Implementation of a chronic disease management programme in primary care in Ireland

Prof. McDonald discusses NT-proBNP testing in chronic disease management
Rationale for the development of the CDM programme in Ireland

Data shows that, even upon tight  control of cardiovascular (CV) risk factors in people with diabetes, heart failure (HF) remains a significant concern, especially in younger populations (<60 years old).1 In the 50–60 year age range, there is a strong prevalence (about 30%) of left ventricular structural / functional abnormalities in the absence of HF symptoms.2 Natriuretic peptides (NPs) are the strongest biochemical predictor of such subclinical HF and play an important role in defining people’s risk of developing subsequent HF.3,4 In fact, NPs serve as a signal for the evolution of heart damage5,6 and are, therefore, more specific indicators of risk than other risk factors.


Currently screening for heart failure in diabetes patients is still lacking in routine primary care practice, indicating the need to explore strategies for its implementation.

Prof Ken McDonald


The STOP-HF randomised clinical trial included patients at risk for developing HF (stage A or B). Patients were randomised based on their NP levels to either routine primary care/CV care delivery, or shared care between primary care and cardiologist specialists. In the intervention group, risk factors were tightly controlled and cardio-protective medication was used.4 The results of the trial demonstrated  a significant reduction in the prevalence of left ventricular diastolic dysfunction (LVDD), left ventricular systolic dysfunction (LVSD) and in the incidence of HF for patients that received shared-care, with strongest reductions observed for patients with highly elevated NP levels. While HF events were significantly reduced from an annual incidence of 1.5% to 0.4%, the intervention also showed dramatic impact on the reduction of other cardiovascular events (i.e. CVA/TIA, dysrhythmia).4 Coupling this strategy with specific therapies7,8 for prevention of HF that have more recently become available (such as SGLT2i) has the potential to lead to even more effective outcomes.7 

Stemming from this background, a structured programme, named Chronic Disease Management Programme (CDM) was developed in Ireland for patients with established CVD, T2D, chronic obstructive pulmonary disease, and asthma. 


More than 90% of general practitioners (GPs) are participating in the CDM programme and the emphasis is on providing care in the community while empowering patients.

Prof Ken McDonald


A closer look at  T2D patient management for CVD prevention  


The programme focuses on a very strict risk factor management and the prescription of cardioprotective therapies (RAAS inhibitors and SGLT2i) after assessment of risk using NPs. GPs are educated on how best to interpret NP results, particularly in the presence of confounding factors such as atrial fibrillation (AF) or renal impairment, and how to act upon elevated NP levels: optimise blood pressure control, look for evidence of stage B HF on echocardiography, look for presence of AF.

The programme provides a variety of GP aids including: 

  • Booklets with detailed information on different NP cut-offs, depending on presence or absence of HF symptoms and patient age 
  • Specialist opinion via virtual or offline consultations in case of uncertainties in the  interpretation of NP results

Currently, NP assessment in the T2D frame of the programme is a one-time test but the need for sequential review, especially for patients whose initial NP level classified them as low risk, is being further evaluated. 

To date, the programme has enrolled more than 500,000 patients, with more than 20% having T2D. Importantly, Prof. McDonald highlighted that the CDM programme has shown a clear impact on CV metrics, such as reduction in low-density lipoprotein (LDL) cholesterol levels, reduction in total patients with uncontrolled hypertension and improvement in overall diabetes control.  




The CDM programme (winner of a United Nations award) offers an innovative approach to the prevention and management of chronic diseases. The programme serves as both an example of the implementation of HF screening in clinical practice, and as an important vehicle to create inroads into the specific risk for HF in the T2D population, particularly by leveraging the value of NPs as an indicator of that risk and triaging patients into specific therapies that can reduce that risk. 

Key facts
  • Heart failure is a significant concern in people with diabetes due to the strong prevalence of left ventricular structural / functional abnormalities in the absence of HF symptoms.
  • Implementation of routine screening for HF in diabetes patients using biomarkers is still lacking in primary care practice.
  • Prof. McDonald describes a Chronic Disease Management Programme (CDM) developed in Ireland, focusing on risk assessment using natriuretic peptides, strict risk factor management and prescription of cardioprotective therapies. 
  • Central focus of the CDM is the implementation of a shared care approach including primary care and cardiology consultations, especially for patients with elevated NP levels.
  • The CDM programme impacted important CV metrics, i.e. hypertension and diabetes control and serves as an example for the implementation of HF screening in clinical practice.

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