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Coronary heart disease: tackling secondary events

Jane E Powell
BSc(Hons) RGN
West Midlands Regional CHD Coordinator
Partnership for Developing Quality
Edgbaston Birmingham
E:jane.powell@wmpdq.org.uk

The National Service Framework for Coronary Heart Disease (CHD) was launched in March 2000.(1) The NSF for Older People came out a year later.(2) These documents have, for the first time, given standards and service models for all practitioners involved with CHD patients and those suffering from stroke. The risk factors are broadly the same for both diseases - hypertension, smoking, poor diet and a low level of physical activity. The risk factors for CHD can be divided into modifiable and nonmodifiable (see Table 1).

There exists substantial evidence that certain therapeutic interventions and modification of CHD risk factors can reduce the risk of recurrent CHD events and premature death in patients with established heart disease.(3) The burden of CHD upon society is great, with an estimated 170,000 deaths in the UK per annum - over 25% of all deaths. Death rates in the UK from heart disease remain among the highest in the world.(4) The British Cardiac Society's national survey, ASPIRE,(5) demonstrated clear discrepancies in the extent to which ­individual risk factors were recorded, and significant shortfalls in risk factor management and use of ­interventions of proven benefit.

What can primary care practitioners do?
As health professionals in the primary care arena, practice nurses have the insight and ability to highlight those with established CHD and those at high risk of developing disease. The main priority is to offer interventions to patients with established CHD, and then to people who are currently without evidence of occlusive arterial disease but whose risk of CHD events is greater than 30% over 10 years (as set out in the NSF for CHD).
 
Practice nurses need to identify their own training needs in order to deliver a comprehensive CHD service. To ensure that standardised care and information is given to these groups of patients, it is imperative that practice nurses attend a recognised course, such as the British Heart Foundation Heart Save course.

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Other requirements of primary care are to ensure that patients are entered onto a register. This requires a collaborative approach by the medical practice; the responsibility should not remain with one individual. Identifying individuals for the register is time-consuming and often the responsibility of the nurse. Drug searches are required to identify patients for the register. A system should be set up whereby the register is maintained and continually updated, which again requires a collaborative approach. To achieve this a systematic approach to follow-up needs to be applied. This has generally taken the form of nurse-led secondary prevention clinics in primary care. To ensure that treatment and follow-up are standardised, protocols need to be developed for use in the clinic. To ensure ownership, these protocols should be agreed among members of the primary care team, local cardiologists/biochemists, and Primary Care Group/Trust representatives.

Follow-up in the clinics should monitor cardiac risk factors, such as:

  • Blood pressure.
  • Cholesterol.
  • Weight.
  • Smoking.
  • Dietary habits.
  • Exercise.

A useful tool for recordkeeping is the "Patient-held Record Card". This helps to involve patients in their care and gives them some ownership.
 
As well as monitoring risk factors the practice nurse needs to be able to give appropriate advice or refer to an appropriate professional. Therefore the practice nurse needs a wider knowledge of the other services available outside general practice.
 
Reviewing patient medication should also be done in the clinic, to ensure the patient continues to take appropriate medication, such as aspirin, statins and b-blockers. Information about the drugs and their importance and possible side-effects should be made available. All information and advice given should be adequately documented and available for other health professionals involved in the patient care. It is important that primary and secondary care professionals break down the barriers at the interface and become mutually supportive for the ­benefit of the patient.
 
Interventions in secondary prevention can be ­separated into nonpharma- cological and pharmacological (see Table 2).

A holistic approach to the review is preferable. This should include social, financial and employment issues. Gaining knowledge of the wider services and where to refer is necessary to achieve this approach.

The secondary prevention clinic
The secondary prevention clinic is about health promotion and health education. Knowledge of the behaviour change model and how to apply it is necessary to ensure that the clinic time is seen as successful for both patient and nurse, that there is no failure, and that people are allowed to relapse and re-enter the cycle of change. It is necessary to give patients a plan, whether a diet or exercise plan or both, and to review this on ­follow-up.

Evaluating the progress against the NSFs should be done at a practice level. Clinical teams should meet every quarter to discuss and plan clinical audit, ensure medical records are well organised, and ensure that there is a systematically developed and maintained CHD ­register.

Patient participation in the process is invaluable, and feedback should be encouraged. Patient satisfaction questionnaires are a good tool to acquire some ­qualitative data. It is advisable for nurses to develop a system for collecting patients' comments so that they can respond in a timely fashion.

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Conclusion
Research has demonstrated that simple treatments and important lifestyle changes can substantially reduce people's risk from further events. Practice nurses have an important role to play in influencing this phenomenon.

For more information on the British Heart Foundation Heart Save course, access the BHF website: www.bhf.org.uk, or tel: 01865 226975.

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References

  1. Department of Health. National Service Framework for Coronary Heart Disease. Preventing coronary heart disease in high risk patients. London: DoH; 2000.
  2. Department of Health. National Service Framework for Older People. London: Department of Health; 2001.
  3. Yusuf S, Lessen J, Jha P, Lonn E. Primary and secondary prevention of myocardial infarction and strokes: an update of randomly allocated controlled trials. J Hypertens 1993;11(Suppl 4):S61.
  4. Boaz A, Rayner M. Coronary Heart Disease Statistics. British Heart Foundation/Coronary Prevention Group Statistics Database. London: BHF; 1995.
  5. The ASPIRE Steering Group. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease. Heart 1996;75(4):334.

Resources
British Heart Foundation
W:www.bhf.org.uk
Primary Care Cardiovascular Society
W:www.pccs.org.uk
British Cardiac Society
W:www.bcs.com
Children's Heart Federation  - information for ­children, their parents and ­professionals
W:www.childrens-heart-fed.org.uk
Heart Diseases
National Electronic Library for Health
W:www.wish-uk.org/znelh
MedwebCardiology - commercial site offering free access to ­cardiology ­publications
W:www.medwebplus.com
National Heart Forum - alliance of national ­organisations ­working to reduce the risk of coronary heart disease in the UK
W:www.heartforum.org.uk
National Heart Support Association - information for patients and their families
W:www.heartlink.org.uk

Further reading
Iqbal Z, Chambers R, Woodmansey P. Implementing the National Service Framework for Coronary Heart Disease in Primary Care. Oxford: Radcliffe Press; 2001