The clinical effectiveness of a novel nurse-led secondary prevention lipid service

Secondary prevention of cardiovascular disease (CVD) is critical to reducing recurrent major adverse cardiovascular events (MACE) and long-term healthcare burden 1. Effective reductions in elevated LDL-cholesterol (LDL-C) has been consistently shown to improve MACE in patients with established atherosclerotic CVD (ASCVD) and is one of the primary treatment goals for its secondary prevention 2, 3. The UK National Institute for Clinical Care and Excellence (NICE) recommends secondary prevention LDL-C treatment target of <2.0mmol/L(4) whereas the European Society of Cardiology Guidelines recommend a LDL_C target of <1.4 mmol/L and a ≥50% reduction from baseline 5. Initiatives designed to improve the delivery of secondary prevention of ASCVD can play a fundamental role in improving lipid lowering and patient outcomes 1, 6. The development of a nurse-led clinic can break down the barriers and improve access to services.

We aimed to assess the efficacy of a novel secondary prevention nurse-led clinic to improve Lipid Lowering therapy regionally.

This was a prospective examination of the efficacy of our regional nurse-led secondary prevention service. Consecutive patients with a history of established ASCVD and a baseline serum LDL-cholesterol (LDL-C) >1.4 mmol/L at the index admission were included. ASCVD was defined as a history of confirmed acute coronary syndrome (ACS), previous coronary revascularisation for flow-limiting coronary artery disease (CAD). The primary outcome was the change in LDL-C from baseline to six months which was examined using a Repeated Measures Anova with a Tukey post-test. The secondary outcomes were the proportion of patients achieving the NICE LDL-C target of <2.0 mmol/L and the ESC Target of <1.4mmol/L (using Chi-Squared Test).

We examined 201 consecutive patients. The mean (± standard deviation) age was 66.30±10.71 (range 32.0-90.0) years of which 132 (65.67%) were men. In total 111 (55.22%) patients had suffered an acute coronary syndrome. The mean ± standard deviation LDL-C was 3.16 ±1.91 mmol/l at the index hospital admission, 2.31±0.87 mmol/l at three months (baseline visit) and 1.92±0.73 mmol/l at six months (p<0.001) Figure 1). The mean LDL-C reduction from baseline to six months was 1.24 (95% CI:1.04 -1.44) mmol/L and a 38.61% relative risk reduction. The proportion of patients at six months who achieved an LDL-C target of <2.0mmol/l and <1.4mmol/L was 65.2% and 18.4% respectively (P<0.001). Overall,11/201 (5.5%) were commenced on injectable lipid lowering therapy with PCSK9 inhibitors within six months of their index admission.

The introduction of a nurse-led secondary prevention service led to a significant reduction in LDL-C and improvements in regional lipid lowering performance. Whilst nearly two thirds of patients achieve the NICE lipid lowering target of <2.0mmol/L at six months post index ASCVD event less than 1 in 5 achieve the ESC target of <1.4mmol/L.