Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care

Editor - Despite excellent data supporting the benefits
of secondary prevention in patients with ischaemic
heart disease (IHD), in clinical practice it remains far
from optimal. In an attempt to improve this within
primary care, Moher et al. evaluated the effects of
setting up a practice register of eligible patients and
arranging systematic recall to see either the general
practitioner or practice nurse . Whilst they confirmed an
increase in follow-up and assessment this
unfortunately did not translate into optimal patient care.

This deficit in secondary prevention is not restricted to
primary care. In 1995 the ASPIRE study revealed that
both risk factor recording and subsequent control were
inadequate in IHD patients in district hospitals within
the United Kingdom . A recent European study has
confirmed that this shortfall remains . Therefore
significant potential still exists to reduce mortality and
morbidity in this large group of patients.

Emphasis on evidence-based medicine and clinical
governance has led to the development of Clinical Care
Pathways, where guidelines encourage appropriate
documentation and suggest treatment regimes. We
have recently shown that the introduction of a
Myocardial Infarction Care Pathway can contribute to
improved clinical care . We assessed 50 consecutive
patients with acute myocardial infarction, 25 constituted
the pre-Care Pathway group and 25 the Care Pathway
group. Risk factor documentation was similar between
groups, varying between 66% for
hypercholesterolaemia and 94% for a family history of
IHD (combined data). At presentation in the pre-Care
Pathway group 88% of the subjects had blood
cholesterol measured and 76% blood glucose.
Although these figures increased to 100% and 92%
respectively, within the Care-Pathway group, the
difference was not significant. The use of intravenous
insulin in patients presenting with blood glucose
>11mmol/L was increased within the Care-Pathway
group (p=0.048). Furthermore, introduction of the Care
Pathway led to enhanced use of
angiotensin-converting-enzyme inhibitors (18/25 vs
7/25, p=0.004). Of additional importance the majority
of patients in both groups were still receiving their
discharge medication at 6-month follow-up (aspirin
98%, angiotensin-converting-enzyme inhibitors 91%,
beta-blockers 87%).

Whilst an improvement was seen in this study
shortcomings still exist and further ways of
implementing secondary prevention need to be sought.
However, our study exemplifies the need to initiate
secondary prevention at the time of presentation, since
once implemented it appears to be continued. Whether
similar pathways can improve the management of all
patients with IHD remains to be seen.

PR Kalra(1), A Jones(2), MD Thomas(1), RS More(3), J
Watkins(3)

1 National Heart and Lung Institute, Imperial College
School of Medicine, Dovehouse Street, London. SW3
6LY

2 Centre For Cardiovascular Genetics, The Rayne
Institute, London

3 Department of Cardiology, Portsmouth NHS Trust, St.
Mary’s Hospital, Milton Road, Portsmouth. PO3 6AD

Correspondence to:

Dr Paul Kalra
Cardiology Research Fellow
National Heart and Lung Institute
Dovehouse Street
London
SW3 6LY
Tel: 0207 351 8513
Fax: 0207 351 8733
Email: p.kalra@ic.ac.uk

Competing interests: None

1. Moher M, Yudkin P, Wright L, Turner R, Fuller A,
Schofield T, et al. Cluster randomised controlled trial to
compare three methods of promoting secondary
prevention of coronary heart disease in primary care.
BMJ 2001;322:1338-1342

2. ASPIRE Steering Group. A British Cardiac Society
survey of the potential for the secondary prevention of
coronary disease: ASPIRE (Action on Secondary
Prevention through Intervention to Reduce Events).
Heart 1996;75:334-342

3. EUROASPIRE II Study Group. Lifestyle and risk factor
management and use of drug therapies in coronary
patients from 15 counties. Principal results from
EUROASPIRE II Euro Heart Survey Programme. Eur
Heart J 2001;22:554-572

4. Kalra P, Jones A, Thomas MD, More RS, Watkins J.
Improved secondary prevention following the
introduction of a myocardial infarction care pathway.
Clin Sci 2000;99 (suppl 43):14p