Disease management programme for secondary prevention of
coronary heart disease and heart failure in primary care: a
cluster randomised controlled trial
Kamlesh Khunti, Margaret Stone, Sanjoy Paul, Jan Baines, Louise Gisborne, Azhar Farooqi, Xiujie
Luan, Iain Squire
............................................................... ............................................................... .....
See end of article for
Dr Kamlesh Khunti,
Department of Health
Sciences (General Practice &
PHC), University of Leicester,
Leicester General Hospital,
Gwendolen Road, Leicester
LE5 4PW, UK;
Accepted 2 January 2007
Published Online First
16 February 2007
Heart 2007;93:1398–1405. doi: 10.1136/hrt.2006.106955
Aims: To evaluate the effect of a disease management programme for patients with coronary heart disease
(CHD) and chronic heart failure (CHF) in primary care.
Methods: A cluster randomised controlled trial of 1316 patients with CHD and CHF from 20 primary care
practices in the UK was carried out. Care in the intervention practices was delivered by specialist nurses
trained in the management of patients with CHD and CHF. Usual care was delivered by the primary
healthcare team in the control practices.
Results: At follow up, significantly more patients with a history of myocardial infarction in the intervention
group were prescribed a beta-blocker compared to the control group (adjusted OR 1.43, 95% CI 1.19 to
1.99). Significantly more patients with CHD in the intervention group had adequate management of their
blood pressure (,140/85 mm Hg) (OR 1.61, 95% CI 1.22 to 2.13) and their cholesterol (,5 mmol/l) (OR
1.58, 95% CI 1.05 to 2.37) compared to those in the control group. Significantly more patients with an
unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed (OR 4.69,
95% CI 1.88 to 11.66) or excluded (OR 3.80, 95% CI 1.50 to 9.64) in the intervention group compared to the
control group. There were significant improvements in some quality-of-life measures in patients with CHD in
the intervention group.
Conclusions: Disease management programmes can lead to improvements in the care of patients with CHD
and presumed CHF in primary care.
countries.1Mortality from cardiovascular disease has declined
over the last 30 years, a trend which has been attributed to
secondary prevention therapies.2 3However, European surveys
have shown considerable potential for improved levels of
secondary preventionin people
Studies in primary care, where most of these patients are
managed, have also reported considerable potential to further
increase secondary prevention through medical and lifestyle
interventions.5 6‘‘Medical’’ measures include aspirin therapy
and blood pressure and lipid control, while ‘‘lifestyle’’ measures
include increased exercise, dietary modification and smoking
cessation.5CHF is also a highly prevalent, chronic condition
with high mortality and morbidity. It is increasing in
prevalence and the public health burden from CHF is therefore
likely to rise substantially over the next 10 years.7The quality of
managed in primary care and five-year survival is worse than for
many malignant conditions.8However, appropriate treatment,
including inhibitors of the renin-angiotensin-aldosterone system
and beta-blockers, has the potential to reduce hospitalisation and
mortality in these patients.9 10The task of implementing a
comprehensive package of effective measures for large numbers
of patients has been described as daunting.5It is therefore
important to develop implementation strategies that are practical
and effective. Many patients with CHF are incorrectly diagnosed
and inadequately treated in primary care11and obstacles to
appropriate primary care management include lack of knowledge,
fear of complications with pharmacological treatments, lack of
time and limited facilities for investigations.12 13
ardiovascular diseases including coronary heart disease
(CHD) and chronic heart failure (CHF) are the main
cause of morbidity and mortality in most European
Systematic reviews indicate that secondary prevention
programmes improve the process of care, reduce admissions
to hospital and enhance quality of life or functional status in
patients with CHD.14Similarly, systematic reviews of disease
management programmes in CHF suggest that specialised,
multidisciplinary follow-up can reduce hospitalisation and may
lead to cost saving.15–17However, all the CHF trials included in
these systematic reviews were conducted in highly specialised
centres and recruited patients following discharge after
hospitalisation. The applicability of the available CHF manage-
ment programmes to countries with a primary care-based
healthcare system has therefore recently been questioned.18
To achieve improved secondary prevention of CHD and CHF,
primary care will need to adopt a systematic approach.
Although disease management clinics for the management of
CHD in primary care can improve patients’ outcomes,5there are
no such studies in the management of patients with CHF. Since
the majority of patients with CHF will also have CHD,19we
investigated the effect of a disease management programme for
patients with either or both conditions in primary care.
Practice recruitment and randomisation
This was a cluster randomised controlled trial with randomisa-
tion at practice level. All primary care practices in one region in
the city of Leicester, UK were invited to participate. A
randomisation procedure based on case-control pairs was
selected to promote similarity between the general practices
included in the two study groups. Twenty volunteer practices
Abbreviations: CHD, coronary heart disease; CHF, chronic heart failure;
NNT, numbers needed to treat
the Southampton heart integrated care project (SHIP). The SHIP Collaborative
Group. BMJ 1999;318:706–11.
36 Galbreath AD, Krasuski RA, Smith B, et al. Long-term healthcare and cost
outcomes of disease management in a large, randomized, community-based
population with heart failure. Circulation 2004;110:3518–26.
37 McAlister FA, Murphy NF, Simpson CR, et al. Influence of socioeconomic
deprivation on the primary care burden and treatment of patients with a
diagnosis of heart failure in general practice in Scotland: population based study.
38 Komajda M, Follath F, Swedberg K, et al. The EuroHeart Failure survey
programme: A survey on the quality of care among patients with heart failure in
Europe. Part 2: Treatment. Eur Heart J 2003;24:464–74.
39 Ekman I, Andersson B, Ehnfors M, et al. Feasibility of a nurse-monitored,
outpatient-care programme for elderly patients with moderate-to-severe, chronic
heart failure. Eur Heart J 1998;19:1254–60.
40 Mejhert M, Kahan T, Persson H, et al. Limited long term effects of a management
programme for heart failure. Heart 2004;90:1010–5.
41 Doughty RN, Wright SP, Pearl A, et al. Randomized, controlled trial of integrated
heart failure management: The Auckland Heart Failure Management Study. Eur
Heart J 2002;23:139–46.
42 Stromberg A, Martensson J, Fridlund B, et al. Nurse-led heart failure clinics in
Sweden. Eur J Heart Fail 2001;3:139–44.
43 Krumholz HMM, AHA/ACC Conference. Evaluating quality of care for patients
with heart failure. Circulation 2000;101:e122–40.
IMAGES IN CARDIOLOGY ............................................................... .................
Severe coronary luminal narrowing ascribed to aortic intramural haematoma after valve surgery
stenosis. A tricuspid annuloplasty and
closure of an ostium secundum atrial
septal defect were also performed. The
preoperative electrocardiogram showed a
left bundle branch block. There were no
significant alterations in the coronary
drugs was 65 mm Hg. The angiogram
63-year-old man underwent an aor-
tic valve replacement (Carbomedics
Top Hat No 23) for a severe aortic
angiogram. A dominant right coronary
artery was seen. While the patient was
coming off the pump he presented severe
haemodynamic instability and diffuse ST
segment alterations (panel A). Trans-
Systolic blood pressure with inotropic
showed luminal narrowing of the ostium
of the right coronary artery (arrow) with
aortic wall deformation (panel B) and a
double-border spot (panel C) on the
aortic wall. These abnormalities were
ascribed to the indentation caused by a
periprosthetic intramural haematoma. No
‘‘flap’’ was detected in the aortography.
To widen the coronary lumen and to
avoid progression of the haematoma,
which might lead to potential occlusion
of the ostium, a non-drug-eluting stent
with a diameter of 4.0 mm and length of
15 mm was implanted. The blood pres-
sure and electrocardiographic changes
improved (panel D) after stent implanta-
tion and the patient was successfully
extubated 8 hours later.
V Marti, P Paniagua, A Ginel
Secondary prevention of coronary heart disease and heart failure 1405