three surveys of coronary patients show persistent smoking is highest in younger patients, and prevalence of obesity and central obesity have increased over this twelve year period. Blood pressure management has not changed, with more than half of all patients above the blood pressure target defined in the guidelines. Prevalence of diabetes is also increasing reflecting the adverse trends in central obesity. Lipid management has improved substantially but almost half of the patients are still above the guideline target. These time trends were published in the Lancet. Kotseva K, Wood D, De Backer G, De Bacquer D, Keil U on behalf of EUROASPIRE Study Group. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II and III surveys in 8 European countries. Lancet 2009; 373(9667):929-940.

The fourth EUROASPIRE survey is part of the EURObservational Research Programme of the ESC and will be launched in hospitals across 25 countries in 2012. The primary care survey is planned for 2013. Please click here for more details of the EURObservational Research Programme. A second ASPIRE survey (ASPIRE-2-PREVENT) has also been undertaken under the auspices of the British Cardiovascular Society but this time in both hospital (coronary patients) and general practice (high risk individuals) and results presented to the Society still show considerable potential to reduce the risk of cardiovascular disease by comparison with the first survey in the early nineties.

Education and Training

MSc in Preventive Cardiology – Cardiovascular health and disease prevention

We developed this postgraduate course following the EUROACTION project in order to provide health care professionals with formal training in all aspects of preventive cardiology. The MSc is full-time over one year or part-time over two years. Options for a Diploma course are available and each module can be taken as a short course. An E-learning platform was launched in 2010  which allows students to learn in their own professional environment in the UK or other countries.

The programme is aimed at all healthcare professionals with a role in prevention of cardiovascular disease, such as physicians, nurses, dieticians, physiotherapists, physical activity specialists, pharmacists, psychologists, occupational therapists, sports scientists, health promotion and public health specialists.

The course provides the theory and application of evidence-based preventive cardiology practice. The programme covers the complete spectrum of preventive cardiology, from the management of patients with established atherosclerotic disease and the relatives of patients with premature atherosclerotic disease, to identifying and managing asymptomatic people, including those with diabetes, who are at high risk of developing cardiovascular disease.

All modules include a taught component which is combined with an online virtual learning environment, enabling students to work flexibly around other commitments.

The PG Dip and MSc programmes additionally include a clinical practice component and a research component. Clinical placements are completed across key areas of preventive cardiology practice such as the MyAction programme (see below) cardiovascular risk reduction clinics, cardiovascular prevention and rehabilitation programmes, diabetes centres and heart failure services. This provides students with the opportunity to be immersed in the practicalities of current service delivery, rather than only learning about theory. The research component provides a strong foundation in practical use of research methods in preventive cardiology, and the translation of research evidence into best practice.

St MaryOur programmes are based at the International Centre for Circulatory Health, at St Mary’s Hospital in Paddington, West London, and are delivered by an interdisciplinary teaching faculty consisting of expert clinicians and researchers in cardiology, nursing, dietetics, physiotherapy, pharmacology and clinical psychology. We also have an expert lecture series allowing our students to interact with leaders in the prevention and management of cardiovascular disease.

The scientific foundation of our programme is lifestyle change (smoking cessation, healthy food choices and physical activity) through behavioural approaches, together with weight management, medical management of blood pressure, blood lipids and blood glucose and use of cardioprotective drug therapies .

All MSc and PG Dip students take our core compulsory module entitled ‘Preventive Cardiology Theory and Practice’ which includes six themes:

  • Cardiovascular risk estimation
  • Smoking cessation
  • Nutrition and weight management
  • Physical activity and exercise
  • Prevention and management of diabetes
  • Medical risk factor management

These themes are then explored in greater detail in specialist optional modules, of which three are taken by both PG Dip and MSc students.

PG Dip and MSc students are also required to take the remaining two core compulsory modules:

  • Reflective clinical practice (clinical placements)
  • Research methods

In addition, MSc students are required to complete an original research project and write a dissertation in the field of preventive cardiology.

Patient Care

The MyAction preventive cardiology programme

The results of the original EUROACTION trial set a new standard for preventive cardiology practice for both hospital and primary care. The principles of the EUROACTION nurse-led, multidisciplinary programme, were embodied in a new service model for the NHS called MyAction which is now being implemented in several Primary Care Trusts in England, and in collaboration with Croi, the heart charity, in Galway, Republic of Ireland. MyAction is a community based preventive cardiology programme which integrates secondary and primary prevention of CVD in one service.  The unique features of this novel programme are: 

  • community location
  • nurse prescriber led
  • multidisciplinary (including dieticians, physiotherapists / physical activity specialists)
  • family based
  • providing integrated care for both coronary patients and those at high risk of developing the disease in the same facility

The MyAction programme was piloted in Beckenham Leisure Centre, in the borough of Bromley, in South East London, and is currently running in NHS Westminster, which is our showcase of programmes, in NHS Heart of Birmingham, and in Galway, Republic of Ireland. This unique programme measures patient and partner end of programme and one year outcomes, and in some programmes is excelling the lifestyle and risk factor outcomes of the original EUROACTION trial.

Academic collaborators and investigators:

Academic Collaborators

Diabetes Centre
Professor Lars Ryden, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Professor Jaako Tuomilehto, Department of Chronic Disease Prevention, University Helsinki, Helsinki, Finland and Professor Oliver Schnell, Forschergruppe Diabetes e.V., Diabetes Research Group, Neuherberg, Germany.

Data Management Centre
Dr Cyril Moulin, Scientific Director, European Society of Cardiology, EuroObservational Research Programme Department, at the European Heart House, Sophia Antipolis, Nice, France

Central Laboratory
Dr Jouko Sundvall, Laboratory of Analytical Biochemistry, National Public Health Institute, Helsinki, Finland.

Statistical Centres
Professor Dirk De Bacquer, Professor of Medical Statistics, Department of Public Health, University of Ghent, Ghent, Belgium and Professor Stuart Pocock, Professor of Medical Statistics, London School of Hygiene and Tropical Medicine, University of London, London

Health Economics Centre
Professor Leven Annemans, University of Ghent, Ghent, Belgium

Principal Investigators

EUROACTION plus Varenicline Trial


Central Team

Dr Kornelia Kotseva, Catriona Jennings, Jenni Jones, Alison Mead, Agnieszka Adamska, Jake Winnicki, Magda Kudyba, Raunaque Hasnat, Ahmadur Rahman from Imperial College London; Shauna Raugust from Imperial College NHS Trust; Dr Anne Majumdar from London Metropolitan University and Mark Alston

Smoking cessation specialists
Professor Peter Hajek and Ronnie Troughton from Queen Mary, University of London; and Dr Serena Tonstad from Oslo University Hospital, Oslo, Norway.

Statistical Support
Professor Dirk De Bacquer from Ghent University, Ghent, Belgium; Tim Collier and Elizabeth Turner from London School of Hygiene and Tropical Medicine

UK staff and practices
Tracey Nolan, Rosie Dada, Sharon Craft, Vicky Studd, Gurpreet Singh Matharu, Michaela Nuttall and Home Visits Nursing Team, Practices in the London Borough of Bromley, South East London

Dr Mike Harrison and Mrs Susan Reeves at Elm House Surgery, Dr Raj Purwar at Eden Park Surgery, Dr Ray Vella at Manor Rd Surgery, Dr Margaret Fagbohun at The Park Practice, Dr Adelaja Mustapha at Wickham Park Surgery, Dr Sittambalam Rajasundaram and Mrs Linda Lugg at Bromley Park Practice, Dr Ellis at London Lane Practice

The Netherlands
Professor Arno Hoes, Dr Monika Hollander (MD, PhD), Dr Frans Rutten (MD PhD), Marieke van Gemert (MD), Judith Lurvink, Diana de Wit, Eveline Fassaert, Brenda Baar, Manon de Leeuw, Simone Sluis, Manon Mees Geesteranus, Margreet van Bemmel, Drs. Eugen Zuiderwijk (MD) (GP from Maarssenbroek)

Practices from Leidsche Rijn Julius Gezondheidscentra: Parkwijk, Terwijde, Vleuterweide and Veldhuizen

Practice from Gezondheidscentra Maarssenbroek: Boomstede

Spain
Professor Jose de Velasco, Dr Jorge Navarro, Dr Rosario Gonzalez, Dr Amparo Soriano, Dr Pilar Roca, Vanessa Priego, Cristina Tirado, Clara Bisquert Lloret, Silvia Gimeno Martos

Centro de Salud Republica Argentina, Salvador Pau, Centro de Salud Chile, Centro de Salud Trafalgar and Centro de Salud Serrería 2

Italy
Professor Silvio Brusaferro, Prof Paolo Fioretti, Luigi Castriotta, Dr Fabrizio Gangi, Tilla Gurisatti, Sabrina Scotti, Associazione Medica

EUROASPIRE IV

National Co-ordinators:

  • Belgium Professor Dirk de Bacquer and Professor Johan De Sutter  
  • Bulgaria Professor Nina Gotcheva
  • Croatia Professor Željko Reiner
  • Cyprus  Dr Evagoras Nicolaides
  • The Czech Republic Dr Jan Bruthans and Professor Renata Cifkova
  • Finland Dr Seppo Lehto
  • France Professor Philippe Amouyel
  • Germany Professor Peter Heuschmann and Professor Stefan Störk
  • Greece Professor Ioannis Goudevenos
  • Hungary Professor Andras Janosi
  • Ireland Dr David Moore
  • Italy Dr Diego Vanuzzo
  • Latvia Professor Andrejs Erglis
  • Lithuania Professor Aleksandras Laucevicius      
  • The Netherlands Professor W. Jaap Deckers 
  • Poland Professor Andrzej Pajak
  • Romania Professor Dan Gaita
  • Russia Professor Rafael Ogano and Professor Goar Pogosova
  • Serbia Professor Dragan Lovic 
  • Slovenia Professor Zlatko Fras
  • Spain Dr Almudena CatroConde
  • Sweden Dr Martin Stagmo and Dr Viveca Gyberg (Primary Care Lead)
  • Turkey Professor Lâle Tokgözoğlu
  • UK David Wood (Project Co-ordinator)
  • Ukraine Professor Maryna Dolzhenko
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