Cvd_Risk

This essay focuses on the case study provided (Sunil Parakh). It aims to provide the rationale for the process of cardiovascular disease (CVD) risk assessment and the risk management indicated. The author aims to discuss the recommended pharmacological and non pharmacological interventions considered as best practice. Cardiovascular disease, also known as heart and circulatory disease, and includes, coronary heart disease (CHD), angina, heart attack and stroke. It is the most common cause of death in the United Kingdom (BHF 2010) In 1999, the UK government acknowledged CVD as a major priority, setting targets for reducing CVD-related death rates by 2010 (DH 1999). In 2000 a National Service Framework (NSF) for Coronary Heart Disease (CHD) was introduced by the Department of Health (DH) to establish clear standards for prevention and treatment of CHD and stroke, which will lead to major improvements in quality and access (DH 2000). Allender et al (2008) states CVD attributes to 198, 000 deaths each year, more than one in three deaths (35%) are from CVD each year. Luengo-Fernandez et al (2006) estimated annual CVD-related healthcare costs to the NHS to total £15.7 billion, representing 21% of overall NHS expenditure. In 2008 a new initiative was introduced, an NHS Health Check for everyone between the ages of 40 and 74, who does not have existing diagnosed vascular disease, this will involve measurements of height, weight and waist circumference, Body Mass Index (BMI) calculation, blood pressure and collection of information about risk factors, such as family history, ethnicity and post code and blood tests for cholesterol and, in some cases, glucose. It will also give health care professionals an opportunity to provide education to patients who may not usually attend the surgery and to identify any concerns a patient may have. This will be calculated into a CVD risk based on 10year risk of fatal and non fatal stroke including TIA added to 10 year risk of CHD. The result is expressed as a percentage over 10years (Education for Health 2009) For example, 10year risk of 20% or greater (high risk). Scenario Sunil has had three recent blood pressure readings of 150/90 mmHg, this links with the National Institute for Health and Clinical Excellence (NICE 2006a) guidelines for Hypertension, which suggests to identify hypertension (persistent raised blood pressure above 140/90 mmHg) readings should be taken from the best of two measurements on 3 separate visits. Pharmacological intervention is then recommended, if there are no contraindications Sunil would be offered an ACE inhibitor as first line choice, blood tests for renal function and electrolytes would be monitored. Sunil’s TC: HDL cholesterol ratio is 5.5. Although this result is borderline, evidence supports the effectiveness of statins in reducing cardiovascular risk and NICE (2008) lowered the threshold for intervention for primary prevention with statins from a 10 year risk of cardiovascular disease of 40% to 20%. From the information a computerised calculation identifies Sunil as having a CVD risk of over 20%. Following local Clinical Effectiveness Group (CEG 2009a) guidance, Sunil would be offered Simvastatin 40mg, unless contraindicated. Antiplatelet treatment would be contraindicated for Sunil due to raised blood pressure and local policy states routine use of aspirin cannot be recommended for primary prevention including people with diabetes (CEG 2009a). The Clinical Knowledge Summaries (CKS 2010) guidance on CVD risk assessment states there is no consensus in the UK about which risk calculator should be used, for England and Wales NICE initially considered recommending the QRISK calculator, but finally decided to recommend that calculators based on the Framingham 1991 10-year risk equations be used. QRISK2, is an updated version of the QRISK calculator. NICE did not assess QRISK2 as it was published after the published guideline. For Scotland, the Scottish Intercollegiate Guidelines Network (SIGN 2007) recommends use of the ASSIGN calculator. Current local policy recommends QRISK2 as it is a more accurate method to identify those people who will benefit from treatment and it is more equitable in a socially and ethnically diverse population (CEG 2009b). To communicate risk effectively the health professional must gain the trust of the patient. This is best achieved when discussion on the balance between risk and benefit is based on reliable information (BHF 2005). Corcoran (2007) suggest a persons behaviour can be predicted based on how vulnerable the individual considers themselves to be, this means they need to weigh up the pros and cons of performing a behaviour however Thornton (2003) suggests enabling patients to understand risk so that they might incorporate it into their decision making processes is fraught with difficulties. Paling (2003) explores strategies to help patients understand risks, such as, using absolute risk terms, using visual aids and everyday analogies. The ‘smiley face’ charts have been used in the authors practice and found to be effective at helping explain risk. Results should be discussed, with Sunil, with a balanced explanation of the targets, the risks of not controlling the risk factors and identifying the modifiable factors which Sunil can change. This will encourage him to take control of his own health and to make changes that may reduce the risk. Long-term behaviour change requires motivation on the part of the patient, in addition to a belief that change is required and confidence that it can be achieved (Rodgers 2005) It is unknown from the scenario what Sunil’s ethnic group is, NICE (2008) recommend multiplying the results of a modified version of the US Framingham score by a correction factor of 1.4 for South Asian men in the UK (Hippesley-Cox et al 2008) as compared with Europeans, South Asians have a 50% greater risk of premature death from CHD and stroke (BHF 2007). In the UK the highest recorded rates of coronary heart disease (CHD) mortality are in people born in the Indian Sub-continent countries of India, Pakistan and Bangladesh. South Asian men have an age standardized mortality rate about 40% higher than the whole population, and for women the figure is 51% (BHF 2004). Although ethnicity is not a modifiable factor, it is important for patients to understand their background as genetics can play a major part in some patients’ health or ill health. Sunil would be encouraged and supported to stop smoking. Erhardt (2009) states smoking and other forms of tobacco use are major risk factors for cardiovascular disease. The effect of cigarette smoking on cardiovascular health is evident even at the lowest levels of exposure. Yet, the adverse effects of smoking are reversible, with cardiovascular risk decreasing substantially within the first 2 years of smoking cessation. NICE (2006b) have produced guidance on brief interventions and referral for smoking cessation in primary care and other settings makes a number of practical recommendations on who should receive advice, as well as on who should advise smokers and how. The DH stated that evidence based effective NHS support to stop smoking is highly cost and clinically effective. It should be offered to every smoker, regardless of whether they are looking to quit (Willis et al 2009). It is acknowledged that patients rarely make all the changes necessary at one time and it may take time for patients to change their behaviour, therefore encouragement and support should be given at each encounter regardless of failings. Prochaska and Diclemente (1986) suggest people change their behaviour at certain stages in life, this transtheoretical model is based on the premise that people are at different levels of readiness to change and during the change process they move through a series of stages. For Sunil it would be important for him to identify which risk he sees as the most important and which risk he believes he could modify. Banduras’ (1986) social cognitive theory is based on the theory that behaviour is guided by its expected consequences and that any changes must lie within the perceived capabilities of the individual. If Sunil does not believe he can change his behaviour, he may be reluctant to try. Evidence suggests that if we work in ways designed to empower people, by supporting them in making their own decisions about how they manage their condition – this is likely to be more effective in changing their behaviour (Rodgers 2005). Diet and exercise are modifiable factors that can be discussed. The Food Standards Agency recommend a healthy balanced diet contains a variety of types of food, including lots of fruit, vegetables and starchy foods such as wholemeal bread and wholegrain cereals; some protein-rich foods such as meat, fish, eggs and lentils; and some milk and dairy foods FSA (2010) and the Governments ‘5 A DAY’ promotion is based on advice from the World Health Organization, which recommends eating a minimum of 400g of fruit and vegetables a day to lower the risk of serious health problems, such as heart disease, stroke, type 2 diabetes and obesity (NHS Choices 2009) Strazzullo et al (2009) state high salt intake is associated with significantly increased risk of stroke and CVD. The BHF support this and publish written information which patients can take and discuss with family members especially the person responsible for cooking in the household. However Lindsey and Gaw (2004) acknowledge there is much evidence to show that eating a healthy diet costs more than a less healthy diet. Cooking and storage facilities maybe limited and for many, health considerations are not a priority, the provision of cheap and filling food being of far greater importance. A patient centred approach is needed where patients can discuss their wants and needs. Saving Lives (DH 1999) has suggestions for promoting healthier neighbourhoods, including access to healthier foods. JBS2 (2005) suggest lifestyle intervention in all high risk people to help make healthier food choices, increase aerobic physical activity, and achieve optimal weight and weight distribution is central to CVD prevention. A referral to a dietician to discuss a cardioprotective diet could be beneficial, Sunil can be encouraged to bring his wife if she prepares the household meals. If Sunil is identified to have an alcohol intake higher than the recommended, he would be advised to limit his alcohol intake to 3–4 units a day, with at most 21 units a week and women 14 units a week (NHS 2010). Klatsky (2009) states with respect to cardiovascular disorders, epidemiologic studies support the hypothesis of increased risks among heavy alcohol drinkers and indicate a lower risk among lighter drinkers. The BHF (2005) calculates that 37% of CHD deaths in those under 75 are attributed to physical inactivity. Recent public health guidance recommends that primary care practitioners should take the opportunity, whenever possible, to identify inactive adults and advise them to aim for 30 minutes of moderate physical activity at least five days a week (NICE 2006c). It is not specified how much activity Sunil undertakes, he would be encouraged to find an activity he enjoys. Sunil is self employed and owns a newsagent shop, this may involve long hours and stress. It is argued that because stress is more difficult for health care practitioners to define and assess, than more widely accepted coronary risk factors, the concept has played a much more important role in ideas about cardiovascular disease among laymen than among experts (EPHA 2006) Research has confirmed the importance of stress as an independent risk factor in the incidence and the course of CVD (EHPA 2006). Although this may be difficult for Sunil to change, he will be more aware of the effects of stress. Health beliefs need to be considered when communicating health and risk to patients. A study by Greenhalgh et al (1998) reported when diabetic patients were shown photographs and asked to identify a healthy person; both the men and women chose photos of large individuals. Large body size is generally viewed as an indicator of more health and thinness as less health. Communicating information that considers cultural, religious and language differences is important to promote effective self-management (Hill 2006). The author has provided information of CVD risk management in general practice and its implications for patients, local level services such as GP practices and higher level services such as the cost to the NHS. The basis for a national screening programme and its implications has been discussed and the findings suggest that offering the checks to those aged 40 to 74, who constitute about a third of the population, will save 2,000 lives a year and prevent 9,500 heart attacks and strokes (Proctor -King 2008). Further areas for development have been identified by NICE, they do not recommend a specific risk calculator but do specify what equations and variables should be used and add further independent research needs to be done into risk estimation methods, including validating the ASSIGN and QRISK methods for use in England and Wales. 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