The Italian pilot project includes a collaboration between the emergency medicine department and the sports medicine unit, with the aim of offering physical activity on prescription (PAP) for therapeutic purposes. PAP is directed towards patients with chronic cardiovascular conditions. These patients are referred by their general practitioners or by the hospital.
Patients are evaluated, with a cardiovascular risk stratification, pharmacological therapy is optimized, and a PAP is provided at the end. Patients are then reviewed at follow-up with variable frequency and, where indicated, the prescribed therapy and PAP are adjusted.
"Usually, patients are referred to us after revascularization procedures or an acute coronary syndrome but why do we have to wait for an event? Can’t we prevent it instead?" - Says doctor Patrizio Sarto, head of the Exercise and Sports Medicine Unit.
Prevalence of Cardiovascular diseases in Italy
Cardiovascular diseases represent the main cause of death in Italy, being responsible for 35% of all deaths (32% in males and 38% in females). According to Istat 2018 data, particularly ischemic heart disease is responsible for 10% of all deaths (11% in males and 9% in females).
Many patients access the emergency room with symptoms suggestive of coronary artery disease and, after finding non-significant plaques on coronary angiography or CT scan, are discharged from emergency medicine with the recommendation of strict risk factor control to prevent progression of the illness. However, there is poor adherence to long-term drug therapy prescribed for chronic conditions, such as cardiovascular diseases. There is even lower adherence to lifestyle changes.
This pilot project creates a path dedicated to non-revascularized coronary heart disease patients, based on the collaboration between the emergency medicine department and the sports medicine unit of the AULSS2 (Treviso district). The project aims to offer an individualized prescription of physical exercise for therapeutic purposes and correction of modifiable cardiovascular risk factors.
“At the exercise and sports medicine of the Treviso prevention department, there is an up and running programme of exercise prescription for patients with chronic conditions who are referred by their general practitioners or by hospital and outpatient specialists”, says doctor Patrizio Sarto, head of the Exercise and Sports Medicine Unit.
“Patients are evaluated, with a complete cardiovascular risk stratification, pharmacological therapy is optimized, and a personalized prescription of an exercise programme is provided at the end. Patients are then reviewed at follow-up with variable frequency and, where indicated, the prescribed therapy and exercise are adjusted. Usually, patients are referred to us after revascularization procedures or an acute coronary syndrome but why do we have to wait for an event? Can’t we prevent it?”
In this project patients are referred from the emergency medicine department and evaluated at the Sports Medicine Unit within 30 days.
Process for evaluating patients
The evaluation protocol is here reported:
First evaluation (doctor + nurse):
• Complete medical history (evaluation of all comorbidities, history of disease, blood pressure values and lipid profile, osteo-articular problems, cardiovascular risk factors, current therapy, any symptoms, habitual physical activity level, possible factors limiting training etc.).
• Physical examination.
• Resting ECG and blood pressure measurement.
• Prescription, if necessary, of blood tests (preliminary to the stress test and / or to complete clinical evaluation) and any other tests.
Counseling by nurse / graduate in motor science which includes assessment of sports and exercise history, preferences on the type of physical activity to be practiced, any barriers and indications on how to reduce sedentary lifestyle.
Further evaluations (doctor): instrumental examinations (echocardiogram, supra-aortic trunk echo-Doppler, fundus oculi evaluation, home or 24h blood pressure monitoring, etc.); Medication adjustment (beta-blocker, antihypertensive, lipid-lowering therapy, other)
Stress test (doctor + nurse): In optimized medical treatment performed in order to
• evaluate functional capacity and identify the target training intensity
• evaluate exercise blood pressure response, arrhythmias and ischemia.
At the end of the evaluation phase, in the absence of contraindications, a monitored training period will be performed at the sports medicine gym (if indicated) and the patients will receive a written personalized physical exercise prescription and a clinical letter for his physician specifying the date of the subsequent control assessment (together with the required prescription).
Since counselling and continuous motivations are key for both drug therapy and lifestyle changes compliance there is an articulate follow up protocol:
After 1 month: Telephone interview by nurse: adherence to therapy, risk factors control, adherence to the training program;
After 3 months: (at the sports medicine gym) monitored training session with re-evaluation of cardiovascular risk factors and of the training habitually performed (nurse + graduate in motor science);
After 6 months: Telephone interview by nurse: adherence to therapy, risk factors control, adherence to the training program;
Medical check-up on an annual basis (doctor + nurse): at each reassessment the anamnesis will be integrated, performed, if indicated, a new exercise test and the additional assessments deemed necessary. A new personalized exercise program will therefore be drawn up on which it will be indicated when it will be necessary to perform the next control assessment (in general, the frequency will be annual).