Nurse-coordinated care improves the achievement of LDL cholesterol targets through more intensive medication titration

Abstract

BackgroundNurse-coordinated care (NCC) improves the achievement of low-density lipoprotein-cholesterol (LDL-C) targets after an acute coronary syndrome (ACS). We hypothesised that NCC improves achievement of LDL-C targets through more intensive medication titration.MethodsWe used data from Randomised Evaluation of Secondary Prevention by Outpatient Nurse Specialists (RESPONSE), a multicentre randomised trial on the efficacy of NCC in 754 ACS patients. Follow-up data were collected at 6 and 12 months. To enable comparison between the various types and dosages of statins, we used the average lipid-lowering potency (ALLP, % LDL-C lowering) as an indicator of lipid-lowering medication intensity.ResultsMost patients in NCC intervention and usual care groups (96%) had started lipid-lowering therapy during the index hospitalisation. At 6 months, titration activities (up or down) were applied in 45% of NCC patients compared with 24% of patients receiving usual care (p<0.001), and a difference was also seen at 12 months follow-up (52% vs 34%, p<0.001). In patients not on LDL-C target at baseline, titration activities at 6 months were recorded in 63% and 30% of NCC and usual care patients respectively (p<0.001), with increased titration activities in both groups at 12 months (69% vs 43%, p<0.001).ConclusionNCC is associated with more frequent and intense lipid-lowering medication titration to reach LDL-C targets as compared with usual care alone. Further, merely starting the guideline-recommended dose is insufficient to reach the guideline-recommended LDL-C target level.Trial Registration numberTC1290 (Netherlands).

Efficacy of a nurse-led lipid-lowering secondary prevention intervention in patients hospitalized for ischemic heart disease: A pilot randomized controlled trial

“…Our results are consistent with those from prior studies assessing the efficacy of nurse-led cardiovascular risk reduction programs in patients with IHD. In the Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists (RESPONSE) trial, 20,21 which included 754 patients from The Netherlands admitted for an acute coronary syndrome and exposed to a nurse-coordinated secondary prevention intervention (comprising 4 outpatient clinic visits to a cardiovascular nurse focused on healthy lifestyle recommendations, improvement of biometric risk factors and of medication adherence, and in which medication adjustment was conducted when necessary), there was a significant improvement in overall cardiovascular risk factor control, in 10-year estimated CVD death risk after 12 months, and in re-hospitalizations among individuals exposed to the intervention as compared to those in the standard care arm.…”

“…Our results are consistent with those from prior studies assessing the efficacy of nurse-led cardiovascular risk reduction programmes in patients with IHD. In the Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists (RESPONSE) trial, 19,20 which included 754 patients from The Netherlands admitted for an acute coronary syndrome and exposed to a nurse-coordinated secondary prevention intervention (comprising four outpatient clinic visits to a cardiovascular nurse focused on healthy lifestyle recommendations, improvement of biometric risk factors and of medication adherence, and in which medication adjustment was conducted when necessary), there was a significant improvement in overall cardiovascular risk factor control, in 10-year estimated cardiovascular disease death risk after 12 months, and in re-hospitalizations among individuals exposed to the intervention as compared with those in the usual care arm. Specifically regarding LDL cholesterol, although study nurses had been trained and were highly confident about their ability to achieve drug-related treatment targets, 21 differences between the two study arms were smaller than in our study, with a target of LDL cholesterol <2.5 mmol/L (≈100 mg/dL) being achieved in 80% of patients in the intervention arm compared with 69% in the usual care arm (as compared with 97% and 67%, respectively, in our study).…”

The scientific basis for secondary prevention of coronary artery disease: recent contributions from the Netherlands

“…At 12-months follow-up, the estimated overall impact on cardiovascular risk was a 17% relative reduction in patients in the intervention group as compared with patients receiving only usual care ( p = 0.021). This difference was largely driven by intensified medication titration [ 10 ], with better treatment to target levels for LDL cholesterol and blood pressure. This was associated with slight increases in health-related quality of life, and a reduction in depressive symptoms in patients randomised to the nurse-coordinated program [ 11 ].…”

Perfil metabólico y uso de terapia hipolipemiante en pacientes durante y post síndrome coronario agudo: evaluación de resultados y adherencia a guías de práctica clínica a mediano plazo en el Instituto Nacional Cardiovascular (INCOR)

“…En un estudio dirigido a evaluar los factores asociados con alcanzar o no este objetivo de cLDL después de 6 meses en pacientes con SCA, se encontró que la terapia previa con estatinas demostró una asociación independiente significativa con el logro de la meta de cLDL (OR 0.21: 0.08-0,79, p 0,008) [31]. Además, se ha demostrado que la persistencia y la adherencia al tratamiento con estatinas se encuentran entre los predictores más importantes del éxito terapéutico tras un SCA [32].…”