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Improving the prevention of cardiovascular disease

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VOL: 102, ISSUE: 07, PAGE NO: 23

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

Cardiovascular disease (CVD) leads to more premature deaths in the UK than any other condition, accounting for nearly 238,000 deaths in 2002 (National Institute for Health and Clinical Excellence, 2006). The 2000 National Service Framework for Coronary Heart Disease made it a top priority. The plan, which aimed to improve prevention, diagnosis, treatment and rehabilitation, is now halfway through its 10-year programme. It has already made a considerable improvement in the management and prevention of CVD (DoH, 2005) with a marked increase in the uptake of protective drug therapy in secondary prevention (Ramsay et al, 2006).

 

Cardiovascular disease (CVD) leads to more premature deaths in the UK than any other condition, accounting for nearly 238,000 deaths in 2002 (National Institute for Health and Clinical Excellence, 2006). The 2000 National Service Framework for Coronary Heart Disease made it a top priority. The plan, which aimed to improve prevention, diagnosis, treatment and rehabilitation, is now halfway through its 10-year programme. It has already made a considerable improvement in the management and prevention of CVD (DoH, 2005) with a marked increase in the uptake of protective drug therapy in secondary prevention (Ramsay et al, 2006).

 

 

Ramsay et al (2006) identify that despite this there is still room for improvement. The prevention guidance in the NSF was based on the first Joint British Societies (JBS) recommendations (Wood et al, 1998). These have now been updated (Wood et al, 2005) and it is important to apply these, along with other new evidence, such as that in the latest NICE (2006) guidance.

 

 

Risk assessment
The object of CVD prevention is to reduce the number of cardiovascular events, and strategies are aimed at those at highest risk (Box 1, p24).

 

 

The latest JBS guidelines (Wood et al, 2005) - JBS 2 - include new CVD risk prediction charts that estimate the risk of CVD over 10 years based on age, sex, smoking habit, systolic blood pressure and total cholesterol to high-density lipoprotein (HDL) cholesterol ratio.

 

 

Like most CVD risk assessment tools, this tool is based on the Framingham risk equation and may underestimate risk for certain subgroups, including British Asians, type 1 diabetics, type 2 diabetics with nephropathy, those with familial hypercholesterolaemia, those with a strong family history of premature coronary heart disease, those with left ventricular hypertrophy, and those with chronic renal disease (NICE, 2006).

 

 

NICE is developing guidance on cardiovascular risk assessment and is expected to publish this in September 2007.

 

 

Prevention
The JBS 2 guideline (Wood et al, 2005) sets targets for prevention in people who are at a high risk of CVD. It is important to be aware that risk factors should not be assessed in isolation as CVD risk is determined by the presence of all risk factors.

 

 

Lipid targets
Statins are first-line drugs for reducing total and low-density lipoprotein (LDL) cholesterol (Wood et al, 2005). The new treatment recommendations for statin therapy from NICE (2006) concur with JBS 2 (Wood et al, 2005), and the threshold for treatment is now lower than stated in the NSF (DoH, 2000).

 

 

Statin therapy is recommended for adults with clinical evidence of CVD and for primary prevention in adults who have a 20 per cent or greater 10-year risk of developing CVD (NICE, 2006). NICE recommends that treatment be started with low-cost drugs, taking both product price and daily dosage into account.

 

 

Blood pressure
Increased blood pressure results in an increased risk of CVD, so vigorous control is recommended (Wood et al, 2005). The relationship between blood pressure and cardiovascular risk is continuous, with recent evidence suggesting that it is steeper than previously recognised. However, thresholds for intervention with drug therapy are given to guide clinical practice (Wood et al, 2005).

 

 

Results from home blood pressure readings or ambulatory monitoring are usually lower than clinic readings, and so thresholds and targets should be adjusted downwards (by 10/5mmHg). Therefore when patients are self-measuring blood pressure, levels above 135/85mmHg should be considered to be in the hypertensive range.

 

 

Blood glucose
Glycaemia, in the population without diabetes, is also continuously related to the risk of developing CVD, in a similar way to blood pressure and cholesterol. This has important implications for measuring glycaemia in the overall assessment of cardiovascular risk and managing it alongside other risk factors (Wood et al, 2005).

 

 

Lifestyle interventions
Increased body weight also increases the risk of CVD. It is now known that this is not just linked to raised body mass index (BMI) but also to the distribution of fat, particularly abdominal obesity. The JBS 2 guidelines highlight evidence that waist circumference is the most practical measure of cardiovascular risk in clinical practice.

 

 

Weight reduction is appropriate for those who have a BMI above 25 and is particularly important for a BMI above 30. A waist circumference over 102cm in men and 88cm in women should also prompt lifestyle interventions.

 

 

Current cigarette smokers should be offered smoking cessation support and sedentary people offered professional support to increase their physical activity.

 

 

In addition advice should be given regarding increasing the intake of fresh fruit and vegetables to at least five portions per day, the regular intake of fish and other sources of omega 3 fatty acids, limiting alcohol intake, limiting salt intake and taking regular aerobic physical activity.

 

 

Cardiovascular protective therapy
Combined drug therapies are recommended in people with CVD and those at high risk of developing it. This includes:

 

 

- Antiplatelet therapies such as aspirin, 75mg;

 

 

- Beta-blockers in all patients who have experienced a myocardial infarction;

 

 

- ACE inhibitors in patients with heart failure or left ventricular dysfunction as well as those with coronary disease if their blood pressure is not meeting target levels;

 

 

- Calcium-channel blockers should also be considered in those with coronary heart disease who fail to reach blood pressure targets;

 

 

- Statins are important in all those with CVD or at high risk of getting it. The drugs should be titrated until total and LDL cholesterol targets are reached;

 

 

- Anticoagulants should be considered in people who are at high risk of systemic embolism.

 

 

Nursing implications
The National Service Framework for CHD has been a significant driver for improved management and prevention of cardiovascular disease.

 

 

Nurses play an important role in the prevention of CVD, taking the lead in both systematic and opportunistic CVD risk assessment.

 

 

The latest charts should be used to assess future risk over the next 10 years and appropriate lifestyle interventions and cardiovascular protective therapy considered if the risk is high. Patients in whom assessment does not give a high risk should then be reassessed within five years (Wood et al, 2005).

 

 

It is not necessary to calculate risk for people who have established CVD, diabetes or familial dyslipidaemia as these individuals already have an established high risk.

 

 

Providing timely lifestyle advice can reduce blood pressure and is an important preventive measure that can obviate the need for drug therapy in people with mild hypertension. All people with a persistent high blood pressure should receive lifestyle advice and this should continue even when drug therapy has been initiated.

 

 

Patient involvement in their own preventive care can be promoted by using risk factor charts to show how lifestyle changes are modifying risk. They can also be used to point out to younger people that if their current blood pressure and lipid levels remain unchanged they will reach the high-risk area at the age of 50.

 

 

This article has been double-blind peer-reviewed.

 

 

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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