Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Reproductive health wikipedia , lookup
Infection control wikipedia , lookup
Health equity wikipedia , lookup
Public health genomics wikipedia , lookup
Fetal origins hypothesis wikipedia , lookup
Race and health wikipedia , lookup
Epidemiology wikipedia , lookup
Epidemiology of metabolic syndrome wikipedia , lookup
Irish society needs to grasp the CVD nettle Further strategic action is needed to impact on CVD mortality and morbidity, writes Prof Colin Bradley. He outlines a three-pronged approach to tackle one of our greatest public health issues I t is hard to believe that it is only 10 years since we had our first cardiovascular health strategy launched with great fanfare by no less a person than Brian Cowen, then Minister for Health and Children. That strategy, called Building Healthier Hearts, surveyed the prevalence of cardiovascular disease and its complications and the provision of services in Ireland at that time. The strategy made 211 recommendations of which 58 related to health promotion and 55 to primary care. Progress on the implementation of the strategy up to 2005 was reviewed by Dr Siobhan Jennings whose findings were published in a report entitled Ireland Take Heart. This report highlighted an encouraging 54% reduction in cardiovascular mortality from 1985, with a pace that appeared to accelerate from the mid-1990s bringing down Ireland’s mortality rate not just in absolute terms but also relative to our European neighbours. 4 1. CV health strategy/Bradley.-NH2* 1 30/10/2009 16:24:43 There is a need to broaden the scope of the strategy to include other manifestations of cardiovascular disease, particularly stroke, heart failure and peripheral arterial disease, and to extend it to include other conditions strongly associated with additional cardiovascular risk, especially diabetes mellitus, metabolic syndrome and chronic kidney disease. As much as 48% of the reduction was deemed to have been due to improvements in lifestyle risk factors, and 44% attributed to improved treatment. The implementation of the cardiovascular health strategy was associated with a major investment of almost €72 million, leading to the appointment of 820 additional staff in the public health services alone. A key success in the health promotion area was the introduction of the workplace smoking ban. There were also dramatic advances in the provision of pre-hospital care, hospital care (including the appointment of 22 additional cardiologists), and cardiac rehabilitation (with the proportion of hospitals providing cardiac rehabilitation rising from 29% to 95%). There were also advances in primary care including the implementation of Heartwatch and the increased prescribing of evidence-based preventive therapies, particularly statins. However, compared to what has been achieved elsewhere in the healthcare system and, given the size of the residual challenge of cardiovascular disease, Heartwatch has still been something of a disappointment. While it has served as a useful demonstration of the potential for general practice/primary care to contribute to the improvement of cardiovascular health, it has been, and remains, much too limited. It is limited in every way: it is limited in scope applying to patients deemed to be in the highest risk categories only; it is limited in reach in that it has only been rolled out to approximately 20% of practices; it was limited, initially, to only 15 patients per practice; and it has been limited in that improvements in prescribing of preventive therapies have not occurred right across the board, and other lifestyle factors also show room for further improvement. Other major gaps remain. Key staff are needed in primary care – dietitians, in particular are still in short supply. The previous strategy was very narrowly focused on coronary heart disease. A new cardiovascular health strategy In September 2007, the Minister for Health and Children established a new cardiovascular health policy group to review progress and advise on policy for the next five to 10 years. The starting point for the policy review was Dr Jennings’ audit of the achievements of the previous strategy. It was immediately identified that there was a need to broaden the concept of cardiovascular disease to encompass stroke, heart failure and peripheral arterial disease. It was also identified that more attention needed to be given to prevention and primary care if further improvements in cardiovascular health were to be obtained and countervailing trends in obesity, smoking, diabetes and other unhealthy lifestyle factors were to be counteracted. It has been recognised that primary prevention of cardiovascular disease depends primarily on lifestyle; specifically diet, physical activity and smoking. Unfortunately, trends in these areas are heading in exactly the wrong direction as highlighted by the 2007 SLÁN report. Obesity rates are increasing; 38% of the adult population is classified as overweight and 23% as obese, according to independently measured BMI. Only 55% of SLÁN respondents reported themselves to be physically active to the level required for health maintenance (ie. “taking part in exercise or sport two to three times per week for 20 or more minutes at a time or engaged in more general activities, such as walking, dancing or cycling, four to five times per week accumulating to at least 30 minutes per day”) and 22% report themselves to be completely physically inactive. 5 1. CV health strategy/Bradley.-NH2* 2 30/10/2009 16:24:43 there will remain a need to continue to deliver effective and efficient health services. The starting point for such services should be in primary care, with an integrated system providing appropriate interventions right up to and including the most advanced technological interventions such as primary percutaneous intervention (PCI) for acute myocardial infarction and emergency thrombolysis for acute embolic stroke. An integrated primary care system should encompass everyone, from those with no obvious cardiovascular risk factors or disease to those who have developed acute and severe manifestations of cardiovascular disease, with the provision of rehabilitation and secondary preventive care as well as acute care for the latter. Such a system should be tiered with actions directed at: • Those without any cardiovascular disease and at no apparent immediate risk of same – for whom a general education and awareness programme is required • Those with possible elevated risk of cardiovascular disease in whom such risks need to be identified and quantified – for whom a risk ascertainment programme is required • Those with already manifest disease or already apparent high risk of diseases – for whom a chronic disease management programme is required. Smoking rates are also still proving very resistant to attempts to bring about further reductions from the current level of 29%. One particular lifestyle factor that, regrettably, almost defines us as Irish is our propensity to consume alcohol to excess; 28% of us indulge in risky drinking, ie. consuming six or more drinks at least once weekly in the last year. This, too, contributes to our cardiovascular mortality and morbidity. Addressing all these lifestyle factors, though, requires action that goes way beyond what can be achieved by healthcare providers. It needs a society-wide response and what is referred to as ‘multi-sectoral’ action, ie. all departments of Government and agencies of the state pulling in the same direction in a co-ordinated fashion. One way that has been identified elsewhere for delivering on these multi-sectoral goals is the setting of targets which are communicated to all and sundry and for which all agencies are made to take responsibility. It is proposed that targets should be set for: • The proportion of the population with a healthy weight • The proportion of the population consuming the recommended five or more servings of fruit and vegetables per day • The proportion of our energy consumption derived from fat (particularly saturated and trans fats) is reduced as a proportion of our total daily energy intake • The proportion of our food with added sugars • The reduction in salt consumption • The proportion of the population undertaking regular physical activity • The proportion of the population who smoke • The per capita consumption of alcohol Tier 1: general population education and awareness programme All members of the population including those without obvious risk factors or disease should be provided with education on healthy lifestyle, including healthy eating, physical activity, and avoidance of smoking and excess alcohol. The general population also needs to be educated on how to identify severe manifestations of cardiovascular disease including heart attack and stroke; how to manage emergencies in the community (including use of CPR, AEDs, etc); and how and when to seek emergency pre-hospital care. Prevention and treatment strategy Given that such changes in lifestyle will take time to deliver reductions in cardiovascular health risk levels in the population, and that there will always be people in the population needing medical intervention to deal with risk factors and actual manifestations of cardiovascular diseases, 6 1. CV health strategy/Bradley.-NH2* 3 30/10/2009 16:24:43 Tier 2 – risk ascertainment and quantification programme A screening system or risk ascertainment programme for the identification and quantification of cardiovascular risks, particularly in higher risk population groups (ie. those over 50 years, those with a relevant family history and those in socially deprived groups) should be established. The European Society of Cardiology SCORE system provides a useful way to quantify total risk arising from multiple risk factors and to identify action lines for intervention. Ideally, every person who might benefit would be offered a consultation with a health professional in which they would go through their family history and life-style risk factors as well as checking BMI (or other indicators of obesity), smoking status, blood pressure, fasting lipids and glucose. On the basis of such data, a risk of future cardiovascular disease can be calculated and the patient advised and treated accordingly. Entry to such a programme could be provided opportunistically as and when such people present to primary care for other services. of preventive pharmacotherapies which may included any or all of anti-thrombotic agent(s) (aspirin, clopidogrel or warfarin as appropriate); a statin or other lipid-lowering agent(s); an ACE inhibitor or ARB; and possibly a beta-blocker. This would be a sort of supercharged Heartwatch embracing a much larger number of the patients at significant risk of future cardiovascular morbidity and mortality and involving the whole primary care team. Hypertension sub-programme Tier 3 – cardiovascular risk and disease management programme(s) Within such a chronic disease management programme there would be important additional elements that would deserve attention and will require development of specific policies and procedures. For example, specific consideration ought to be given to the detection and management of blood pressure. The role for ambulatory blood pressure measurement needs to be properly established. If it is not to be used for all patients we need to clarify what the group of patients is for whom it is most beneficial. The benefits of treatment for hypertension are pretty incontrovertible at this stage although there is still debate as to which treatments are best for which patients. It is clear, and has been borne out by the most recent SLÁN survey, that there remains a good deal of improvement required in the detection and treatment of hypertension. Thus, within whatever risk-detection programme and chronic Patients at high risk should be entered into a chronic disease management programme along with patients who have already acquired clinical manifestations of cardiovascular disease, including patients with angina; a history of myocardial infarction; a history of a revascularisation procedure; a history of stroke or TIA; a history of heart failure; or a history or manifestations of peripheral arterial disease. While elements of this programme would be specific to the particular manifestation of cardiovascular disease experienced by the patient, there are significant elements that need to be provided for all patients. These include detailed and ongoing dietary advice provided, preferably, by a dietitian; smoking cessation counselling and treatment; an individualised exercise or physical activity programme; and treatment with a range 7 1. CV health strategy/Bradley.-NH2* 4 30/10/2009 16:24:43 The proportion of the ever-ageing population who could benefit from anticoagulants is now such that it is no longer feasible for anticoagulation services to be provided exclusively through traditional hospital-based clinics. Fortunately, the technology now exists for anticoagulation treatment to be safely administered and monitored in general practice and GPs have already shown willingness and capability to provide services using this technology. However, it needs to be properly resourced and this will involve not just financial recompense to cover the costs of provision of the service but also back-up from secondary care services for management of difficult cases and for quality assurance. Given the enormous potential of anticoagulation to prevent devastating stroke with its attendant costs of long-term care, the development of an effective integrated primary and secondary care anti-coagulation service would undoubtedly prove cost-effective. Once an anti-coagulation programme with sufficient capacity were in place it would also be worth instituting a screening programme for the earlier detection of atrial fibrillation – something fairly readily achieved using ECG. disease models are developed, the detection and management of hypertension will need particular consideration. Heart failure sub-programme The detection and management of heart failure is another area where we could do much better. Our current pattern of care of heart failure is characterised by a rather reactive response more reliant on hospital than primary care, involving late diagnosis (usually in a presentation of acute left ventricular failure to accident and emergency) followed by erratic application of treatment and poor ongoing monitoring leading to recurrent admissions in crises. There is an urgent need to shift to a system that integrates primary and secondary care with more emphasis on prevention and early diagnosis with the availability on a 24/7 basis to primary care of a dedicated secondary care heart failure diagnosis and management service. Atrial fibrillation detection and management sub-programme The prevention and management of TIA and stroke is another area that has been identified as amenable to improvement. Clearly, efforts to improve the detection and management of cardiovascular risk factors – particularly hypertension – can be expected to reduce the incidence of stroke. However, the prevention of embolic stroke also requires the detection and management of atrial fibrillation. The prevalence of atrial fibrillation rises dramatically with age with a reported prevalence of 4-7% in people aged over 65 rising to 14-19% in those over 85. Atrial fibrillation is associated with a five-fold increase in stroke risk and up to 70% of stroke events in these patients can be prevented by anticoagulation. In a recent study of stroke patients presenting in North Dublin it was found that only 25% of those with known atrial fibrillation were on anti-coagulant treatment. The principal challenge here is in the provision of adequate anticoagulation services. Peripheral arterial disease subprogramme Peripheral arterial disease (formerly known as peripheral vascular disease) is yet another manifestation of cardiovascular disease that deserves more attention. As with other cardiovascular conditions cited above, our traditional approach to this condition has been a rather passive and reactive one, relying on patients to present with symptoms and then offering only salvage treatment in late-stage disease. Doctors are clearly dissatisfied with this state of affairs and, while surgery is usually accepted as the only option, we have, in the past, embraced with enthusiasm various pharmacological treatments that have been proposed, only to be disappointed in the long run with their 8 1. CV health strategy/Bradley.-NH2* 5 30/10/2009 16:24:44 Conclusion So a new strategy has been envisaged in which there will be much more activity directed at prevention and taking place in primary care. However, in the current economic climate, there is an understandable concern that there will be no resources available to invest in the implementation of such a strategy and nothing may happen. There are two counter-arguments to this pessimism. Firstly, some of what is envisaged does not necessarily require new resources but rather a more intelligent application of existing resources. Setting targets for the health of the population and requiring multi-sectoral support costs little and even multi-sectoral action will be cheap relative to its potential benefits. Delivery of the three-tiered primary care strategy will require some new resources but could also make some headway with a better deployment and co-ordination between existing assets such as health promotion and community health services and general practice. The second counter-argument is that, whatever is spent on primary care initiatives, it will end up delivering savings further up the chain of disease-related costs. Thus, for example, early interventions to improve the risk profile with patients with asymptomatic PAD will save costs of late surgical interventions in patients with ischaemic limbs and, more frequently, costs of the treatment of heart attack and strokes to which such patients are also highly prone. The same principle applies across the range of cardiovascular disease; lower cholesterol in the population reduces the need for PCI, CABG, stents and so forth. Benjamin Franklin’s adage that an ounce of prevention is worth a pound of cure applies here. So if asked if, in these recessionary times, can we afford the primary care cardiovascular strategy envisaged here, I would be inclined to ask if we can afford not to implement it. n Colin Bradley is professor of general practice at UCC and is a member of the National Cardiovascular Policy Review Group lack of effectiveness. A new approach is emerging, though, that is beginning to capitalise on the possibility offered by Doppler ultrasound determination of ABI (ankle brachial index) of early detection of disease and the institution of treatments more focused on prevention of further disease progression than on treatment of symptoms. What is now lacking is adequate availability of the Doppler ultrasound technology in practices and sufficient numbers of staff trained and resourced to undertake ABI measurement in appropriate patients; this would include those identified through the risk screening programme as envisaged above. A recent pilot study in which practices were so trained and equipped showed that early detection of PAD did lead to greater implementation of all relevant preventive strategies in patients and was not associated with any great increase in the referral of patients to hospital, which it was feared such provision might precipitate. Such an endeavour is clearly worthwhile as it has also been noted that up to 30% of patients with PAD (as detected on ABI measurement) will die within five years from other manifestations of their cardiovascular disease such as heart attack or stroke. 9 1. CV health strategy/Bradley.-NH2* 6 30/10/2009 16:24:44