Lessons from France

Abstract

Cardiovascular disease is the principal cause of morbidity and mortality in the Netherlands. In this background, various initiatives have been launched to reduce the frequency of cardiovascular disease. One of those is the creation of clinical units with a special focus on prevention of cardiovascular disease. Hitherto, the prevention programmes of these clinics have been heterogeneous and therefore difficult to compare with respect to results. Similar developments in creating clinical initiatives concerning prevention of cardiovascular disease are found across Europe. With this in mind, lessons could be learned from each other’s experiences. In our contribution, we would like to present the Cardiovascular Prevention Clinic in the Pitié- Salpêtrière Hospital in Paris, France, as an interesting example of a well-acknowledged cardiovascular prevention clinic that combines both daily clinical care and cardiovascular science. (Neth Heart J 2007;15:22-6.)

Despite a decline in age-adjusted mortality during the past 30 years, complications of cardiovascular disease are still the principal cause of morbidity and mortality in the Western World.¹ Indeed, one third of all men and women will subsequently die due to cardiovascular disease.² Despite the fact that several risk factors for cardiovascular disease are well recognised, the benefit from this knowledge appears to be disappointing.

Nowadays, several initiatives have been taken in cardiovascular prevention in Europe. Special units with a focus on prevention of cardiovascular disease have been developed. In the Netherlands, most programmes about secondary cardiovascular prevention are running in a hospital environment in the cardiology department. Additionally, some structured programmes with (primary) prevention as major goal have been developed.^3,4 Most of these programmes are quite heterogeneous and are characterised by a short-term clinical follow-up.

In order to learn lessons from other European initiatives, we present here the Cardiovascular Prevention Clinic and how it functions in the Pitié-Salpêtrière Hospital in Paris, France. This clinic is an example of a specialised unit in which a structured evaluation of individual cardiovascular risk profiles has now been performed for more than a decade.

Cardiovascular Prevention Clinic in La Pitié-Salpêtrière

The Cardiovascular Prevention Clinic in the Pitié- Salpêtrière Hospital in Paris is a clinical unit that is part of the Department of Endocrinology and Metabolic Diseases. A programme (a one-day visit) for primary and secondary prevention of cardiovascular diseases has been running since 1988. Currently, nine patients a day, four days a week, are admitted for this one-day visit. Every year a total of 1600 patients, including new and returning patients, visit the clinic. For a description of the total visiting population per year see table 1.

Table 1.

Characteristics of the patients who attend the Cardiovascular Prevention Clinic.

Characteristics
Men (%)	54
Women (%)	46
Average age of the patients (years)	52
Patients coming for primary prevention (%)	88
Patients coming for secondary prevention (%)	12
Patients with dyslipidaemia (%)	92
Patients with hypertension (%)	40
Patients with diabetes (%)	12
Patients with obesity (BMI > 30 kg/m2) (%)	15
Patients who smoke (%)	22

These values represent mean values of patients (>10,000) who visited the outpatient clinic in the past 10 years. BMI=body mass index.

Patient referral and selection

In general, patients with two or more cardiovascular risk factors are included in the programme. A large proportion of the patients (40%) are referred by specialists working in the Department of Endocrinology and Metabolic Diseases of the Pitié-Salpêtrière Hospital; 50% of the patients are referred by a general practitioner or specialists from other departments. Another 10% apply to the clinic on their own initiative. These patients are first assessed by a nurse during a ‘teleconsultation’ to see whether they are suitable to take part in the programme. Most patients have to wait one to three months before they finally attend the cardiovascular prevention programme.

Structure of one-day programme

The one-day programme is covered by a strict protocol that consists of distinctive stations. Each patient goes through these stations, as presented in figure 1. After arrival, at 7.30 a.m., patients sign an informed consent form, which had been sent to them by post. They are

Benjamin Delessert Pavilion, the part of La Pitié-Salpêtrière Hospital (Paris, France) in which the Cardiovascular Prevention Clinic is located.

interviewed by a nurse to complete a questionnaire. In addition, all patients visit station II to XII (in a random order).

Figure 1.

Structure of the cardiovascular prevention programme in the Pitié-Salpêtrière Hospital. XIII, XIV and XV take place in groups. ECG=electrocardiogram.

To calculate body mass index (BMI), biometry is performed (II); weight, height and waist/hip ratio are measured. Fasting venous blood samples are drawn and analysed for lipid profile, other biochemical parameters, a haematological screening and thyroid-stimulating hormone (III). Using a dipstick analysis, urine is screened for leucocytes, loss of protein, casts, haematuria and glucose (IV). If positive leucocytes or haematuria are detected, bacteriology is performed the same day. If a positive screen for proteins is found, 24-hour urine is quantified for proteins at a follow-up consultation. For 20 minutes, while the patient is in a supine position, blood pressure (RR) is monitored on one single arm (VI) with the use of an automatic blood pressure device (Dynamap registration). In order to obtain a detailed medical history, patients need to complete a health questionnaire (VIII) and are seen by a medical student who also performs a physical examination (VII). Again blood pressure is measured with the use of the automatic blood pressure device, once on the left side and once on the right side. B-mode ultrasound imaging techniques are used to determine intima media thickness (IMT) and to screen for the presence of atherosclerotic plaques in both carotids and femorals (IX). If dyslipidaemia, overweight, obesity and/or diabetes are found, subjects visit a dietician (X) who provides personal advice about improving daily food intake and physical activity. An ECG in rest (XI) is performed by a nurse to score left ventricular hypertrophy and/or signs of cardiac ischaemia. In addition to routine analysis, other tests can be performed on indication (XII). The referring physician decides which are necessary.

In the afternoon, after having lunch, all the patients follow courses about atherogenesis and nutrition (XIV, XV), as part of a group. At the end of these courses, the patients receive a handout in which all information is summarised. In parallel, all results of the tests of that day are collected, in order to complete the patient’s file (XVI).

At the end of the day, when almost all the individual results have been collected, the staff (resident, chef de clinique and dietician) discuss each patient for about 15 minutes. An individual cardiovascular risk assessment is made according to ANAES (Agence Nationale d’Accréditation et d’Evaluation en Santé) guidelines. Afterwards, they visit each individual patient (XVII) to inform them about the results of the tests carried out during the day (total length of consultation 5-10 minutes per patient). Within this consultation, the patient also receives lifestyle recommendations. If necessary, medication is prescribed or changed, according to AFSSAPS (Agence Francaise de Sécurité Sanitaire des Produits de Santé) guidelines. After two to four weeks, the patient receives a document in which all results and recommendations are listed (XIX). Their general practitioner or specialist also receives a copy of this document.

Follow-up after one-day visit

Of all patients, 80% return to the Cardiovascular Prevention Clinic three to six months after the initial visit in order to evaluate the effectiveness of prescribed medication and lifestyle adaptation. Fifty percent of all the patients return to the Cardiovascular Prevention Clinic for a regular follow-up. For unknown reasons, the remaining 50% never come back for follow-up or only come to the previously mentioned three to six months’ consultation. In deciding the frequency of follow-up, extension of coronary and femoral plaques, aspects of plaque, age and presence of other cardiovascular risk factors play an important role. To obtain the most optimal support in losing weight (or in their maintenance of a specific diet), a dietician is available for regular consultations. Additionally, a special stopsmoking programme has been created at the Department of Lung Disease in the Pitié-Salpêtrière Hospital.

Key points of the Pitié-Salpêtrière programme

To determine which parts in their programme could be used to extract lessons for initiatives in the Netherlands, we will highlight some of the key elements of the cardiovascular prevention programme in the Pitié-Salpêtrière Hospital.

Structured programme with research databank

Most cardiovascular prevention programmes in European clinics are not uniform in structure over time. Moreover, there are frequent changes in their set up. The programme in the Pitié-Salpêtrière Hospital, however, has been running for more than 15 years at a stretch. Among our French colleagues, this structure is well recognised as a high-quality protocol. Cardiovascular risk assessment for the individual patient, subsequent recommendations about lifestyle adaptation and prescription of drugs is included in a one-day programme and located at one site with a multidisciplinary input (dietary, kinesiology, internal medicine, cardiology and endocrinology). Due to this approach, there is no delay in the diagnosis and therapy, and participants feel satisfied because of its efficiency and individual approach. Since it started, all results have been collected in a large data file. With the use of this data file, several scientific reports have been published in international scientific journals.^5-14

Patient education

In addition to oral and written information about the origin and the development of premature cardiovascular disease, patient education is offered in group meetings during the second half of the one-day visit. In these courses, members of both the nutrition department and the sport medicine department teach patients about the composition of diet, physical exercise and lifestyle adaptation in relation to premature cardiovascular disease. These courses are given in an interactive way. Worth mentioning is the creation of a special volume featuring cartoon figures that are known from Asterix and Obelix. This cartoon was specially developed as an educational tool to make the topic of atherosclerotic disease more accessible to a more extended public. In this way, less-educated individuals or illiterates (indeed, a growing ‘hidden’ social problem in Western European Societies) could be reached. Indeed, it is known that education is inversely related to the prevalence of subclinical coronary artery disease in early middle age with particularly high risk for individuals with less than a high school diploma.¹⁵

Lifestyle adaptation

A further reduction of cardiovascular risk could be accomplished by lifestyle adaptation programmes. Therefore, in the Pitié-Salpêtrière Hospital, a stopsmoking programme is offered. Indeed, the relative risk for cardiovascular diseases increases by 2 to 3.5 with regard to smoking.¹⁶ On the other hand, cessation of smoking and an increase in physical activity have a significant effect on prevention of cardiovascular morbidity and mortality. It is recommended that individuals of all ages obtain a minimum of 30 minutes of physical activity of moderate intensity (e.g. brisk walking) on most, if not all, days of the week.^17,18 The importance of physical exercise is also taught during the session in the afternoon, as previously described.

Final report with an individual approach

In addition to the education during group meetings, each patient is approached individually with regard to the individual risk assessment with subsequent recommendations. Patients are given individual advice about adaptations in their diet and lifestyle from both a dietician and a physician at the end of the one-day visit. It is known from previous studies that an optimal compliance is obtained by awareness.

We are of course aware that several initiatives concerning cardiovascular prevention are running in the Netherlands. In the University Medical Centre Utrecht, for example, SMART (Secondary Manifestations of Arterial Disease) is an interesting programme that shares elements (such as a thorough screening within a structured programme) that are comparable with those in the Cardiovascular Prevention Clinic in the Pitié-Salpétrière Hospital in Paris. A difference between the two programmes is the presence of education in group sessions and a final individual report in a one-day intramural setting. Furthermore, the SMART programme is by definition secondary prevention. Our description of the Cardiovascular Prevention Clinic in the Pitié-Salpétrière Hospital in Paris, however, is not meant to offer you the ideal structure, but more to bring you in contact with a well recognised and uniform structure that has survived for more than a decade in France. Perhaps some Dutch lessons could be drawn from these French initiatives within the actuality of the European region.

Acknowledgements

Marieke Timmerman and Katrijn Rensing are both medical students who visited the Cardiovascular Prevention Clinic in the Pitié-Salpêtrière Hospital in Paris. The French-Dutch Network (Marieke de Bakker and Anièce Heijnen) and the Van Wijck Stam Caspers Fund are gratefully thanked for their financial support by providing the Leonardo da Vinci Bourse and the WSC Fund Bourse, respectively. We would like to sincerely thank Dr Philippe Giral, Professor Eric Bruckert, members of the Endocrinology Department in the Pitié-Salpêtrière Hospital, and Dr John Chapman for their warm hospitality.