FM&PH – Primary prevention of Cardiovascular disease

In module Family Medicine and Public Health

Brian is a 50 year old man who visits his doctor because his wife told him he needed a check-up. She attends with him.

MAIN CASE

Guidance and Resources – Primary prevention of Cardiovascular disease 

Case Introduction – Primary prevention of Cardiovascular disease 

Further Case Information – Primary prevention of Cardiovascular disease 

Background Science – Primary prevention of Cardiovascular disease 

Case Conclusion – Primary prevention of Cardiovascular disease 

CASE COMPONENT

Guidance and Resources – Primary prevention of Cardiovascular disease 

In case FM&PH – Primary prevention of Cardiovascular disease

Reference material and Resources

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

Recommended essential reading:

· Case of Hypertension ( year 4)

· JNC-8-Guidelines

· 2014-JNC-8-Hypertension

· preventing the onset of cardiovascular disease

· Risk factors for CVD

· NHS.UK: Physical Activity information

· NHS.UK: The Eatwell Guide

· Smoke-quit-smoking-coaching-guide

· Tobacco intervention pocket card

· QRISK 2 Online Tool

Additional Information/References

1) AHA-Hypertension-Guideline-Highlights 2

2)ACC AHA 2017

3)Saudi Clinical Preventive Guideline (2023 final Version)

4) Murtagh 8th Edition

· NICE Cardiovascular disease: risk assessment and reduction including lipid modification

· NHS Choices: Healthy Eating Resources

· You might also want to remind yourself of the terms ‘absolute’ and ‘relative’ risk.

· You have learnt about psychological intervention strategies in Lifestyle Change Communication. Remind yourself of this material.

CASE COMPONENT

Case Introduction – Primary prevention of Cardiovascular disease 

In case FM&PH – Primary prevention of Cardiovascular disease

Brian is a 50 year old man who visits his doctor because his wife told him he needed a check-up. She attends with him. He visits Dr Johan, who checks with Brian that he is happy to have the consultation with his wife present. Brian says he’d rather speak alone with the doctor, so Dr Johan invites her to wait in the waiting room. She agrees to this – at the door before leaving she adds ‘He needs his cholesterol checking too’ and then leaves, closing the door behind her.

Dr Johan starts the consultation with Brian alone. He asks if there is anything particular he wants to discuss. Brian admits that he has been worried about his health, as he’d not attended for a health check, which many of his friends, and his wife had been to. He says he feels well although he thinks he is unfit. He has never had any illness in his life and takes no regular medication.

Brian works as an accountant. He currently smokes 10 cigarettes a day. He says he doesn’t like to drink during the working week as he feels it makes his working day more difficult. He has no significant past medical history, but he knows that both his parents had type 2 diabetes. He doesn’t take any medication.

Brian is feeling pleased that he has come now and would like his cholesterol checking. His father had an MI at the age of 60, and died from heart failure last year. Since then Brian has cut down cigarettes from 20 per day to his current amount of 10 per day. He knows that smoking and cholesterol can increase the risk of heart disease and stroke. He says he also knows that he should exercise more, but finds it hard to find the time with work, which is mainly sedentary.

Dr Johan outlines that cholesterol can be checked by a blood test, but it does not give all the information that Dr Johan would need to make sure that Brian is doing all he can to reduce his risk of cardiovascular disease.

There are also certain conditions which have associations with cardiovascular disease and in which modification of any risk factors is even more important. These conditions include HIV, renal disease, gout and erectile dysfunction. Brian does not have any other conditions.

Dr Johan outlines to Brian about the risk factors for cardiovascular disease, and asks permission to take his height, weight and blood pressure, which Brian agrees to. Dr Johan enters the results as follows onto the computer system:

· BP: 178/96

· HR: 88 bpm (regular)

· Height: 178cm

· Weight: 92kg

Dr Johan discusses the findings with Brian, and arranges a 24 hour blood pressure recording for the following week. He also suggests that they arrange some blood tests, and also book in with the nurse to discuss lifestyle and smoking cessation, which Brian is keen to do.

You have learned about psychological intervention strategies in Lifestyle Change Communication. Remind yourself of this material. Remember the dual processing model of behaviour, which states that people’s behaviour is a result of both their impulses and their reflective decision making. Harnessing impulses that are positive and coping with impulses that are negative will help someone to make changes. Positive reflective decision making can also be helped. This is most effective when the motivations come from the patient. Telling people what to do and making them scared rarely changes behaviour.

The nurse discusses with Brian about the current guidelines about physical activity (as above) and about smoking cessation. She also discusses the current dietary recommendations, using ‘The Eatwell Guide’.

IN PRACTICE:

Ask the nurse at your practice how he/she approaches discussions with patients about lifestyle, diet and smoking cessation. When you are familiar with the current guidelines find out if you could join him/her to see a patient together.

CASE COMPONENT

Further Case Information – Primary prevention of Cardiovascular disease MED 35

In case FM&PH – Primary prevention of Cardiovascular disease

Brian returns a couple of weeks later and Dr Johan has the results of the 24 hour blood pressure reading and his blood tests. It confirms that he was hypertensive with an average BP of 150/94. You have covered diagnosis and management of hypertension, so remind yourself of this material.

IN PRACTICE:

Ask you GP tutor to show you an example of a 24hr BP readout.

IN PRACTICE:

Can you find any patient information leaflets that might help? Again, ask you GP or practice nurse what they use in the practice.

Lifestyle

Losing weight, increasing exercise and adopting a low salt diet are all important. Don’t forget that a low salt diet isn’t just about not adding salt to your food. Processed foods (cheeses and meats) and ready meals all contain significant amounts of salt.

Brian might not have thought about changing, or he might have tried to change before and not been successful, or he might have thought about it but not tried.  It is important to establish what Brian’s currently thinking about making changes.  There are many changes that Brian could make.  We know that changes are more likely to happen if they are small and if there are only one or two at a time.

You could find out from Brian what behaviours would be easier to try changing.  He might be totally resistant in which case you can explore this. Responding to resistance with arguments or fear messages (“you really should do it or you might become very ill”) is unlikely to make someone change.  Exploring resistance by asking open questions about the behaviour, experiences of trying to change and, crucially, asking Brian to offer ideas for change is more likely to increase motivation for change.

If Brian is or becomes motivated, it is important to specify a behavioural or outcome goal (where will he end up) and a plan to achieve that goal (what will he do, when, where, how, with whom, how often) and perhaps a coping plan (what if something gets in the way).  These methods are all discussed in the elearning Lifestyle Change Communication which you might want to review.

Medication

You have already covered the guidelines for hypertension management.

ACE inhibitors were prescribed for Brian (a Caucasian man under 55 years). Brian would need his renal function testing prior to starting and again 2 weeks after starting medication. He would then need regular testing of his renal function. Brian might find regular blood tests unacceptable. However the benefits of ACE inhibitors are well known. They can help preserve renal function in those with early chronic kidney disease and they reduce the risk of stroke.

You should think about possible side effects such as cough. Despite the obvious benefits Brian may decide against taking medication. Everyone has the right to make an unwise decision as long as they have capacity to do this. By giving Brian all the information he needs he can then decide what he thinks if best FOR HIM. There is more about capacity in the case of Mrs Gerald this week and Mrs Hall next week (link to acute confusion).

IN PRACTICE:

Looking at the NHS as a whole, think about the individual’s right to decide about his lifestyle choices vs impact on healthcare and demands on the NHS from a population perspective, due to conditions which are known to be modifiable through lifestyle measures. Expand this to think about the effect of obesity on global health. To what extent is an individual responsible? What role does the Government have? What about the food industry, schools, workplaces, Public Health policy? You might want to talk about what you think with your colleagues or your GP tutor.

Brian’s blood results are as follows:

· Total cholesterol: 5.1mmol/l

· Triglycerides: 1.4mmol/l (normal range 1.2-2.4 mmol/l)

· HDL: 1.5 mmol/l (normal range 1.1-2 mmol/l)

· LDL: 2.8 mmol/l (Normal range under 3 mmol/l)

· TC:HDL ratio: 3.4

· HBA1C: 38 mmol/l (normal)

· Normal thyroid, renal and liver profiles.

Dr Johan goes through the results with Brian of his blood tests. He calculates his ‘QRISK 2’ score.

IN PRACTICE:

Ask your GP Tutor to see how the QRISK2 is calculated and see if you can see this on their computer system for a patient.

QRisk2 (see below) is a tool, used in primary care, to calculate a patients risk of suffering a cardiac event, or a stroke, over the next 10 years as a percentage. It takes into account the patient’s age, cholesterol results, family history, ethnicity, blood pressure and other existing conditions. NICE recommends that patients with a risk score of 10% or more should have a discussion about lifestyle modification, support to make changes and the offer to re-assess their risk again after they have tried to change their lifestyle. If lifestyle intervention is ineffective or inappropriate, then statin treatment should be offered.

This is an example of PRIMARY PREVENTION which is aimed at preventing the onset of cardiovascular disease, rather than SECONDARY PREVENTION which aims to reduce the risk of a further cardiovascular event once an initial one (eg MI or stroke) has occurred.

Brian’s QRisk2 score is 12.5%. This represents Brian’s absolute risk of developing CVD over the next ten years. This could be communicated to the patient in various ways, but one way might be to say that for every 100 people the same age as Brian with the same risk factors, about 12 of them are likely to have a heart attack or stroke within the next 10 years. Another way of describing this is using an ‘infographic’ such as:

You can have a go at calculating a QRISK2 using this QRISK2 online tool which also produces infographics which could be shared with a patient.

You might also want to remind yourself of the terms ‘absolute’ and ‘relative’ risk:

· Absolute risk: The risk of developing a condition over a time period.

· Relative risk: Used to compare the risk in two different cohorts of people (e.g. those taking the medication vs those not taking it).

Patient.info: Absolute risk and relative risk

Currently the recommendation is for 20mg atorvastatin for the primary prevention of CVD in people who have a 10% or greater 10 year risk of developing CVD, to reduce this risk. This is the benefit of a statin, which works by inhibiting HMGcoA reductase in the liver, preventing the conversion of saturated fats into cholesterol.

There are however factors which might mean a patient may not want to take a statin. These need to be discussed with a patient, and include:

· Other medications and foods, including grapefruit, can interfere with statins. This might mean that a person’s regular medications might need alteration, and that if they start on a new medication or buy over the counter medications, they need to ensure that the statin is known about

· This medication would be taken for life, each day

· Repeat blood test would be required at 3 months for total cholesterol, HDL and non-HCL cholesterol, plus liver function tests at 3 months and 12 months. This is because there is a small risk that atorvastatin can affect the liver.

· Every medication is associated with various possible side effects, and patients are often worried about muscle aches and pains, which is a common complaint with statins and should be advised to return if they develop this, and to stop the statin and seek medical advice if they develop pain, tenderness or weakness of the muscles. If this happens as further testing (e.g. Creatine Kinase levels) may be indicated.

· It is important to understand a patient’s perspective on all of these issues, and if they have been influenced by information other than what is provided by the GP, such as:

·   Friends , family and even complete strangers who have given advice about statins and voiced their experiences of taking them can influence a patient’s view about this common medication

·   Media. There are often television programmes, websites and newspaper articles about statins. Although the patent may not have kept the newspaper article, or remember the specific programme or website, exposure to the information may influence their understanding.

NICE guideline CG 181: Cardiovascular disease: risk assessment and reduction, including lipid modification

It the GP’s job to provide every patient with the information to enable each individual to make an informed choice. To help with this, NICE give the following advice:

NICE: Lipid modification therapy for the primary and secondary prevention of CVD

Communication about risk assessment and treatment

NICE has produced guidance on the components of good patient experience in adult NHS services. These include recommendations on the communication of risk.

IN PRACTICE:

You will probably have the opportunity to see the GP discuss a cholesterol result and QRISK with a patient. Reflect on how this is done within a consultation and how the GP makes best use of the (sometimes limited) time available. How are other members of the practice team involved e.g. practice nurses, healthcare assistants? What patient information is available e.g. leaflets, information in the waiting room, other support agencies such as locality smoking cessation clinics?

CASE COMPONENT

Background Science – Primary prevention of Cardiovascular disease MED 35

In case FM&PH – Primary prevention of Cardiovascular disease

You have already covered aspects important to this case during Year 3 cases and also through your PCC sessions.

Please also see the following link and video regarding risk, which is a useful reminder.

· Absolute and Relative Risk

· https://youtu.be/xk2uK14eHNs

If you feel you need to revise some of the topics in this case, please see the following resources:

· Hypertension case

· You have learnt about psychological intervention strategies in Lifestyle Change Communication.

· Sharing Information with Patients and Carers

· Physical Activity information

· NHS Choices Healthy Eating Resources

Case Conclusion – Primary prevention of Cardiovascular disease 

·       In case FM&PH – Primary prevention of Cardiovascular disease

·       Brian embraced an improved diet and lifestyle, to include playing tennis with his wife twice a week. His wife has also been in to see Dr Johan, and has herself made changes to her diet and lifestyle (a common scenario in primary care).

·       He has started Ramipril which he takes every day, and he has reduced his alcohol intake to just 2-3 pints at the weekends only.

·       Three months on he weighs 88kg and his BP on a follow up 24hr ABPM has averaged out at 130/70, and his cholesterol has improved to give to give a Qrisk now of 9.4%.

·       He has not yet stopped smoking although he has cut down to 5/day and set himself a ‘stop date’ for his wedding anniversary in 1 month. He will have a medication review each year for his Ramipril (which will also include renal function testing) and is confident he can reduce his cardiovascular risk further by the next assessment.