Preventing Cardiovascular Disease in Primary Care

Clive Handler, Gerry Coghlan

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781138446250
• eBook ISBN: 9781315357300
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Cardiovascular disease is the leading cause of death and disability in the world. It is largely preventable, and can certainly be delayed by attention to established risk factors. Primary care is the natural and most appropriate location for cardiovascular prevention. This accessible and practical reference and everyday manual covers the organisation of prevention services, estimating risk and using guidelines, and examines each key area with extensive use of clinical case studies. It provides the information necessary to answer the concerns of patients on areas such as cholesterol, diet, exercise, alcohol, smoking and medication. General practitioners, practice nurses, physiotherapists, dieticians and pharmacists will find this book to be an essential aid to their daily work.

One

Developments in cardiovascular disease prevention

The changing role of primary care in cardiovascular disease

The past decade has seen a seismic shift in the management of cardiovascular conditions. As fund-holding has moved to the primary care sector (managed by Primary Care Trusts), so has responsibility for ensuring equal access to high-quality medical care throughout the patient’s care pathway. This places an enormous burden on the primary care team, as it is responsible not only for the care it delivers, but also for ensuring that it purchases quality services for secondary care. In addition, the team must cater for the needs of the whole population, not merely those who come through the door. The primary care physician now lives in a world of targets relating to management of obesity, smoking, cholesterol, blood pressure, heart failure and several other conditions.

The good (bad) old days

The obligations, duties and nature of the work of GPs and primary care nurses have changed considerably over the last 20 years. Home visits and out-of-hours duties have more or less disappeared from the routine work of GPs, except perhaps in isolated rural areas. Whether GPs will again take up these ‘traditional’ duties is unclear.

Until quite recently, GPs could essentially abandon all responsibility for the management of cardiovascular diseases to the specialist ‘expert’ if they so wished, for several reasons – both professional and scientific. GPs were not expected to provide specialist services, but were considered to be ‘experts’ on the ‘best way’ to treat patients. ‘Experts’ practised ‘eminence-based’ rather than evidence-based medicine; they had to because there were no nationally agreed management guidelines.

There were scant long-term epidemiological data to inform GPs about the relevance of individual risk factors. Some of the early large studies produced confusing information. Twenty years ago, there was controversy about the importance of what today are accepted as major risk factors. There was also less incentive to identify patients at high cardiovascular risk, because there were few available treatments. There was little information about the optimal levels of blood pressure, cholesterol and blood sugar. Where treatments were available, for example in type 2 diabetes, there were inadequate data to inform and persuade clinicians about which risk factors were important and should be treated. The same paucity of information applied to management of common cardiac conditions including angina, myocardial infarction and heart failure. The major advances in cardiovascular disease prevention and management, which younger clinicians take for granted, have occurred in the last 25 years.

Service provision

Rationing of healthcare could simply be managed through waiting lists. As there was no agreement on how to administer optimal cardiac care, the quality of and waiting times for services varied widely between hospitals just a few miles apart, depending on local ‘expert’ advice and management competence. Lapses in care were considered to be the responsibility of secondary care. There was, therefore, little incentive for or expectation of GPs to try to improve the situation, and there were no levers available to those who recognised the limitations of care delivery.

Drivers for change: guidelines and audit

In the 1970s, politicians and the public became increasingly disgruntled about the fact that there appeared to be no mechanisms for ensuring that recognised standards of care could be delivered. Similar levels of funding appeared to produce very disparate levels of care in different areas of the country. By the mid-1990s it was absolutely clear that the NHS was failing to deliver first-world-quality healthcare. However, despite the shortcomings of the new system, compared with the situation 10 years ago, high-quality care is now available to a much larger proportion of the population.

Throughout the 1980s and 1990s, large, randomised, controlled studies provided convincing evidence of the value of drug and other treatments in a variety of conditions. This led to a proliferation of guidelines on disease management. These allow clinicians and healthcare managers to evaluate whether treatments are justified and cost-effective, and whether service delivery is ‘up to standard’. Questions including: Does the patient need to be referred to a specialist? Does the patient need to be treated in a hospital by a specialist? What investigations should be performed? What is the most appropriate and cost-effective treatment? are now addressed in several national and international practice guidelines. Guidelines have become an integral part of all areas of clinical practice and the management mindset of clinicians in Europe and the USA.

Clinical audit was introduced a few years ago to allow healthcare professionals to measure and demonstrate their performance against agreed standards, introduce measures to improve their performance and re-check their performance in order to ‘close the audit loop’. Audit is a difficult discipline but it helps clinicians think about how they can improve their clinical practice and service, and provides objective information to help justify changes.

The NSF and all that

The National Service Framework (NSF) documents changed our world dramatically. Here, for the first time, we had the Government and medical experts agreeing on measurable standards of care that should be delivered. This contracted the Government to paying for a certain level of care, and the medical community to ensuring that this level of care would be delivered. Of course, the Government is committed to achieving this at the least possible cost, so there was a drive, largely based on cost, to deliver as much care as possible in primary care. This has been facilitated by the development of usually robust, evidence-based clinical management guidelines and new service delivery; for example, chest-pain clinics and nurse-delivered domiciliary care for heart failure.

Preventative care in the community based on global risk estimation

The aims of prevention are to reduce the risk of heart attack or stroke, to reduce the need for revascularisation in all arterial territories, and to improve the quality and length of life. Chapter 2 of the NSF requires all primary care practices to assess the cardiovascular risk profile of their patients. Non-pharmacological or ‘lifestyle’ advice is recommended for all. Drugs to reduce thrombosis, blood pressure, lipids and glucose are used if non-pharmacological methods are inadequate.

Practices should audit the outcome of smoking cessation, and achieve targets for blood pressure and lipids. Weight loss is easy to measure; diet and exercise are less easy to measure, but important in prevention.

Global risk of cardiovascular disease

It is recommended that all adults aged over 40 years who are not already on treatment, and who have no history of cardiovascular disease or diabetes, should have global risk estimation. In addition, global cardiovascular risk should be estimated in people with a family history of premature cardiovascular disease, or with symptoms suggestive of cardiovascular disease. This should include ethnicity, smoking history, family history of cardiovascular disease, weight and waist measurements, blood pressure, non-fasting lipids, and non-fasting glucose. In the UK, people’s 10-year cardiovascular risk is estimated using the Joint British Societies’ risk charts. In Europe, SCORE tables are used. These provide an approximate estimated probability based on five risk factors: age, gender, smoking, systolic blood pressure, and the ratio of total cholesterol: HDL cholesterol (total cholesterol in mainland Europe).

People with established cardiovascular disease or diabetes, those with high levels of one or more risk factors, and apparently healthy individuals who are at high risk (>20% risk over 10 years) of developing atherosclerotic disease, should be treated equally. All their risk factors should be treated. Initially, patients with a 10-year risk of more than 30% were to receive treatment; this has been reduced to include those with a 10-year risk of more than 20%.

The concept of global or total cardiovascular risk is sensible and practical. It has always, even subconsciously, underpinned clinical management decisions. In the same way as clinicians look at the ‘whole patient’ before recommending medical or surgical treatments when balancing the risk and the benefit of any intervention – whether aspirin or an aortic valve replacement – global risk estimation helps clinicians and patients make balanced decisions about preventative strategies and treatments. Total risk, based on all risk factors, rather than a single risk factor, is assessed. This is because cardiovascular disease is multifactorial; the presence of more than one risk factor is multiplicative and not additive, and risk factors tend to be associated or are clustered. Even if a target for one risk factor cannot be reached, a patient’s global risk can still be reduced by treating other risk factors. Nevertheless, treatment of a high single risk factor is necessary.

Lifestyle advice for all

All people should have lifestyle advice, irrespective of their global risk. Low-risk individuals should be reassessed annually depending on their age. Those at high risk should have lifestyle advice and treatment of individual risk factors.

Lipids

Statins have revolutionised the management of hypercholesterolaemia and have made a considerable difference to the prognosis of patients with vascular disease, and the clinical outcomes in all age groups.

Patients with a total cholesterol: HDL cholesterol ratio of >6.0 mmol/l should be treated with lifestyle and dietary advice, and a statin. People with familial hyperlipidaemia should be treated with a statin. An LDL-cholesterol target of <2.5 mmol/l (<2.0 mmol/l in the USA, and some parts of Europe) for those with vascular disease and 3 mmol/l for primary prevention have provided simple, auditable targets.

Hypertension

Stepped therapy for hypertension (calcium channel blockers, ACE inhibitors and diuretics), has provided a logical sequence of drugs to be prescribed before patients are referred to secondary care.

Simple guidelines for therapy (all patients with a persistent level above 160/100 mmHg and those above 140/90 mmHg who have end-organ damage, or a greater than 20% 10-year risk), identify the population to treat.

Treatment targets (<140/85 mmHg for most patients, and <130/80 mmHg for diabetics) have simplified and standardised management. Lower treatment targets in high-risk patients reinforce the concept of global risk and more aggressive intervention to achieve more stringent targets in high-risk patients.

Service organisation and delivery of care

Service delivery for cardiovascular prevention has required major reorganisation of primary care services. As most of this care is protocol-driven, nurse-led clinics have been set up throughout the country. Computerisation of practices and live database entry has made it possible to simplify audit. Regular audit meetings are held by most practices to ensure that standards are being met. Limited resources have forced clinicians and healthcare managers to question the merits and necessity of traditional practices, which sometimes make life uncomfortable and uneasy for patients, doctors and nurses.

Primary care clinics are now established in railway stations in the UK to offer ease of access to medical advice to people who work and have difficulty finding time to see their GP during working hours. Continuity of care and availability of patients’ medical records are problems encountered by such clinics, but are not insurmountable.

In-store primary care clinics are becoming more common in the USA. They are less expensive with low overheads because staffing and estate costs are low and are shared by the store. Appointments are almost immediate with a walk-in service offered, and this is more convenient for patients. But physicians express concern about quality of care. This type of clinic is staffed by nurse practitioners and provide only certain services (for example, vaccination; infections treatment; lipid screening; pregnancy tests; wart removal; bladder, chest, ear and throat infection treatment; minor sunburn treatment) which they feel do not require physician evaluation. The menu items are diagnoses and this puts more of the onus on patients to take responsibility for their health. Patients with important conditions are referred immediately to hospital emergency departments, but this assumes that these conditions are correctly diagnosed. Nurse-led, protocol-based triage is established in accident and emergency departments and so this potential problem is manageable.

NHS Direct and nurse-run, protocol-based decision-making services in UK primary care offer a similar concept of service. A similar model of in-store clinics could work in the UK.

GPs with a special interest in cardiology

The Department of Health advocates the use of GPs with a special interest (GPSI) in cardiology to improve access to cardiology services in the community. A national training and accreditation programme is being developed. The scheme has been endorsed by the British Cardiovascular Society, the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Nursing, the Primary Care Cardiovascular Society and the British Society of Echocardiography. It is not yet known whether this service will be popular with GPs or what the cost-effectiveness and clinical outcomes will be.

Specialist advice for dyslipidaemia, hypertension and diabetes

Secondary care is now recommended only for those with complex lipid abnormalities (familial hyperlipidaemia, some endocrine associated dyslipidaemia) and for the more complex hypertensive patients (unsatisfactory control despite three or more different medications; secondary hypertension – for example, hypertension during pregnancy; and young patients – below the age of 25 years).

The NSF for diabetes has also cleared the way for most diabetics to be managed in the community, setting simple strategies for regular assessment of complications and simple goals for therapy (HbA₁c <6.5%). Specialist referral is now necessary only for the minority of patients with type 2 diabe...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• About the Authors
• Acknowledgements
• 1 Developments in Cardiovascular Disease Prevention
• 2 Organisation of Prevention Services in Primary Care
• 3 Risk Factors, Risk Estimation and use of Guidelines
• 4 Hypertension
• 5 Lipid Disorders and Emerging Risk Factors for Cardiovascular Disease
• 6 Atherosclerosis Imaging and Screening
• 7 Obesity and Diet
• 8 Smoking
• 9 Exercise and Rehabilitation
• 10 Diabetes and the Heart
• Index