Delyth Rucarean, chair of the British Society for Heart Failure (BSH) Nurse Forum and an advanced heart failure nurse practitioner in Wales, gives Nursing in Practice editor Carolyn Scott her perspective on current priorities in cardiovascular disease prevention and management
Where are we now regarding cardiovascular disease, from your point of view?
We know cardiovascular disease (CVD) is very common, with really high mortality rates, and that it is the largest cause of premature death in areas of deprivation across the UK. The rate of death from acute events such as heart attacks has fallen in recent decades, but the number of people living with heart conditions and associated risk factors has risen, possibly linked to the 1950s baby boom translating into a peak of people in their 70s with CVD.
Looking at heart failure, for example, we know prevalence is set to double by 2040.1 Currently, we have a million people in the UK with heart failure and 200,000 people receiving a new diagnosis each year. We also estimate there are some 385,000 people living with undiagnosed heart failure1 who are consequently missing out on life-preserving treatments. But we can make a big impact in the NHS in the next 10 to 25 years.
The BSH’s ‘#25in25’ quality-improvement programme aims to help reduce heart failure deaths by 25% in the next 25 years.1 This could translate to 10,000 lives saved each year. There will be a pilot phase in 2024 and the initiative will roll out nationally in 2025. It aims to improve population health by identifying undetected heart failure, based on four domains: risk analysis; accurate and timely diagnosis; guideline-directed medical therapy; and patient quality of life measures such as mental health and wellbeing.
There will be a focus on health inequalities by tackling access, patient experience and improving outcomes in under-served communities.
While 80% of people are diagnosed in hospital, 40% of them have symptoms that might have triggered concern earlier through assessment in primary care.2 I often see patients in hospital who have had leg oedema or breathlessness for several months that they have put down to other things such as ‘getting older’. They may not recognise their symptoms as potentially indicating heart failure.
This is highlighted by the BSH’s ‘The F Word’ campaign, which encourages people to recognise the common heart failure symptoms of Fighting for breath, Fatigue and Fluid build-up.3 This provides an early-warning system for symptoms leading to heart failure, and encourages prompt diagnosis and referral.
What’s being done across the UK in cardiovascular disease?
A range of things is being done to help with this sizable challenge, such as the national cardiovascular disease programme alongside the NHS Long Term Plan, which looks to promote early detection and treatment optimisation, and identify undetected and high-risk conditions, such as high blood pressure, raised cholesterol and atrial fibrillation (AF).4
Nationally, we are looking at improving data flow and referral across pathways between primary secondary care. In Wales, for example, we have the Welsh clinical portal, which enables us to share information between hospital and community settings.5 From the hospital side, we can’t necessarily see all the GP consultations but we can see the medications issued, blood test results and so on. Within our area, nurses in general practice can see hospital discharge letters and clinic letters, and the results of tests done in hospital, such as bloods, chest X-rays and echocardiography.
A more collaborative approach is needed between primary and secondary care, local authorities and voluntary sector partners and others such as community pharmacies. We’ve been working in silos for too long, and we need to change the way we deliver healthcare. More community pharmacists are offering hypertension checks and health-check services, for example.
I think it’s useful to be aware of the new national cardiovascular disease prevention audit for primary care – the CVDPREVENT audit.6 This will pull out routinely recorded but anonymised GP data, to enable GP practices to identify individuals whose treatment can be improved or risks reduced. This will help to address inequalities and improve outcomes for individuals and populations.
It will focus on six high-risk conditions that cause stroke, heart attack and dementia: AF; high blood pressure; high cholesterol; diabetes; non-diabetic hyperglycaemia; and chronic kidney disease. It also has a range of online resources for patients.
Testing and evidence
There is much work to be done. Better identification and management of AF is a priority to reduce stroke risk – there are a lot of people with undetected AF, putting them at high risk of stroke. Then there’s a need to expand access to genetic testing for familial hypercholesterolaemia, and – coming back to heart failure and heart valve disease – increase access to diagnostic tests.
We need greater access to echocardiography within primary care settings, not just in secondary care. The gold standard for diagnosing heart failure is an echocardiogram, but I think we also need to ensure access to the B-type natriuretic peptide (BNP) blood test, which is recommended by NICE for the assessment of suspected heart failure.7 It’s a simple, cheap test – it’s not diagnostic but it will help rule out heart failure in a patient presenting feeling breathless.
It’s important that we all ensure that we are aware of what’s in the NICE guidance, and that we are all working to that evidence-based approach.
It’s also great that we have a national network of trained community first responders and defibrillators, known as GoodSAM.8 This is a large system that integrates with ambulance services and computer-aided dispatch to initiate bystander response to someone having a cardiac arrest outside hospital.
What can be done by nurses and other staff in general practice in 2024?
While I’ve not worked as a general practice nurse, I was a chronic conditions nurse for many years in primary care, attached to GP surgeries and seeing patients in their homes. I was then part of an acute response service, and ran a heart failure clinic in a community setting. I now work in an acute setting in Swansea.
Prevention
We all need to work together to focus on preventing cardiovascular disease. CVD is largely preventable and there are things that we can do, in primary and secondary care, to reduce the risk. As we know, one of the simplest things – yet the hardest to achieve – is a healthy diet and exercise, and people need support to make lifestyle changes. We need a combination of public health and NHS action on aspects such as smoking and tobacco addiction, obesity and alcohol. Simply eating too much salt results in thousands of heart attacks, strokes and early deaths. Better prevention could result in a huge cost saving for the health service. We want to avoid unnecessary admissions and reduce mortality rates, and we need to build on that together.
Advice for lifestyle change
One of the key roles of general practice nurses is to offer education and opportunistic guidance in support of lifestyle change. Many patients I see in hospital with heart failure have multiple comorbidities, such as diabetes or hypertension, and they will have been seen many times for those conditions.
Of course, it is difficult to get people to change their lifestyle; we need the public to engage in healthy behaviours. Education is needed around things like weight management, alcohol consumption, lipid modification, healthy eating, exercise, stopping smoking, optimising diabetes management and using opportunities such as social referral schemes.
We all need to make every contact count. What is the cause of a patient’s leg oedema? Has a patient who wants advice on losing weight also been tested for diabetes? Seeing the patient as an individual rather than a set of conditions, as well as making time for holistic review, has never been more important.
Coding
If coding isn’t right in the general practice records then people with, say, heart failure or AF may not get the follow-up they need. Someone might have been coded with heart failure yet never had an echocardiogram or been seen by a specialist heart failure team, for example. Perhaps they did have an echo in hospital but that information wasn’t passed on or recorded in primary care. Getting coding right will provide greater access to resources and follow-up, contributing to better outcomes.
Medication review
Medication review performed by the pharmacist or advanced nurse practitioner can be pivotal, of course. Reviewing patients on specific medications – such as sacubitril/valsartan (Entresto), which is only used for patients with heart failure with reduced ejection fraction – is an opportunity to ensure they are coded correctly and have appropriate follow-up in place.
Signposting resources and linking with other organisations
Lots of educational resources are available for patients with heart failure, and it is important that general practice nurses have a full range of information available for patients with chronic diseases. Having that information is really important, as is drawing on the support of other colleagues and having access to social prescribing.
Communication between primary and secondary care
We all need to focus on better communication. Was a patient’s discharge summary completed when they were discharged from hospital? If not, that should be looked in to. Without effective two-way communication, we may duplicate or request unnecessary tests, and may lack the full picture of the cause of admission or the care delivered.
Looking ahead
The role of nurses in primary care has never been more important. GPNs are in a prime position to make a significant impact on the future health of our society. However, with an ageing population, health inequalities and the problem of undetected heart disease, we need to make every contact count, be proactive and work collaboratively, using all the resources available to us.
Resources
- British Society For Heart Failure. bsh.org.uk
- NHS England. Cardiovascular disease. tinyurl.com/NHSE-CVD
- CVDPREVENT. tinyurl.com/CVD-PREVENT
- NHS Health Check: Coronary heart disease. tinyurl.com/NHS-Hcheck
- NHS Long Term Plan: Cardiovascular disease. tinyurl.com/LTP-CVD
- NHS Wales. The quality statement for heart conditions. tinyurl.com/Wales-heart
- GRIFT report: Cardiology. tinyurl.com/GRIFT-CVD
- NICE CG181. Cardiovascular disease: risk assessment and reduction, including lipid modification. nice.org.uk/cg181
- Primary Care Cardiovascular Society.Transform HF Toolkit. pccsuk.org/programme
- NICE NG106. Chronic heart failure in adults: diagnosis and management. nice.org.uk/ng106
