Clinical implementation of secondary prevention

Following up on the recent update to the World Heart Federation (WHF) Roadmap on Secondary Prevention of Cardiovascular Diseases (CVDs), the WHF is now conducting a survey on the clinical implementation of secondary prevention*, with a focus on lower or limited resource settings.

This survey is mainly aimed at primary care physicians in an effort to understand some of the barriers and facilitators to the clinical implementation of secondary CVD prevention.

The data collected will inform the development of tools to guide the clinical implementation of secondary prevention of CVDs in lower resource settings.

The survey is anonymous and all the answers are optional. You may choose to answer as many of the questions as you are able to. We also encourage you to share the survey among your primary care physician colleagues. We thank you in advance for your cooperation.

*Secondary CVD prevention can be defined as a strategy aimed to reduce the probability of a recurrent cardiovascular event in patients with known atherosclerotic CVD (ASCVD), including coronaty artery disease, cerebrovascular artery disease, peripheral artery disease and atherosclerotic aortic disease. Secondary prevention thus refers to counseling and drug therapy for individuals with known ASCVD that is evidenced to prevent subsequent heart attacks and strokes.

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* 1. Which country are you come from?

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* 2. If different from 1, which country are you currently working in?

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* 3. What is the setting where you practice/work at least 50% of your time?

Private hospital/healthcare centre

Government hospital/healthcare centre

Private outpatient clinic

Public/government outpatient clinic

Research centre

Government organization

Non-government organization

Other (please specify)

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* 4. What is your specialty?

Primary care physician

Primary care provider

General practitioner/physician

Community health worker

Cardiologist

Endocrinologist

Epidemiologist

Nurse

Nephrologist

Policy maker

Pharmacist

Researcher

Surgeon

Other (please specify)

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* 5. What area is your practice predominantly based in?

Urban

Semi/peri-urban

Rural

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* 6. The following priority secondary prevention medications are:

	Registered in my country	On the list of essential medicines in my country	Included in secondary prevention guidelines in my country	In my experience these drugs are well accepted by patients with ASCVD.	In my experience, these drugs are available in public primary healthcare settings in my country	In my experience, these drugs are affordable in public primary healthcare settings
Asprins	Asprins Registered in my country menu	Asprins On the list of essential medicines in my country menu	Asprins Included in secondary prevention guidelines in my country menu	Asprins In my experience these drugs are well accepted by patients with ASCVD. menu	Asprins In my experience, these drugs are available in public primary healthcare settings in my country menu	Asprins In my experience, these drugs are affordable in public primary healthcare settings menu
Beta-blockers	Beta-blockers Registered in my country menu	Beta-blockers On the list of essential medicines in my country menu	Beta-blockers Included in secondary prevention guidelines in my country menu	Beta-blockers In my experience these drugs are well accepted by patients with ASCVD. menu	Beta-blockers In my experience, these drugs are available in public primary healthcare settings in my country menu	Beta-blockers In my experience, these drugs are affordable in public primary healthcare settings menu
Statins	Statins Registered in my country menu	Statins On the list of essential medicines in my country menu	Statins Included in secondary prevention guidelines in my country menu	Statins In my experience these drugs are well accepted by patients with ASCVD. menu	Statins In my experience, these drugs are available in public primary healthcare settings in my country menu	Statins In my experience, these drugs are affordable in public primary healthcare settings menu
Ace-inhibitors	Ace-inhibitors Registered in my country menu	Ace-inhibitors On the list of essential medicines in my country menu	Ace-inhibitors Included in secondary prevention guidelines in my country menu	Ace-inhibitors In my experience these drugs are well accepted by patients with ASCVD. menu	Ace-inhibitors In my experience, these drugs are available in public primary healthcare settings in my country menu	Ace-inhibitors In my experience, these drugs are affordable in public primary healthcare settings menu
Angiotensin II inhibitors	Angiotensin II inhibitors Registered in my country menu	Angiotensin II inhibitors On the list of essential medicines in my country menu	Angiotensin II inhibitors Included in secondary prevention guidelines in my country menu	Angiotensin II inhibitors In my experience these drugs are well accepted by patients with ASCVD. menu	Angiotensin II inhibitors In my experience, these drugs are available in public primary healthcare settings in my country menu	Angiotensin II inhibitors In my experience, these drugs are affordable in public primary healthcare settings menu
Ezetimibe	Ezetimibe Registered in my country menu	Ezetimibe On the list of essential medicines in my country menu	Ezetimibe Included in secondary prevention guidelines in my country menu	Ezetimibe In my experience these drugs are well accepted by patients with ASCVD. menu	Ezetimibe In my experience, these drugs are available in public primary healthcare settings in my country menu	Ezetimibe In my experience, these drugs are affordable in public primary healthcare settings menu
Fixed-dose combinations (2 or more anti-hypertensives)	Fixed-dose combinations (2 or more anti-hypertensives) Registered in my country menu	Fixed-dose combinations (2 or more anti-hypertensives) On the list of essential medicines in my country menu	Fixed-dose combinations (2 or more anti-hypertensives) Included in secondary prevention guidelines in my country menu	Fixed-dose combinations (2 or more anti-hypertensives) In my experience these drugs are well accepted by patients with ASCVD. menu	Fixed-dose combinations (2 or more anti-hypertensives) In my experience, these drugs are available in public primary healthcare settings in my country menu	Fixed-dose combinations (2 or more anti-hypertensives) In my experience, these drugs are affordable in public primary healthcare settings menu
Fixed-dose combinations (2 or more antidyslipidemic)	Fixed-dose combinations (2 or more antidyslipidemic) Registered in my country menu	Fixed-dose combinations (2 or more antidyslipidemic) On the list of essential medicines in my country menu	Fixed-dose combinations (2 or more antidyslipidemic) Included in secondary prevention guidelines in my country menu	Fixed-dose combinations (2 or more antidyslipidemic) In my experience these drugs are well accepted by patients with ASCVD. menu	Fixed-dose combinations (2 or more antidyslipidemic) In my experience, these drugs are available in public primary healthcare settings in my country menu	Fixed-dose combinations (2 or more antidyslipidemic) In my experience, these drugs are affordable in public primary healthcare settings menu
Fixed-dose combinations (2 or more drugs for multiple conditions)	Fixed-dose combinations (2 or more drugs for multiple conditions) Registered in my country menu	Fixed-dose combinations (2 or more drugs for multiple conditions) On the list of essential medicines in my country menu	Fixed-dose combinations (2 or more drugs for multiple conditions) Included in secondary prevention guidelines in my country menu	Fixed-dose combinations (2 or more drugs for multiple conditions) In my experience these drugs are well accepted by patients with ASCVD. menu	Fixed-dose combinations (2 or more drugs for multiple conditions) In my experience, these drugs are available in public primary healthcare settings in my country menu	Fixed-dose combinations (2 or more drugs for multiple conditions) In my experience, these drugs are affordable in public primary healthcare settings menu

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* 7. The following diagnostic and monitoring/management tools for cardiovascular diseases are generally available and functioning in the public primary healthcare setting of my country (multiple selection possible)

Blood pressure measurement (sphygmomanometer)

Electrocardiogram machine

Blood sugar testing device

Blood lipids (or cholesterol) testing device

Blood testing for cardiac markers

2D echocardiography

BMI measurements

Ambulatory Blood Pressure Monitoring

Ambulatory ECG monitoring (Holter)

Home blood pressure monitoring

Angiography

Other (please specify)

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* 8. The following lifestyle intervention programs are:

	In my experience, well accepted in my country by ASCVD patients	In my experience, available and used in public primary healthcare settings in my country	In my experience, affordable in my country in public primary healthcare settings
Smoking cessation	Smoking cessation In my experience, well accepted in my country by ASCVD patients menu	Smoking cessation In my experience, available and used in public primary healthcare settings in my country menu	Smoking cessation In my experience, affordable in my country in public primary healthcare settings menu
Healthy diet recommendations	Healthy diet recommendations In my experience, well accepted in my country by ASCVD patients menu	Healthy diet recommendations In my experience, available and used in public primary healthcare settings in my country menu	Healthy diet recommendations In my experience, affordable in my country in public primary healthcare settings menu
Physical activity	Physical activity In my experience, well accepted in my country by ASCVD patients menu	Physical activity In my experience, available and used in public primary healthcare settings in my country menu	Physical activity In my experience, affordable in my country in public primary healthcare settings menu
Psychological management	Psychological management In my experience, well accepted in my country by ASCVD patients menu	Psychological management In my experience, available and used in public primary healthcare settings in my country menu	Psychological management In my experience, affordable in my country in public primary healthcare settings menu

Other (please specify)

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* 9. Please indicate the relevance of these suggested barriers to providing optimal secondary cardiovascular prevention in public primary healthcare facilities in your country?

	Highly relevant	Relevant	Somewhat relevant	Not relevant	Not applicable
Patients with known CVDs do not have access to the healthcare system	Patients with known CVDs do not have access to the healthcare system Highly relevant	Patients with known CVDs do not have access to the healthcare system Relevant	Patients with known CVDs do not have access to the healthcare system Somewhat relevant	Patients with known CVDs do not have access to the healthcare system Not relevant	Patients with known CVDs do not have access to the healthcare system Not applicable
Patients are not aware of the importance and need of long-term treatment	Patients are not aware of the importance and need of long-term treatment Highly relevant	Patients are not aware of the importance and need of long-term treatment Relevant	Patients are not aware of the importance and need of long-term treatment Somewhat relevant	Patients are not aware of the importance and need of long-term treatment Not relevant	Patients are not aware of the importance and need of long-term treatment Not applicable
Patients do not adhere to medications or lifestyle modification recommendations	Patients do not adhere to medications or lifestyle modification recommendations Highly relevant	Patients do not adhere to medications or lifestyle modification recommendations Relevant	Patients do not adhere to medications or lifestyle modification recommendations Somewhat relevant	Patients do not adhere to medications or lifestyle modification recommendations Not relevant	Patients do not adhere to medications or lifestyle modification recommendations Not applicable
There is a low awareness of CVDs among the population	There is a low awareness of CVDs among the population Highly relevant	There is a low awareness of CVDs among the population Relevant	There is a low awareness of CVDs among the population Somewhat relevant	There is a low awareness of CVDs among the population Not relevant	There is a low awareness of CVDs among the population Not applicable
Priority lifestyle intervention programs are not available	Priority lifestyle intervention programs are not available Highly relevant	Priority lifestyle intervention programs are not available Relevant	Priority lifestyle intervention programs are not available Somewhat relevant	Priority lifestyle intervention programs are not available Not relevant	Priority lifestyle intervention programs are not available Not applicable
Priority lifestyle intervention programs are not affordable	Priority lifestyle intervention programs are not affordable Highly relevant	Priority lifestyle intervention programs are not affordable Relevant	Priority lifestyle intervention programs are not affordable Somewhat relevant	Priority lifestyle intervention programs are not affordable Not relevant	Priority lifestyle intervention programs are not affordable Not applicable
Guidelines are not available	Guidelines are not available Highly relevant	Guidelines are not available Relevant	Guidelines are not available Somewhat relevant	Guidelines are not available Not relevant	Guidelines are not available Not applicable
Recommendations are too complex	Recommendations are too complex Highly relevant	Recommendations are too complex Relevant	Recommendations are too complex Somewhat relevant	Recommendations are too complex Not relevant	Recommendations are too complex Not applicable
Healthcare providers are not aware of guidelines	Healthcare providers are not aware of guidelines Highly relevant	Healthcare providers are not aware of guidelines Relevant	Healthcare providers are not aware of guidelines Somewhat relevant	Healthcare providers are not aware of guidelines Not relevant	Healthcare providers are not aware of guidelines Not applicable
Healthcare providers are aware but do not follow guidelines	Healthcare providers are aware but do not follow guidelines Highly relevant	Healthcare providers are aware but do not follow guidelines Relevant	Healthcare providers are aware but do not follow guidelines Somewhat relevant	Healthcare providers are aware but do not follow guidelines Not relevant	Healthcare providers are aware but do not follow guidelines Not applicable
Priority medications are not affordable	Priority medications are not affordable Highly relevant	Priority medications are not affordable Relevant	Priority medications are not affordable Somewhat relevant	Priority medications are not affordable Not relevant	Priority medications are not affordable Not applicable
Priority medications are not available	Priority medications are not available Highly relevant	Priority medications are not available Relevant	Priority medications are not available Somewhat relevant	Priority medications are not available Not relevant	Priority medications are not available Not applicable
There is a lack of healthcare providers/physicians to prescribe priority interventions	There is a lack of healthcare providers/physicians to prescribe priority interventions Highly relevant	There is a lack of healthcare providers/physicians to prescribe priority interventions Relevant	There is a lack of healthcare providers/physicians to prescribe priority interventions Somewhat relevant	There is a lack of healthcare providers/physicians to prescribe priority interventions Not relevant	There is a lack of healthcare providers/physicians to prescribe priority interventions Not applicable
There is a shortage of healthcare providers	There is a shortage of healthcare providers Highly relevant	There is a shortage of healthcare providers Relevant	There is a shortage of healthcare providers Somewhat relevant	There is a shortage of healthcare providers Not relevant	There is a shortage of healthcare providers Not applicable

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* 10. What additional type of training on secondary prevention related topics would be beneficial for healthcare providers in public primary care settings? (mark in order of importance with 1 being most important)

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* 11. Please indicate which of these solutions would be relevant in the public primary healthcare setting? (select the top 6 most relevant solutions)

Integrate secondary prevention interventions with simple cardiac rehabilitation programs

Integrate cardiovascular secondary prevention with management of other chronic conditions (HIV, TB, etc)

Increase opening times of clinics and locate them close to communities

Integrate primary and secondary care services for secondary prevention (i.e. care transition to primary care upon discharge from cardiology ward, patient information exchange system between secondary and primary healthcare)

Team-based care (multidisplinary team involving doctors, nurses, dietitions, physiotherapists, pharmacists, etc)

Develop simple and locally applicable guidelines

Simplify use of multiple drugs by using fixed dose combination therapy

Provide pre-packaged blisters with multiple medications

Share or shift the roles of healthcare providers to non-physician health workers/community health workers

Clinical decision support system

Patient shared decision aid

Other (please specify)

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* 12. Please indicate which of these lifestyle interventions/solutions would be relevant in the public primary healthcare setting? (multiple selection possible, mark in order of importance with 1 being most important)

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* 13. On average, what is the frequency with which patients with ASCVD have to travel to a healthcare setting/clinic for a follow-up?

More than once in 3 months

Every 3 months

Once every 3-6 months

More than once in 6 months

Once in 6-12 months

More than once every year

Other (please specify)

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* 14. On average, how long does it take for patients to travel to the clinic for secondary prevention follow-ups/ treatment?

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* 15. On average, do most patients adhere to follow-up visits for secondary prevention? If not, why not (comment)?

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* 16. What is the flow and course of action from discharge to presentation in the clinic/healthcare setting for secondary prevention care? (write in each box)

What is done at discharge (eg advice given, medications prescribed)

When is the first follow-up visit scheduled

What is done during the follow-up visit (eg basic check-up, medication evaluation, lifestyle changes recommended)

Are patients ever referred to a rehabilitation centre? If so, when?

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* 17. Can non-physicians (nurses, community health workers, pharmacists) legally prescribe medicines in your country?

Yes

I don't know

In some cases/only certain drug classes

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* 18. Is it common in your public primary healthcare settings to use clinical decision support algorithms/tools for diagnosing cardiovascular diseases?

Yes

I don’t know

Only in some cases/only for some conditions

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* 19. Is it common in your public primary healthcare settings to use clinical decision support algorithms/tools for prescribing medication for patients with ASCVD?

Yes

I don’t know

Only in some cases/only for some conditions

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* 20. If you are aware of any clinical decision support tools/algorithms used in your country or health system for the secondary prevention of cardiovascular diseases, would you be able to upload it/ provide a link in the next question?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 21. If you are aware of any clinical decision support tools/algorithms used in your country or health system for the secondary prevention of cardiovascular diseases, would you be able provide a link to it?