Cardiovascular disease prevention: where are we now?

Although cardiovascular disease mortality rates have been declining, morbidity remains high – meaning that prevention is as important as ever. General practice nurses can make a real difference to patients’ risk of future or further events

Despite major investment and policy reform, cardiovascular disease (CVD) continues to be the biggest cause of mortality and morbidity in the UK, and has the highest associated costs to the NHS and the overall economy of any long term condition.¹

In 2000, the Department of Health published the National Service Framework (NSF) for coronary heart disease (CHD), a ten-year strategy designed to achieve a 40% reduction in premature mortality.² Although the implementation of NSF standards has made a tremendous positive impact and the mortality reduction targets have been met, the overall prevalence of CVD remains on the increase. With improvements in screening, diagnostics and treatments, many lives have been saved, but as a result many people are living with CVD as a long-term health condition.³

SO WHERE ARE WE NOW?

Premature death rates from CVD have been consistently falling since 2000. Medical treatments have been responsible for about half of the reduction in mortality, and approximately one third is attributable to lifestyle changes, such as stopping smoking, reducing cholesterol and being more active. Despite massive advances, however, the job is far from done and, with an ageing population, rising retirement age and increased poverty, it is more important than ever to try to keep the population healthy.

The CVD Outcomes Strategy⁴ was published in 2013, to provide advice to the NHS and local authorities on improving outcomes for people with, or at risk of CVD and, in 2014, the Joint British Societies produced JBS3, their latest consensus guideline on CVD prevention.⁵ Nationally, the NHS Health Checks Programme is the main means of delivering primary prevention of CVD.⁶

ASSESSING CARDIOVASCULAR RISK

The process of cardiovascular risk assessment involves gathering measurements and information from an individual regarding their status and exposure to known cardiovascular risk factors. Most commonly used risk assessment tools, such as the QRisk2 tool,⁷ widely used in primary care, are designed to express risk as a percentage figure over a given time frame, usually 10 years. Newer methods of expressing risk, such as those included within the JBS3 system, have emerged in recent years. These enable a broader view of risk to be taken, and offer a number of ways to present the information in order to communicate cardiovascular risk to an individual in a personalised and meaningful way.

Due to the formulae upon which they are based, cardiovascular risk engines and risk scoring tools are only appropriate for use in individuals who do not already have a diagnosis of CVD, i.e. for primary prevention. Those who already have a diagnosis within the cardiovascular spectrum should have individual risk factors assessed and treated (secondary prevention), but we cannot score the ‘risk’ of something that has already happened.

The risk of cardiovascular events in individuals with existing disease, such as diabetes and chronic kidney disease, is amplified to the extent that risk reduction attempts should be intensive and lifelong.⁵

MAKING A DIFFERENCE

Communicating cardiovascular risk

Effective communication of cardiovascular risk is essential to enable people to understand how and why they are at risk, and how they may address this. An understanding of their cardiovascular risk is key to an individual making informed choices about their treatments and any lifestyle modifications, and their motivation to maintain them. NICE prioritised the ‘high quality communication of cardiovascular risk’ in the 2012 Commissioning Guide to support services for the prevention of cardiovascular disease, reflecting the importance of this element of the risk assessment process. Many studies suggest that patients understand ‘absolute risk’ poorly and care needs to be given to the way information is presented and the language that is used. Often it can be helpful to make use of the variety of pictorial resources available, although this will not suit all people in the same way that statistics will mean nothing to some.⁸

Behaviour change

Managing lifestyle changes to reduce their risk will be one of the key challenges for patients with, or at risk of CVD. The range of lifestyle recommendations given will only help in the longer term if people are able to incorporate them into their lives and maintain the change.

Over the years it has become increasingly clear that behaviour change is a complex process and bombarding patients with unsolicited lifestyle advice is unlikely to result in any lasting change. Instead, it is helpful to focus on specific advice, tailored to the individual, so that they can judge what and how they want to change. Ideally this would follow an assessment of the importance of change to that person, and their readiness to undertake it, which then helps them to set realistic goals that they can monitor themselves.⁹ As Miller and Rollnick once pointed out: ‘If you are told what to do, there is a good chance you will do the opposite!’¹⁰

Behavioural advisor Damien Edwards gives some interesting insights into gender differences in the way we think, and provides some helpful considerations when communicating with behaviour change in mind.¹¹ Using the behavioural theory of communication (the ‘Theory of Primitive Concerns’), Edwards looks at how different responses to risk can result in people responding differently. With women typically being risk-averse and men being risk-seeking, two alternative styles of clinical instruction, based on using ‘power language’ and ‘safety language’, could be used, the theory being that we can help men to look after their own health by using language that matches their attitude to risk and presents self-care in a more powerful way.

Communication and behaviour change are, without doubt, complex subjects but it should be remembered that neither the patient, nor the risk assessor, is in this alone. Many other members of the healthcare team can support the communication, understanding and modification of cardiovascular risk, using the range of resources now available to support this process.

ALTERNATIVE WAYS OF LOOKING AT CARDIOVASCULAR RISK

Heart age

Heart age is an evidence-based concept that provides a simple way of predicting and showing risk in a way that most people can understand. It uses the same risk factor information as the 10-year risk score but presents it as the person’s heart age. This can then be compared to their chronological age.

A study of 3,000 people evaluated the impact of using heart age to promote healthier lifestyles and improved CVD risk factors compared with a conventional risk score tool.¹² The results showed that using heart age to raise awareness of CVD risk promoted behavioural changes that resulted both in a decrease in risk and a reduction in heart age, and was more effective than conventional risk scoring. The term has been introduced by JBS3 to help individuals visualise their current risk rather than relating it to events that may or may not happen in the future.

Lifetime risk

As well as adopting heart age, the JBS3 guidelines introduce the concept of ‘lifetime risk’. Until now risk stratification and prevention strategies have been based on the quantification of an individual’s absolute risk of developing disease over the next ten years. While this strategy does enable those with the highest short-term risk to be identified and offered treatments, it does little to address risk in the majority of younger people.

JBS3 describes the ‘continuum of risk’ in the population and highlights that most CVD events occur in those at ‘intermediate’ risk. Although current guidance would not indicate the use of statins and other risk modifying therapies in this group, it is possible that more people could be motivated to make lifestyle changes if their risk of CVD over their lifetime was understood. There is also a risk that people could be falsely reassured by a low 10-year risk score, particularly younger people and women, and that these individuals could have substantially elevated modifiable risk factors contributing to a higher risk over their lifetime. JBS3 provides us with some helpful new approaches to give meaningful information to those people who may be storing up potentially devastating health problems for the future as a result of the choices they make today.

SECONDARY PREVENTION OF CVD

People with established disease of any nature within the cardiovascular spectrum have the highest level of risk and will benefit from intensive risk factor modification, particularly high intensity statins following myocardial infarction, anticoagulation for individuals with atrial fibrillation (AF) and antiplatelet therapy in peripheral arterial disease (PAD).⁵ Current guidance suggests that individuals with evidence of CVD should be treated in a similar way, regardless of clinical presentation and the vascular territory affected. In other words, whether the patient has had an MI or stroke, or has PAD, or any other form of CVD their preventative treatments should largely be the same.

The key treatment aim for all people with CVD is to delay disease progression and prevent cardiovascular events. There are extensive recommendations from NICE and JBS for risk reduction in coronary artery disease, stroke, PAD and chronic kidney disease (CKD) reflecting the high-risk nature of these groups.

The influence of diabetes on CVD risk must be addressed and there are specific recommendations on control of blood pressure, lipids and glycaemia in people with both type 1 and type 2 diabetes.⁵

Managing cardiovascular risk

Therapies

For the primary prevention of CVD, therapy recommendations focus on blood pressure control and lipid modification, accompanied by professional lifestyle support. NICE provides guidance for the management of hypertension and lipid lowering and JBS3 suggests therapeutic targets for those receiving lipid-lowering drugs (Table 1).⁵ These target levels are repeated for people with established CVD risk, which should help avoid confusion in practice. JBS3 does, however, endorse the use of non-HDL cholesterol as a predictor of risk and a measure of treatment efficacy rather than total cholesterol and LDL cholesterol alone. This will, if implemented, be a new approach for most healthcare professionals.

We are also reminded that addressing overall CVD risk rather than focusing on blood pressure and lipid lowering alone is likely to be most beneficial. The guidance is clear that there is no role for aspirin in the primary prevention of CVD or for stroke prevention in AF, though aspirin remains a standard secondary prevention measure for coronary heart disease.

Following MI or percutaneous coronary intervention (PCI) time-limited dual antiplatelet therapy with another agent such as clopidogrel or prasugrel will be used.⁹ Additional condition-specific treatments will be required in the majority of patients, and newer drugs such as PSK9 inhibitors, the new lipid lowering agents, are becoming available to support or provide an alternative to existing therapies and should be welcomed into the ‘prevention fold’. Drugs used in CVD prevention are shown in Table 2.

LIFESTYLE STRATEGIES

Modification of an unhealthy lifestyle is really effective in reducing the risk of CVD in both primary and secondary prevention. The issue is that people have to make the changes and stick to them, which is a challenge to many of us!

What we should all be doing doesn’t change; not smoking, following a balanced diet that is low in sugar and saturated fats, maintaining a sensible weight and being physically active are the mainstay of a healthy lifestyle. Nurses in general practice have been advising and supporting patients to make lifestyle changes for decades and will all have seen challenges and successes in this field. Recommendations have varied slightly over the years but the key messages remain.

A really important influencing factor is how the advice is offered (see Communication, above) The evidence suggests that the way cardiovascular risk is communicated can be very helpful in influencing an individual to improve their lifestyle,12 and to further support this many risk assessment tools can be populated in such a way to demonstrate the impact of change on that person’s risk.

LIFELONG MONITORING AND SUPPORT

The annual review of patients with CVD is a routine element of primary care. To help direct a systematic approach to care the Quality and Outcomes Framework (QOF)¹³ lists a number of clinical indicators to be attained in this population and, in most practices, the nursing team delivers much of the routine care.

The annual review encompasses all of the routine monitoring required for people living with a long-term condition. As well as assessing any symptoms, routine monitoring should include:

• Physical examination involving blood pressure and pulse assessment
• Height and weight
• Blood tests.

Monitoring blood pressure and pulse offers the opportunity to ensure that any hypertension is being managed within recommended targets, and will also detect any potential cardiovascular side effects of medications, including hypotension or bradycardia. It also provides an opportunity to screen for any cardiac rhythm disorders such as atrial fibrillation (AF).

Routine blood tests, to monitor effects of medications, risk factors and disease progression, will usually include:

• Renal function
• Liver function
• Lipids
• Glucose.

It’s worth remembering that the actual evidence-based targets for blood pressure and cholesterol are lower than the minimum standard threshold required by the QOF, and may be lower still in patients with co-morbidities such as diabetes or CKD. The annual review also provides a useful opportunity to check patients are on the right medications, at the right doses, and to assess and support adherence.⁹

CONCLUSION

The need to quantify cardiovascular risk and offer interventions to those at higher risk, along with advice and support to help those at lower risk remain healthy, remains a clinical priority in healthcare today, with primary care nurses at the forefront of delivery. Public health programmes such as NHS Health Checks and disease management strategies in primary and secondary care will continue to be the key methods of improving cardiovascular health across the UK.

JBS3 serves to enhance existing initiatives by supporting the all-important communication of risk to individuals and, in doing so, should promote the uptake of lifestyle changes and therapies to reduce CVD risk. We now have a variety of ways to present information to people, empowering them to make informed decisions about their future. There is little to be gained from taking measurements and questioning people about their risk factors if they are unable to understand the significance of the results and how they can influence them. There seems to be no real ‘right or wrong’ way to present and discuss these results with people, the skill may be in finding out which method ‘speaks’ to the individual and is meaningful to them.

In managing risk we have all the tools to do the job, the challenge is using these appropriately and effectively.

Whether you are a healthcare assistant in general practice, a practice nurse or a highly qualified nurse practitioner, the prevention of CVD is everybody’s business and everybody working in primary healthcare has the opportunity to make a difference.

REFERENCES

1. British Heart Foundation. Cardiovascular Disease Statistics Compendium 2017. https://www.bhf.org.uk/research/heart-statistics/heart-statistics-publications/cardiovascular-disease-statistics-2017

2. Department of Health. The National Service Framework for Coronary Heart Disease, 2000.

3. Lampe FC, Morris RW, Walker M, et al. Trends in rates of different forms of diagnosed coronary heart disease, 1978 to 2000: prospective, population based study of British men. BMJ 2005 BMJ 330 : 1046

4. Department of Health. Cardiovascular Disease Outcomes Strategy, 2013.

5. JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014; 100:ii1-ii67

6. Department of Health. Putting Prevention First – vascular checks: risk assessment and management, 2008 (Archived).

7. Hippisley-Cox J et al. Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ 2010 341:c6624

8. Manis K. Communication of Cardiovascular Risk. Pulse 1 September 2014

9. NICE CG172. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease, 2013. https://www.nice.org.uk/guidance/cg172

10. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change. 2002;Guilford press

11. Edwards D. Motivating Men and Women: what presses the right buttons: British Journal of Primary Care Nursing 2011 8(3) 113-115

12. Lopes-Gonzales AA et al. Effectiveness of the Heart Age tool for improving modifiable cardiovascular risk factors in a Southern European population: a randomized trial. Eur J Prev Cardiol. 2015 Mar;22(3):389-96

13. NHS employers. Changes to QOF 2017/18.

14. British National Formulary. Treatment summaries, September 2017 https://bnf.nice.org.uk/treatment-summary/