- Email: [email protected]
Secondary Prevention: Why Does it Seem to be so Hard?
EDITORIAL
Editorial
Secondary Prevention: Why Does it Seem to be so Hard? Richmond W. Jeremy, PhD, FRACP, FCSANZ, Editor-in-Chief Room 203, Medical Foundation Building K25, University of Sydney, Sydney, NSW 2006, Australia
I
f one were to ask the average passer-by in the street whether they thought a healthy lifestyle or regular exercise was important, the almost universal answer would be in the affirmative. If one were to ask the same passerby what they considered a healthy lifestyle, or how much physical exercise they undertook, then one might get an answer very different from one’s expectations. This is the problem highlighted by Murphy et al. [1] in this issue of the journal. The authors report follow-up of 275 patients at six weeks after hospital admission for ischaemic heart disease, including myocardial infarction, coronary artery bypass grafting or percutaneous coronary intervention. Amongst these patients, 70% were above treatment target for waist girth and 48% above treatment target for blood pressure, whilst 27% did not achieve treatment targets for total cholesterol level or for physical exercise levels. Before asking what we might do to address this problem, we should perhaps look more closely at the current report. The patient cohort is small, being only 275 out of 787 eligible patients and the authors rightly note that extrapolation of their findings to a larger or different population may be problematic. Nonetheless, their findings are broadly consonant with those of larger European [2] and Australian [3] studies of cardiovascular disease prevention. Similarly, treatment targets for cholesterol and blood pressure were met in less than 50% of post-infarction patients in a South Wales population [4], whilst recent data again highlights the difficulties of ensuring patient adherence to secondary preventive medications, including antihypertensive agents, after stroke [5]. The reader may well have some questions of the report by Murphy et al. Was six weeks a long enough interval to expect a significant reduction in waist girth or would a E-mail address: [email protected]
more realistic time frame have been 12 months? Although the proportion of patients not reaching treatment targets is presented, the authors do not provide further information about how far the non-compliers deviated from the desired treatment target. This is key information in defining the real magnitude of the treatment gap. Another key question is what change in patient behaviour or lifestyle occurred during the six weeks between hospitalisation and follow-up. Although some patients may not have reached treatment targets at six weeks, they may have already made significant progress and be well upon the way to reaching the targets. Finally, it is perhaps a little unfair to criticise failure to reach desired HDL levels, given the real difficulty in altering HDL levels in those individuals with very low HDL, who are at some of the greatest risk of cardiovascular disease. The real situation may not therefore be quite as bleak as it first appears, but a more complete appreciation of the magnitude of the problem requires answers to these questions. Nonetheless, if we accept the argument that a real gap exists between desired treatment targets and actual achieved outcomes, we must ask about the origins of this gap. The authors identify some possibilities, including patient perceptions about different revascularisation procedures. The real key lies in understanding patient perceptions about their own health and addressing the dissociation between their knowledge of general public health matters and the application of that knowledge to their particular personal circumstance. Effective secondary prevention begins at the time of the acute cardiac event and has its foundations in the patient’s illness perception. Those patients who are reflective, can accept cardiovascular disease as a chronic illness and can identify ways in which they can influence their future health are very different from the non-reflective individual who sees the illness as an acute event, to be put behind them and one which they would rather not think about [6]. The compliance of these groups with secondary prevention will be quite different. An informed approach to promoting constructive illness perception in hospital is critical. All too often, patients think of coronary artery disease as something that can be cured or made to go away. It is probably a mistake for attending physicians and surgeons to tell patients they are “all fixed now”, “won’t have angina again” or that
© 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2011.05.001
424
Jeremy Secondary Prevention: Why Does it Seem to be so Hard?
EDITORIAL
“we’ve dealt with it and got a beautiful result”. Whilst these statements can superficially make the patient (and the doctor) feel good, they are not aligned with the true nature of coronary artery disease. It is important that patients have a clear understanding of the lifelong nature of coronary disease, its exacerbations and remissions and the fact that a current acute situation has been remedied is not a guarantee of a trouble-free future. In addition, targeted intervention programs, designed to support constructive illness perception can improve patient outcomes and quality of life after hospital discharge [7]. Unfortunately, with time after the acute event, patients tend to forget key information about cardiovascular health and prevention [8], highlighting the need for coherent followup and reinforcement of treatment targets. The time of hospital admission is a key opportunity to engage the patient in addressing difficult matters such as weight loss. There is evidence that a medical trigger, such as myocardial infarction, increases a patient’s receptiveness to educational material about weight loss and is associated with more effective long-term maintenance of weight [9]. These initiatives require time and engagement with the patient, whilst they are in hospital. There is an element of relationship building with the patient, which must carry over into their outpatient care, if these long term objectives are to be realised. It is not enough to simply give the patient a load of information when they are in hospital and then give them bald instructions about weight loss and lifestyle. Few will take in all the information and even fewer will really respond to this sort of approach. One can look at the data of Murphy et al. in another way. Perhaps the real message should not be disappointment in how many patients fail to reach treatment targets, but surprise at how many actually do achieve the targets in a medical system, which is under pressure to deal with people as quickly as possible and get them out of hospital as quickly
Heart, Lung and Circulation 2011;20:423–424
as possible. In some ways, we may actually be victims of our own success, or perhaps we are just shooting ourselves in the foot.
References [1] Murphy BM, Worcester MU, Goble AJ, Mitchell F, Navaratnam H, Higgins RO, et al. Lifestyle and physiological risk factor profiles six weeks after an acute cardiac event: are patients achieving recommended targets for secondary prevention? Heart Lung Circ 2011;20:446–51. [2] Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U. 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. [3] Reid C, Nelson MR, Shiel L, Chew D, Connor G, DeLooze F. Australians at risk: management of cardiovascular risk factors in the REACH registry. Heart Lung Circ 2007;17:114–8. [4] Underwood P, Beck P. Secondary prevention following myocardial infarction: evidence from an audit in South Wales that the National Service Framework for coronary heart disease does not address all the issues. Qual Saf Health Care 2002;11:230–2. [5] Lager K, Mistri AK. Current status of blood pressure management after stroke. Expert Rev Cardiovasc Ther 2010;8:1587–98. [6] Alsen P, Brink E, Persson LO. Patients illness perception four months after a myocardial infarction. J Clin Nurs 2008;17:25–33. [7] Petrie KJ, Cameron LD, Ellis CJ, Buick D, Weinman J. Changing illness perceptions after myocardial infarction; an early intervention randomized controlled trial. Psychosom Med 2002;64:580–6. [8] Rahe RH, Ward HW, Hayes V. Brief group therapy in myocardial infarction rehabilitation: three to four-year follow-up of a controlled trial. Psychosom Med 1979;41:229–42. [9] Gorin AA, Phelan S, Hill JO, Wing RR. Medical triggers are associated with better short- and long-term weight-loss outcomes. Prev Med 2004;39:612–6.
Editorial
Secondary Prevention: Why Does it Seem to be so Hard? Richmond W. Jeremy, PhD, FRACP, FCSANZ, Editor-in-Chief Room 203, Medical Foundation Building K25, University of Sydney, Sydney, NSW 2006, Australia
I
f one were to ask the average passer-by in the street whether they thought a healthy lifestyle or regular exercise was important, the almost universal answer would be in the affirmative. If one were to ask the same passerby what they considered a healthy lifestyle, or how much physical exercise they undertook, then one might get an answer very different from one’s expectations. This is the problem highlighted by Murphy et al. [1] in this issue of the journal. The authors report follow-up of 275 patients at six weeks after hospital admission for ischaemic heart disease, including myocardial infarction, coronary artery bypass grafting or percutaneous coronary intervention. Amongst these patients, 70% were above treatment target for waist girth and 48% above treatment target for blood pressure, whilst 27% did not achieve treatment targets for total cholesterol level or for physical exercise levels. Before asking what we might do to address this problem, we should perhaps look more closely at the current report. The patient cohort is small, being only 275 out of 787 eligible patients and the authors rightly note that extrapolation of their findings to a larger or different population may be problematic. Nonetheless, their findings are broadly consonant with those of larger European [2] and Australian [3] studies of cardiovascular disease prevention. Similarly, treatment targets for cholesterol and blood pressure were met in less than 50% of post-infarction patients in a South Wales population [4], whilst recent data again highlights the difficulties of ensuring patient adherence to secondary preventive medications, including antihypertensive agents, after stroke [5]. The reader may well have some questions of the report by Murphy et al. Was six weeks a long enough interval to expect a significant reduction in waist girth or would a E-mail address: [email protected]
more realistic time frame have been 12 months? Although the proportion of patients not reaching treatment targets is presented, the authors do not provide further information about how far the non-compliers deviated from the desired treatment target. This is key information in defining the real magnitude of the treatment gap. Another key question is what change in patient behaviour or lifestyle occurred during the six weeks between hospitalisation and follow-up. Although some patients may not have reached treatment targets at six weeks, they may have already made significant progress and be well upon the way to reaching the targets. Finally, it is perhaps a little unfair to criticise failure to reach desired HDL levels, given the real difficulty in altering HDL levels in those individuals with very low HDL, who are at some of the greatest risk of cardiovascular disease. The real situation may not therefore be quite as bleak as it first appears, but a more complete appreciation of the magnitude of the problem requires answers to these questions. Nonetheless, if we accept the argument that a real gap exists between desired treatment targets and actual achieved outcomes, we must ask about the origins of this gap. The authors identify some possibilities, including patient perceptions about different revascularisation procedures. The real key lies in understanding patient perceptions about their own health and addressing the dissociation between their knowledge of general public health matters and the application of that knowledge to their particular personal circumstance. Effective secondary prevention begins at the time of the acute cardiac event and has its foundations in the patient’s illness perception. Those patients who are reflective, can accept cardiovascular disease as a chronic illness and can identify ways in which they can influence their future health are very different from the non-reflective individual who sees the illness as an acute event, to be put behind them and one which they would rather not think about [6]. The compliance of these groups with secondary prevention will be quite different. An informed approach to promoting constructive illness perception in hospital is critical. All too often, patients think of coronary artery disease as something that can be cured or made to go away. It is probably a mistake for attending physicians and surgeons to tell patients they are “all fixed now”, “won’t have angina again” or that
© 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2011.05.001
424
Jeremy Secondary Prevention: Why Does it Seem to be so Hard?
EDITORIAL
“we’ve dealt with it and got a beautiful result”. Whilst these statements can superficially make the patient (and the doctor) feel good, they are not aligned with the true nature of coronary artery disease. It is important that patients have a clear understanding of the lifelong nature of coronary disease, its exacerbations and remissions and the fact that a current acute situation has been remedied is not a guarantee of a trouble-free future. In addition, targeted intervention programs, designed to support constructive illness perception can improve patient outcomes and quality of life after hospital discharge [7]. Unfortunately, with time after the acute event, patients tend to forget key information about cardiovascular health and prevention [8], highlighting the need for coherent followup and reinforcement of treatment targets. The time of hospital admission is a key opportunity to engage the patient in addressing difficult matters such as weight loss. There is evidence that a medical trigger, such as myocardial infarction, increases a patient’s receptiveness to educational material about weight loss and is associated with more effective long-term maintenance of weight [9]. These initiatives require time and engagement with the patient, whilst they are in hospital. There is an element of relationship building with the patient, which must carry over into their outpatient care, if these long term objectives are to be realised. It is not enough to simply give the patient a load of information when they are in hospital and then give them bald instructions about weight loss and lifestyle. Few will take in all the information and even fewer will really respond to this sort of approach. One can look at the data of Murphy et al. in another way. Perhaps the real message should not be disappointment in how many patients fail to reach treatment targets, but surprise at how many actually do achieve the targets in a medical system, which is under pressure to deal with people as quickly as possible and get them out of hospital as quickly
Heart, Lung and Circulation 2011;20:423–424
as possible. In some ways, we may actually be victims of our own success, or perhaps we are just shooting ourselves in the foot.
References [1] Murphy BM, Worcester MU, Goble AJ, Mitchell F, Navaratnam H, Higgins RO, et al. Lifestyle and physiological risk factor profiles six weeks after an acute cardiac event: are patients achieving recommended targets for secondary prevention? Heart Lung Circ 2011;20:446–51. [2] Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U. 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. [3] Reid C, Nelson MR, Shiel L, Chew D, Connor G, DeLooze F. Australians at risk: management of cardiovascular risk factors in the REACH registry. Heart Lung Circ 2007;17:114–8. [4] Underwood P, Beck P. Secondary prevention following myocardial infarction: evidence from an audit in South Wales that the National Service Framework for coronary heart disease does not address all the issues. Qual Saf Health Care 2002;11:230–2. [5] Lager K, Mistri AK. Current status of blood pressure management after stroke. Expert Rev Cardiovasc Ther 2010;8:1587–98. [6] Alsen P, Brink E, Persson LO. Patients illness perception four months after a myocardial infarction. J Clin Nurs 2008;17:25–33. [7] Petrie KJ, Cameron LD, Ellis CJ, Buick D, Weinman J. Changing illness perceptions after myocardial infarction; an early intervention randomized controlled trial. Psychosom Med 2002;64:580–6. [8] Rahe RH, Ward HW, Hayes V. Brief group therapy in myocardial infarction rehabilitation: three to four-year follow-up of a controlled trial. Psychosom Med 1979;41:229–42. [9] Gorin AA, Phelan S, Hill JO, Wing RR. Medical triggers are associated with better short- and long-term weight-loss outcomes. Prev Med 2004;39:612–6.