Download Irish society needs to grasp the CVD nettle

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.
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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.
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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,
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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
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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
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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.
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