Treat the heart holistically

Treating cardiovascular diseases and the risks of suffering heart problems should be liberated from isolated health silos, writes Joshi Herrmann


How possible is it to deliver the government’s aim of treating cardiovascular diseases as a “single family”? That is the big question of the moment and, for Professor David Wood at Imperial College London, the answer is an emphatic “very possible”.

For Professor Wood, the recent strategy document from the Department of Health was both a personal fillip and a cause for optimism.

He is the clinical lead for a trailblazing programme called MyAction, which launched in 2009 and is available to those Westminster residents who have a one-in-five chance of developing a cardiovascular condition or provides aftercare for heart patients after their discharge from hospital.

“Saying that we should treat cardiovascular diseases as a family of diseases with common antecedents means that we take a holistic view rather than the silos of care which are operating now,” he says, and MyAction has shown the feasibility of such an approach.

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After a Europe-wide study, published in The Lancet, showed that a “more modern approach” of a nurse-led, multidisciplinary programme could bring about real lifestyle change and effective risk factor management, Professor Wood took things a step further. He located MyAction, which combines primary and secondary prevention, in the community – in leisure centres.

“That’s where we assess patients’ lifestyle, and monitor and manage the other risk factors, all in one programme,” he says. Participants are given health advice by a team of professionals, including a nurse, a dietician and a specialist in physical activity, who then produce a tailored programme.

Professor Wood, who is Garfield Weston professor of cardiovascular medicine at Imperial and honorary consultant cardiologist to Imperial College Healthcare NHS Trust, explains the realignment of services MyAction has involved.

“At the moment, someone presenting with high cardiovascular risk, identified through a health check, could be referred to a smoking cessation service, to a weight management programme, to exercise on prescription, to a hypertension clinic to manage their blood pressure, to a lipid clinic to manage their lipids – and sending people to all these silos of care is an absolute waste of money. What these patients require is a service that addresses all aspects of cardiovascular risk.”

What these patients require is a service that addresses all aspects of cardiovascular risk

Early results from MyAction have been promising, with 60 per cent of participants taking part in regular physical activity and 80 per cent reducing their blood pressure and blood lipid level.

NHS Westminster, which commissioned the programme, made increased uptake among black and minority ethnic groups in deprived areas a particular priority. And MyAction seems to be succeeding as half of the patients joining the programme have been from minority ethnic backgrounds. Also, whereas the uptake of cardiac rehabilitation offered to the post-surgical population is about 44 per cent of all eligible patients nationally, “what we are achieving in MyAction is between 70 and 80 per cent, so almost double that of the national average”, says Professor Wood.

If radically integrated and holistic community care is one promising avenue for improving cardiovascular outcomes, another is the use of telemedicine. The first European conference on eHealth and telemedicine in cardiovascular prevention and rehabilitation took place in July, and signalled the growing enthusiasm for using technology to remotely assess acute patients and monitor those living with heart conditions.

For example, Scotland’s Centre for Telehealth and Telecare has broadened its remit from dealing only with acute stroke to include heart disease. NHS Fife have trialled a home monitoring telehealth system that feeds back a patient’s weight and questionnaire answers to specialist nurses. The trial reduced admissions among a group of 22 patients from 127 bed days in a year before using the system to just 12 in the average 4.5 months after and garnered positive feedback from patients.

Paul Davies, a consultant at North Cumbria University Hospitals NHS Trust, led the successful telestroke network for Cumbria and Lancashire NHS, an area where transporting a patient to a specialist in less than half an hour is often difficult.

Telestroke, which is now used widely in the UK, allows a consultant working at a hub hospital to view the CT scan of a patient at a different hospital remotely via video link and come to a view on the severity of the stroke.

Dr Davies says telemedicine’s role in cardiovascular care is about “doing things more locally and using the technology to transport the expert to the patient rather than moving the patient to the expert all the time”. It allows a previously unachievable pooling of resources: in Cumbria and Lancashire 15 consultants can cover on a rota covering nine sites, spread as far apart as Southport and Carlisle.

While stroke assessment is particularly suited to video-link because it is very visual, Dr Davies thinks similar telemedicine systems can also help reduce non-acute hospital visits from an ageing population who present for treatment when they have had a slow decline in one of their long-term cardiovascular conditions. “With somebody, who may be accumulating fluids with heart failure over days or weeks, you may be able to prevent that kind of admission at an earlier stage,” he says.

Using telemedicine to tackle cardiovascular diseases isn’t a cheap option, but those who have used it point to longer-term savings. Modelling done by Cumbria and Lancashire NHS forecasts that telestroke could save them £2.03 million over a decade because of the reduction in dependent patients it delivers.

Integrated programmes, such as MyAction, on the other hand are less about spending big money than realigning the services and people already working in smoking cessation, alcohol help and traditional post-acute rehabilitation.

A health economics analysis of MyAction will report in October, but Professor Wood says the changes that need to be made have more to do with using the NHS’s highly skilled people in more intelligent and efficient ways. “I think the key to achieving the aspiration [of integrated care] is reconfiguration of services,” he says, “so using staff in a very different way to deliver more effective care.”