Online treatment beneficial to heart disease patients

Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial

J W P Vernooij, H A H Kaasjager, Y van der Graaf, et al., on behalf of the SMART study group
BMJ 2012; 344 doi: 10.1136/bmj.e3750

Background

Patients with vascular disease are at higher risk of suffering a further event or death [1].  Vascular risk can be effectively reduced by treating hypertension, reducing LDL-c, using platelet inhibitors, controlling weight, stopping smoking, and increasing physical exercise [2-5]. However, treatment goals are often not reached in daily clinical practice.
Treatment of vascular risk factors by nurse practitioners is proven to be very effective in reducing this risk [6,7] although treatment goals are often not reached and it is costly and time-consuming. Previous studies did not show clear beneficial effects.
This study looks at one year effect in a relatively large group of patients. 330 patients with a recent manifestation of atherosclerosis (MI, stroke, or peripheral arterial disease) and at least two treatable risk factors not at goal were randomized to the online intervention for 12 months on top of usual care or to usual care only. The internet-based programme included a personalised website, mail communication via the website with a nurse practitioner, self-management support, monitoring of disease control and pharmacotherapy. The primary end point of the study was the relative change in Framingham risk score (FRS) after one year.

Main results

• The relative change in Framingham risk score (FRS) after one year was -14% in the intervention group compared with the usual-care group (significant).
• After adjustment for the separate variables of the FRS and for the baseline FRS, the difference was -12% (significant) and -8% (not significant), respectively.
• Participants showed improvement in smoking (8 smokers stopped compared to 4 starting in usual care group), BMI, blood pressure and renal function.

Conclusion

An internet-based nurse-led vascular prevention programme, on top of usual care, may help reduce long term risk of vascular event or death.

Author’s comments

The effect on Framingham Risk Score represents a small effect, but the intervention is easy to implement at low cost and could be used for various groups of patients at high CV risk. The FRS is not the best tool for estimating risk in this patient group, having been designed for those without CV disease. A new risk score is developed for those with vascular disease to be published in the near future.

References

1. Kannel WB. Overview of atherosclerosis. Clin Ther1998;20(suppl B):B2-17.
2. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ2002;324:71-86.
3. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet2005;366:1267-78.CrossRefMedlineWeb of Science
4. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med2000;342:145-53.
5. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med2008;358:580-91.
6. Goessens BM, Visseren FL, Sol BG, de Man-van Ginkel JM, van der Graaf Y. A randomized, controlled trial for risk factor reduction in patients with symptomatic vascular disease: the multidisciplinary Vascular Prevention by Nurses Study (VENUS). Eur J Cardiovasc Prev Rehabil2006;13:996-1003.
7. Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. BMJ2003;326:84.

Abstract

Objective
To investigate whether an internet based, nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinically manifest vascular disease.

Design
Prospective randomised controlled trial.
Setting
Multicentre trial in secondary and tertiary healthcare setting.
Participants 330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with at least two treatable risk factors not at goal.
Intervention Personalised website with an overview and actual status of patients’ risk factors and mail communication via the website with a nurse practitioner for 12 months; the intervention combined self management support, monitoring of disease control, and drug treatment.

Main outcome measures
The primary endpoint was the relative change in Framingham heart risk score after 1 year. Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor.

Results
Participants’ mean age was 59.9 (SD 8.4) years, and most patients (n=246; 75%) were male. After 1 year, the relative change in Framingham heart risk score of the intervention group compared with the usual care group was −14% (95% confidence interval −25% to −2%). At baseline, the Framingham heart risk score was higher in the intervention group than in the usual care group (16.1 (SD 10.6) v 14.0 (10.5)), so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score. This produced a relative change of −12% (−22% to −3%) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and −8% (−18% to 2%) adjusted for the baseline score. Of the individual risk factors, a difference between groups was observed in low density lipoprotein cholesterol (−0.3, −0.5 to −0.1, mmol/L) and smoking (−7.7%, −14.9% to −0.4%). Some other risk factors tended to improve (body mass index, triglycerides, systolic blood pressure, renal function) or tended to worsen (glucose concentration, albuminuria).

Conclusion
 An internet based, nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease.