The patient journey in secondary prevention


Nick Hartshorne-Evans, Chief Executive (Founder), Pumping Marvellous Foundation

Despite progress in technology, knowledge and new drugs, cardiovascular disease remains the leading cause of death globally,1 and accounts for 45% of all deaths in Europe.2

One area of concern for physicians is lack of implementation of preventive measures, in particular when it comes to secondary prevention in high-risk patients who have already had a cardiovascular event.3

Healthcare professionals must assess the risks associated with a patient’s lifestyle and convince and coach them to make the appropriate changes to minimise their chances of further cardiovascular problems further down the line, in addition to determining appropriate medical intervention.

Aside from changing entrenched lifestyle habits, patients can improve outcomes by ensuring they stick to drug regimes designed to reduce the risk of further events.3

In Europe, the European Society of Cardiology (ESC) has created guidelines for physicians outlining best practice in several areas, including secondary prevention. These guidelines present relevant evidence to help physicians weigh the benefits and risks of a particular diagnostic or therapeutic procedure. Similar guidelines relating to secondary prevention have also been developed at the national level by local country organisations, such as the National Institute for Health and Care Excellence (NICE) in the UK.4

However, there are still opportunities to improve the patient journey, as outlined in this conversation with Nick Hartshorne-Evans, Chief Executive and Founder of the UK heart failure charity, the Pumping Marvellous Foundation.

From a patient’s perspective, what is the awareness of the risk of secondary events?

It varies between people because patients are often either looking back in anger and thinking ‘what’s happened’, dwelling on the fact they had a cardiac event, or they are looking forward and wanting to move on. The ability of the person to understand that they need to make a number of changes after an event, and in order to prevent further events, is key. It’s very much based on how the information given is adapted to the patient as well. If you are told why you need to do something there is a better chance you will do what’s required instead of just following instructions you’re given. That’s quite a clinical conversation.

Based on your experience, if a patient has had a primary event, what’s the right time to start talking about secondary events?

It’s never the perfect time but it really depends how you can interact with the patient. If a patient is non-responsive because they have had the biggest shock of their life, is it right to possibly overload them with detailed information? Or are they somebody who understands what has happened and can deal with it? Perhaps you can provide more information to that person because they can take it. Understanding that difference in a patient is a skill that healthcare professionals can develop – it’s a skill to give the right level of information so the patient believes in it, takes it on board and acts on it.

How do you make sure patients understand the advice and get feedback, or validation, on how it’s working?

It’s a two-way process; it comes from the physician and from the patient and there needs to be an element of accountability. I was amazed when I saw examples of appraisal documents used in the NHS in the UK, they were all about clinical appraisal. It should include people management as well, because the physician is trying to coach the patient and manage their condition. Then, on the other side, you have patients who are all different types of people. Patients need to challenge the physician constructively because ultimately, it’s their health at stake. Wouldn’t you?

How well do you think patients appreciate clinical guidelines around secondary prevention?

I don’t think patients understand them at all; they’re not that aware of guidelines relating to secondary prevention. Patients who really get involved in their condition and self-management might learn about some guidelines, but they won’t know about guidelines outside their country. Then for patients to actually use that knowledge is a different matter entirely. They may read about the guidelines and then, at a check-up with their healthcare professional, discuss their condition. It’s unlikely that guideline information will be introduced into the conversation though.

There could be a better way of publicising the relevant guidelines so that a bigger proportion of the patient population sees them and understands why they are important. A significant other benefit to this would be that you are equipping patients to understand the system and how they interact with it.

How can patient groups make sure the patient voice is represented at the government level?

Patient groups have to find a way to get in on the discussion. Sometimes it’s very difficult to meet the criteria to influence national health institutions or governmental departments of health; the patient group should be a representative organisation that covers all areas of the country geographically. If the patient group covers a single area, they will find it difficult to influence the right people. Patient groups need to offer insight to groups like NICE in the UK or their equivalents in other countries. Being seen to have value in the system is everything. If the patient group has value in the system then people will listen. We supply patient insights others could only dream of. Our value is to shape these into the system, therefore adding value, giving a seat at the table.

If you could change one thing in terms of how we manage secondary prevention now, what would it be?

Preparing the patient better for the challenges that they face when they’re diagnosed.

It’s not just the healthcare professional’s responsibility – the patient needs to understand that drug adherence is very important in the management of their condition as well as improving their lifestyle. The key is telling patients what ‘good’ looks like and then coaching them to achieve it. Peer to peer coaching and development is a really untapped opportunity, people buy from people they like or have commonality with. Because of the pressure on hospitals, taking the patient out of the hospital setting is very important as it reduces costs, so managing secondary prevention is a step in the right direction. We need good information, that is relevant to the patient, and for them to be coached by the healthcare professional.


1. WHO Cardiovascular Diseases Fact Sheet. Updated May 2017. Available from Accessed on 29 September 2017.

2. European Cardiovascular Disease Statistics 2017. Available from Accessed on 29 September 2017.

3. Piepoli MF, et al. Challenges in secondary prevention after acute myocardial infarction: A call for action. Eur J Prev Cardiol 2016;23(18):1994–2006.

4. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. Available from Accessed on 29 September 2017.