CARDIOVASCULAR HEALTH WHAT HAS BEEN DONE SO FAR?


The Clinical Standards Board for Scotland published standards in 2000 for Secondary Prevention following acute myocardial infarction, which was supported by the Scottish Government with the introduction of the National Strategy for Coronary Heart Disease and Stroke in 2002. This strategy has since been reviewed twice in 2004 and 2009.5


The Heart Disease Improvement Programme 2008 was coordinated nationally to help improve the quality of care and outcomes for patients with coronary heart disease and their families. The programme was established to ‘support sustainable measurement and review of the heart disease standards over the longer term’.6


In 2014, there was an update completed and the Heart Disease Improvement Plan was published. It details the work already being done with the network approach of the MCNs (Managed Clinical Networks). It also highlights the crucial role they have in the development of services to help support quality of care, in promoting preventative action and in measuring and monitoring the progress of the improvement plan/ priorities.7


It also sets out the next steps to progress forward. There is a continued ambition to deliver world-leading health and social care which is person- centred, clinically effective and safe.


The ban on smoking in enclosed public spaces in March 2006 also represents a landmark strategic initiative targeted at reducing morbidity and mortality associated with cardiovascular disease.5


Identified ways of improving heart disease treatment include the development of a care bundle. A care bundle is a structured way of improving the process of care and patient outcomes. This is achieved using evidence-based practices which, when performed collectively, have been proven to improve patient outcomes. An example would be in some cardiology units throughout Scotland, where they follow a three- step care bundle¹:


1. Expert review of patients during admission


2. Prescription of evidence-based medication during inpatient stay


40 - SCOTTISH PHARMACIST


3. Referral of patients to specialised nurse before or at the time of discharge


This has been shown to decrease the average length of stay in hospital, reduce the readmission rate to hospital within 30 days and reduce the mortality rate at one month, six months and one year.


WHAT CAN WE DO AS PHARMACISTS?


As pharmacists, we are the most accessible of all healthcare professionals. This gives us the unique opportunity to engage with our patients without the need for an appointment. We have a pivotal role in the prevention of cardiovascular disease. As pharmacists, we can also contribute to reducing heart disease through services such as smoking cessation, risk screening services and medicines management. We are in a great position to provide information and advice tailored towards individual needs.


Through medicines management we can help patients to get the best out of their medicines and help with concordance. Risk factors for cardiovascular disease that can be modified include: hypertension, diabetes, hypercholesterolemia and smoking. With medicines management we can optimise the effectiveness of a patient’s medication in those with the above conditions. Through education, a pharmacist can help patients understand the rationale behind their medicines, any potential side effects of the medication, the benefits of the medication and the importance of adherence.


For those who are overweight or obese, we can suggest healthy lifestyle measures to help reduce a patient’s risk of heart disease (table 1).


These measures will go a considerable way to helping patients who already have heart disease and in those who may be at risk of heart disease. It is good advice for everyone to follow regardless of cardiovascular risk.


As pharmacists, we also offer easy access to health checks that can help identify a patient’s risk. These include blood cholesterol checks, blood pressure checks and body mass index (BMI) measurements and all accompanied with expert advice.


Unless hypertension is newly diagnosed, blood pressure should be checked every six months to one year.


Patients should have their cholesterol checked annually. Some people may know their most recent results, however, if the patient has no idea, encourage them to discuss this with their GP or nurse at their next visit. The non-diabetic target for blood pressure is: systolic <140 and diastolic <85. Ideally it should be a minimum of lower than 150/90mmHg. For those, who have diabetes, then the diabetic target for blood pressure is: systolic <130 and diastolic <80. Ideally it should be a minimum of lower than 140/80mmHg.


Regarding cholesterol, the aim is to lower the value to below 5mmol/l or to achieve 30 per cent reduction from baseline cholesterol, whichever is greater. A statin may still be indicated even if baseline cholesterol is less than 5mmol/l.


Regarding patients’ BMI, the healthy range should fall between the 18.5 to 24.9 range and is measured by dividing an adult’s weight in kilograms by their height in metres squared.9


When a patient is in the pharmacy, it provides the opportunity to provide appropriate advice and encourage attendance at GP or nurse clinics. If measurements are taken for the patient’s blood pressure and cholesterol - and they are not within target ranges - consider whether it is possible to optimise the therapeutic plan further and make recommendations to the GP or nurse. A brief look at the patient’s PMR will enable you to see if your recommendations have been tried before.


To help improve knowledge and skills of health and social care staff, Chest Heart and Stroke Scotland has worked in partnership with NHS Scotland, British Heart Foundation


TABLE 1: TABLE SHOWING HEALTHY LIFESTYLE ADVICE (8)


Eating less saturated fats, sugar and salt


Increase the amount of omega-3 fat eaten (oily fish two or three times per week)


Increase fruit and vegetable intake Weight reduction if obese


Reduction in energy dense/ convenient food and drinks


Reduce alcohol intake to >21 units/ week for men and >14 units/week for women


Increase physical activity and a less sedentary lifestyle


(BHF) Scotland and the University of Edinburgh to produce HEART-e, which is funded by the Scottish Government through the National Advisory Committee for Heart Disease.10


HEARTe (Heart Education Awareness Resource and Training e-learning project) is the first comprehensive, web-based, free training programme for all health and social care staff caring for people with heart disease. This is a great tool through which the enhancement of the skills of health and social staff will improve the care of people living with heart disease across Scotland.


In conclusion, it is clear that, moving forward, the fight to improve the health of the nation with respect to cardiovascular disease is a high priority. It will require a network of teams and healthcare professionals to deliver on the plan set out by the Scottish government, and pharmacists are at the forefront of providing the care and support that patients with cardiovascular disease require. Through networking and liaising with MCNs, pharmacists can contribute to the improvement of the nation’s health. •


REFERENCES


1. Heart Disease Improvement Programme Sept 11. Scotland, NHS.


2. Choices, NHS. NHS Choices CV Disease. http://www.nhs.uk/ conditions/cardiovascular-disease/ pages/introduction.aspx. [Online] 3. https://www.isdscotland.org/ Health-Topics/Heart-Disease/ Publications/2016-01-26/2016-01- 26-Heart-Disease-Report.pdf. 15, Scottish Heart Disease Stats March. 4. Survey, Scottish Health. Scottish Health Survey 2015. http://www. gov.scot/Resource/0050/00505745. pdf. [Online]


5. Clinical Standards for Heart Disease April 2010. Scotland, NHS. 6. Heart Disease Improvement 2008. Scotland, Health Improvement.


7. Heart Disease Improvement Plan 2014. Government, Scottish. 8. Scotland, NHS. Pharmaceutical Care of people with coronary heart disease. http://www.nes. scot.nhs.uk/media/678320/ chd_information-no_articles.pdf. [Online]


9. choices, NHS. What is Body Mass Index. http:// www.nhs.uk/chq/Pages/3215. aspx?CategoryID=52. [Online] 10. Scotland, Community Pharmacy. HEARTe. http://www. communitypharmacy.scot.nhs. uk/nhs_boards/NHS_Forth_ Valley/redesign/core_services/ cardiovascular.html. [Online]


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