Key Points
- Nurses are increasingly responsible for cardiovascular risk management, but randomized data supporting this approach is lacking, especially for secondary prevention.
- ALLEPRE randomized 2060 hospitalized patients in Italy with ACS to a nurse-coordinated prevention program (NCPP), which included a visit with a trained nurse before discharge and 8 additional post-discharge visits over 2 years, or standard of care. Nurses provided education and counseling on CV risk factors, lifestyle, and medications adherence, and referred patients to a multidisciplinary teams for risk factor optimization when indicated.
- The NCCP led to a significant 30% reduction in the primary composite MACE endpoint of CV death, non-fatal MI, and non-fatal ischemic stroke, driven primary by a reduction in MI. The NCCP was also associated with improvements in BMI, exercise levels, and medication adherence.
- A structured, nursing-led program to promote secondary prevention can lead to lower MACE among high-risk patients following an ACS hospitalization.
Secondary prevention is critical to the treatment of patients with acute coronary syndrome (ACS), and includes both medications and lifestyle interventions, such as following a heart healthy diet, increasing physical activity, reducing excess weight, and quitting smoking. The counseling and support necessary to optimize these risk factors are increasingly falling to nursing staff, but the impact of a nursing-led optimization program on clinical outcomes is uncertain.
On March 30th 2025, results from “ALLEPRE: Alliance for Secondary Prevention After an Acute Coronary Syndrome” were presented at ACC Scientific Sessions 2025. The purpose of this study was to determine whether a structured, intensive, fully nurse-coordinated prevention program (NCPP) improves major adverse cardiac events (MACE) in hospitalized ACS patients.
ALLEPRE was a pragmatic, multicenter, trial performed in Italy that randomized patients hospitalized for ACS to standard of care or the NCPP in a 1:1 fashion prior to discharge. The NCPP consisted of over 250 cardiology nurses who underwent an in-person training course on cardiovascular prevention run by experts in medicine, nursing, and psychology. A validated form was used to teach the nurses the study protocol procedures. The NCCP intervention involved an in-hospital visit from the nurse as well as individual educational sessions post-discharge at 1, 2, 6, 12, 23, and 48 months. The sessions included CV risk profile assessment, healthy lifestyle promotion, monitoring of medication adherence, and referral to a nurse-independent multidisciplinary team when needed. The primary MACE outcome was a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI), or non-fatal ischemic stroke at 5 years.
Overall, 2,057 patients were randomized, 1,0231 to the NCCP arm and 1,026 to the standard of care arm. The median age was ~63 years, 22% were female, and 37% were current smokers. The majority of events were STEMI (47%) or NSTEMI (45%) with 86% undergoing revascularization during their index hospitalization.
The primary MACE outcome occurred in 16.2% of patients in the NCCP arm and 22.6% of patients in the standard of care arm; those in the nursing arm were 30% less likely to experience MACE, a significant difference (HR 0.70 [95% CI: 0.57, 0.85]; p=0.004). This was primarily driven by a significant 40% reduction in the risk of non-fatal myocardial infarction (9.3% in the NCCP arm vs. 15.2% in the standard of care arm; HR 0.60 [0.46, 0.77]; p=0.001]). There was no difference in ischemia-driven revascularization or all-cause mortality between the two groups. There was no evidence of heterogenous treatment effects across pre-specified subgroups. The NCPP was also associated with an improvement in BMI, physical exercise intensity, and medication by the end of the follow up period compared to the standard of care; no differences between the groups were seen for smoking cessation or LDL cholesterol.
Limitations include generalizability, although the training program for the nurses is validated and reproducible. Giulia Magnani, MD, PhD, a cardiologist at Parma University Hospital in Parma, Italy, and the study’s lead author, concluded: “Nurses are very important, because they are often the first point of contact for patients and their caregivers. Patients often feel more comfortable talking with a nurse about lifestyle modification. As cardiologists, we do very well with treating the disease with drugs, but we are not as good with changing behaviors, which is the hardest part…The ALLEPRE trial demonstrates that a fully nurse-coordinated prevention program significantly reduces the long-term incidence of the composite endpoint of CV death, non-fatal MI or stroke, in a high-risk ACS population. The benefit…emerged early and further accrued over time. Further studies and a cost-effectiveness analysis are needed before implementing the NCPP in the healthcare system.”