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Cardiovascular risk factors and their management in primary care

Key learning points 

  • 7 million people have been diagnosed and are living with cardiovascular disease (CVD)
  • CVD is largely preventable and addressing risk factors dramatically reduces the likelihood that it will develop
  • Primary care nurses have a significant role to play in reducing cardiovascular risk, especially by instilling healthy lifestyle choices in children

Cardiovascular disease (CVD) kills more than one in four people in the UK, with 435 dying each day, 190 of those from myocardial infarction (MI).1 Some 40,000 people die annually from stroke. Conditions such as transient ischaemic attack, atrial fibrillation (AF) and peripheral artery disease are included under this umbrella term. The prevalence of CVD is expected to rise. Although many people now survive their initial event, they then may go on to develop heart failure, incurring suffering for themselves and expense for the NHS. 

Cardiovascular disease is predominantly caused by smoking, hypertension, high cholesterol and diabetes.2 Evidence suggests that modifiable risk factors such as eating a diet high in salt and saturated fat, leading a sedentary lifestyle, depression and obesity are also inextricably linked.3

Bearing in mind that CVD is largely preventable, addressing the modifiable risk factors and adopting healthier lifestyle habits early in life would dramatically reduce the risk of developing it in the future. As healthcare professionals, we need to encourage and support, although ultimately it is down to the choice of the individual.

Definition of cardiovascular disease

Cardiovascular disease is defined as conditions that involve the heart, blood vessels or both, caused by atherosclerosis. This also includes some rheumatic and congenital heart diseases.3

The process of atherosclerosis can start at a young age and no one is exempt. Atherosclerosis occurs when the endothelial lining of artery walls becomes narrower because of atheroma (fatty substances, cholesterol, calcium etc), which develop into plaque deposits. This reduces the flow of oxygen-rich blood to the cells, tissues and organs and can eventually lead to symptoms of angina and intermittent claudication, which are all warning signs of CVD. If a plaque ruptures, platelets form at the site of injury, most commonly causing MI or stroke. Stroke and MI are of acute onset and are often the first time a patient realises they have developed CVD. Sadly, sudden death from MI accounts for 63% of women and 48% of men who may not have previously presented with any symptoms or have ignored them.4

CVD is subsequently a major cause of ill-health and can result in significant physical and psychological distress and long-term irreversible disability.

WHAT FACTORS CONTRIBUTE TO CVD?

Modifiable risk factors are:

  • Smoking – this remains the primary cause of preventable illness and premature death from CVD.5 A person under 40 who smokes is at five times greater risk of MI than a non-smoker of the same age. If they are able to quit, within a year their risk of MI falls to half that of someone who has never smoked and after 15 years, to that of someone who has never smoked at all. Despite the public awareness campaigns and evidence-based links to other serious health conditions, an individual often doesn’t realise the detrimental effect smoking has had on their health until a cardiac (or otherwise) event actually occurs. We need to reinforce that it is the toxins and carcinogens in smoke that cause ill health, not the nicotine.6 
  • Sedentary behaviour – this is linked to high blood pressure, high cholesterol, diabetes, weight gain and depression, all of which are intrinsically linked to CVD.6 In the current climate, much of our school and working lives involve sitting down for long periods of time, and we heavily use devices and social media – which means that as a nation, we can effectively run our lives without leaving the sofa. This could also impact on people’s social life, depriving them of social contact – hence the link with depression.
  • Eating an unhealthy diet – a diet that is high in saturated fat, sugar and salt, and lacks fruit and vegetables, or is of greater portion size than indicated for the individual, can have detrimental effects on cardiovascular health as well as general health. 
  • Excess alcohol intake – exceeding the recommended government guidelines of more than 14 units per week. 
  • Hypertension – some 30% of the adult population are living with undiagnosed hypertension and are therefore at greater risk of CVD. It is the single most modifiable risk factor associated with stroke, causing 50% of ischaemic stroke and increasing the risk of haemorrhagic stroke.7 Investigate if blood pressure (BP) is persistently greater than 140/90mmHg.
  • High cholesterol levels – these contribute to atheroma forming within the artery walls. Although we need a balance of good and bad cholesterol for healthy cell formation, when excessive levels of bad low-density lipoproteins (LDL) are circulating in the blood, atheroma is more likely to form within the artery walls. 
  • Diabetes – this damages blood vessels and nerves, and 80% of people with existing diabetes die from CVD-related complications.8

Non-modifiable risk factors are: 

  • Age – risk of CVD increases with age.
  • Family history – a family history is considered positive if there is CVD in the father, mother or siblings, if men are diagnosed aged 60 or under, women aged 65 or under. 
  • Gender – men are at greater risk. Women’s risk increases after the menopause.
  • Psychosocial factors – there is evidence to suggest that chronic stress, socioeconomic status, personality, depression and social support are strongly associated with the development of CVD – specifically coronary artery disease.8
  • Ethnicity – those of South East Asian origin are at higher risk of MI and those of African Caribbean origin are at higher risk of stroke.
  • Erectile dysfunction (ED) – this is a risk factor, but men are not likely to consult their GP about this because of embarrassment, so they miss opportunities for healthcare checks such as blood pressure measurement and lipid profile. Studies have suggested it is well documented that men with established CVD also have ED.8

HOW CAN PATIENTS MINIMISE THEIR RISK OF CVD?

Encourage patients to address their modifiable risk factors. Some may try to do everything at once, and then ‘crash and burn’, and return to unhealthy habits feeling very demotivated – which adds to the issues. Here’s a more sensible approach: 

  • Smoking cessation – advise patients not to start smoking if they are a non-smoker. Strongly discourage any children or teenagers from starting. If a patient does smoke, stopping is the most important thing they can do to protect their heart.
  • Becoming more active – advise patients to take part in physical activity and exercise, but be realistic. If they are housebound or restricted physically, they will not be able to do much, so encourage physical activity around the house as they are able.
  • Make small achievable dietary changes – reduce portion size, increase fruit and veg, trim visible fat, reduce salt, cook more healthily. They shouldn’t buy food they know is unhealthy. They may benefit from seeing a dietitian for an individualised plan.
  • Reducing alcohol intake – and encourage non-drinkers never to start. Apart from containing ‘empty’ calories, it can lead to weight gain and can increase triglycerides.
  • Signing up to campaigns as part of community and support networks – any changes they make are long term and may need motivation from others on the same path. Suggest they use health apps on their phones and devices to set themselves goals.

WHAT IS THE ROLE OF THE PRIMARY CARE NURSE?

The nurse’s role is to support, listen, encourage, advise and direct on modifiable risk factors – but not to lecture.

Nurses should use NHS screening to assess patients’ risk of developing CVD – it should be offered to individuals between 40 and 74 years of age. Take a family history of CVD, blood pressure and assess cholesterol status. If a high level is identified, a statin should be started as primary prevention to help reduce the LDL level and reduce the risk of CVD. The current recommendation is usually atorvastatin 20mg.  

Also take a random blood glucose level, measure the weight and BMI, and ask about alcohol intake. Discussing the results enables the patient to make informed choices about their health. They are then more likely to adhere to a treatment plan.9 The nurse should also discuss with patients their perceived risk and health-related behaviour, and be aware of influences such as the blame culture, the environment and stress.

Risk levels are as follows:

  • If <10% – at low risk of developing CVD.
  • If 10-20% – moderate risk.
  • If >20% – high risk.

Nurses should reinforce the importance of adopting a healthy lifestyle, even if all screening results are negative and low risk.

No one is exempt and we do not want to cause a false sense of security. The nurse should also explain that once CVD is
diagnosed, it never goes away and more risk factors are likely to develop.

  • If a patient has been prescribed medication for any of the following – hypertension, hyperlipidaemia, angina, atrial fibrillation (AF) and diabetes – discuss the importance of compliance because it reduces the risk of having an MI or a stroke. Discuss complications associated with type 2 diabetes.10 
  • If appropriate, refer the patient to a smoking cessation clinic, local support networks or to the GP for nicotine replacement therapy.
  • Encourage physical activity and exercise as appropriate. Refer to local exercise programmes, safety permitting.
  • Provide dietary advice literature on reducing intake of salt and saturated fat, or refer to a dietitian.
  • Be alert for the early stages of diabetes so that diagnoses can be made and management started.
  • Provide links to alcohol support networks. 
  • Encourage realistic and achievable goal setting for patients and their families.

Nurses should also keep their own professional development up to standard. Guidance can be obtained from the British Heart Foundation Alliance and advice from the National Institute for Health and Clinical Excellence (NICE) – see resources.

 

References

1 British Heart Foundation CVD statistics  March 2017) BHF fact sheets (accessed 13 April 2017).

2 National Institute For Health and Clinical Excellence. CKS CVD risk and assessment (2017) nice.org.uk/cvd/risk-assessment-and-management (accessed 13 April 2017).

3 World Health Federation. Cardiovascular disease risk factors. world-health–federation.org/cardiovascular-health/cardiovasculardisease (accessed 4 April 2017).

4 American Heart Association Heart attack symptoms in women. Accessed 17 April 2017.

5 Action on Smoking and Health ASH (2016) ash.org.uk/home/

6 National Institute For Health and Clinical Excellence, 2013. Smoking: harm reduction (guideline PH45).

7 Department of Health. Sedentary Behaviour and Obesity: review of the current scientific evidence, March 2010. 

8 Diabetes UK, 2007 diabetes.org.uk/.

9 Jackson G. Erectile Dysfunction and Cardiovascular Disease. Arab Journal of Urology 2013;11:212-16.

10 Strike P, Steptoe A. Psychosocial Factors in the development of Coronary Artery Disease. Abstract from Progress in Cardiovascular Disease 2004;46:337-47.

11 National Institute For Health and Clinical Excellence 2015. Cardiovascular risk assessment and lipid profile (guideline CG181) Quality Statement: Statins for primary prevention.

12 Nguyen GT, Klusaritz H, O’Donnell A et al. Examining the Feasibility of a Simple Intervention to Improve Blood Pressure control for Primary Care Patients. Journal of Cardiovascular Nursing 2016;31:291-5.

Resources

Alcohol support networks, nhs.uk/Livewell/alcohol/Pages/Alcoholsupport.aspx.

British Heart Foundation for support and provision of health education publications, bhf.org.uk/healthcare-professionals/bhf-alliance.

Heart UK – the cholesterol charity, heartuk.org.uk/.