Q J Med 1999; 92: 245-250
© 1999 Association of Physicians
Secondary prevention of coronary heart disease in primary care: a healthy heart initiative
From the Bournemouth Diabetes and Endocrine Centre, and 1 Department of Audit and Clinical Effectiveness, Royal Bournemouth Hospital, Bournemouth, UK
Received 23 November 1998 and in revised form 5 March 1999
Dr M. Armitage, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset BH7 7DW
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Summary |
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We assessed the effectiveness of secondary prevention of coronary heart disease (CHD) in primary care, in a cross-sectional study of 1015 patients aged <75 years with documented CHD. Patients records were examined for documentation of CHD risk factors; 722 patients then attended education sessions where blood pressure and cholesterol were measured, a supervised questionnaire detailing modifiable risk factors was completed, and advice on lifestyle modification was given. Management of risk factors was generally poor, and was worse in women. Approximately 20% of subjects remained hypertensive, with half of these receiving anti-hypertensive medication. Examining the primary care records, serum cholesterol was documented in 17.5% of men and 26.5% of women. Of the 722 subjects who had cholesterol measured, 30% of men and 25% of women had cholesterol <5.2 mmol/l. Mean cholesterol was significantly higher in the women (6.1 mmol/l vs. 5.6 mmol/l, p=0.001). Lifestyle risk management was also poor, with significant numbers smoking and drinking more than recommended. Women were more overweight than men (mean BMI 27.9 kg/m2 vs. 26.9 kg/m2, p=0.006). Aspirin was being taken by 56% of patients.
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Introduction |
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There is continuing debate regarding the primary prevention of coronary heart disease (CHD). This is a multifactorial disease with a number of possible management strategies but the question remains: who should we be treating? Large numbers of well individuals may need to take treatment over many years, as absolute risk reductions are small. This risk/benefit analysis can be difficult for the primary care practitioner, and there are a number of evaluations (e.g. Sheffield and New Zealand risk tables) trying to address the overall risk of a coronary event in an individual.1,2
There should be no such difficulties in the management of secondary prevention of CHD (i.e. preventing progression in people with established disease). Patients with established CHD are the highest risk group for further coronary events, and there is considerable scientific evidence that specific interventions will reduce the risk of further vascular events in these patients. Proven interventions include the use of aspirin,3 and anti-hypertensive4 or lipid lowering drugs.5,6 Other cardiac risk modifications, such as stopping smoking,7 encouraging a healthy diet,8,9 exercise,10,11 and moderate alcohol consumption12 require non-pharmacological interventions, but the responsibility for all of these aspects of the patients' care lies predominantly with the Primary Care Team. In the current era of evidence-based medicine, we know how these patients should be managed—but how well are we doing and how can this be improved?
The British Cardiac Society survey (ASPIRE) of secondary prevention of CHD in a hospital setting determined that both the management and the documentation of risk factors in patients with established coronary disease was suboptimal with considerable room for improvement.13 They concluded that a comprehensive prevention strategy bringing together the different groups of health-care professionals involved in the long-term modification of CHD risk factors was required. A more recent study of secondary prevention of CHD in general practice again showed suboptimal management.14 The same group attempted to address the problem with a study assessing the role of nurse-run secondary prevention clinics, and concluded that within 1 year, secondary prevention clinics improved patient health and reduced hospital admissions.15
The aim of our study was to assess secondary prevention of CHD in primary care in East Dorset and to evaluate the role of a hospital-based secondary prevention team working in collaboration with the local practices to improve the management of cardiac risk factors. As gender differences have previously been demonstrated in the provision of care for subjects with CHD, we also examined whether gender differences are apparent in the provision of secondary prevention measures.
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Methods |
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The Royal Bournemouth Hospital employed a CHD Nurse Practitioner to liaise with the Primary Care Teams. Sixty practices in East Dorset were invited to participate in the study, and 14 practices accepted. The CHD nurse practitioner visited each practice and helped them identify their patients with established CHD aged <75 years. Patients were identified using existing databases, specific registers, searches based on medication prescriptions and GP knowledge of their own patients. Previous studies have shown that data collected in this way is 80% sensitive for myocardial infarction and 60% for angina.16
The medical records of these patients were examined by the nurse practitioner and baseline data abstracted from the notes. The diagnostic category of CHD was recorded together with details of recent medication and history of diabetes. Details of whether or not blood pressure (BP) and cholesterol had been measured in the previous 2 years were recorded. The medical records were also examined for details of lifestyle modifications attempted since the diagnosis of CHD. These patients, together with their partners/carers, were invited by the Primary Care Team to attend a `Healthy Heart Evening' in the surgery.
Education and information
The CHD nurse practitioner gave a presentation with slides in an informal interactive group session. Medical management of risk factors and rationales for treatment were explained, and advice given for a healthy lifestyle. The lipid specialist dietitian discussed healthy eating options using slides and a food display. Written information on all the modifiable risk factors was also offered, based on current best practice. During the course of the evening there was time to discuss specific problems with patients on an individual basis. The sessions lasted about 2.5 to 3 h. Arrangements were made by the relevant member of the practice team for further advice or intervention if considered necessary.
Data collection
During the education sessions, data were collected using a supervised questionnaire on current smoking history, alcohol consumption, aspirin usage, exercise levels and any anti-hypertensive and/or lipid-lowering medication used. Alcohol consumption was graded as moderate up to 21 units per week for men and up to 14 units per week for women, and high above this. Exercise level was graded as moderate up to three sessions of 45 min exercise per week and high above this. Smoking was graded as moderate up to 10 cigarettes per day and high above this. Dietary advice was assessed as having been given if the subjects had received any advice from any health-care professional on modifying cardiovascular risk. Each patient had a single measurement of height, weight and blood pressure using the surgery equipment and cholesterol (using an Accutrend/Lipotrend desktop meter). At the end of the evening, a satisfaction questionnaire was offered to patients. Data from these evenings were then made available to general practitioners to target further treatment and intervention.
Statistical analysis
Data were collected and stored using Microsoft Excel version 5.0 Data were analysed using SPSS for Windows, release 7.5.1 standard version. Proportions between attenders and non-attenders and between gender were measured using the 
2 test. Where data were normally distributed, independent samples T tests were used to compare means. Analysis of variance was used to compare lifestyle data between sexes and attendance or non-attendance at the sessions.
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Results |
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We identified 1015 patients (691 men, 324 women) with CHD from the 14 practices. Twenty-six `Healthy Heart' evenings were held and 722 patients (487 men, 235 women) together with their relatives attended. Table 1
compares baseline data and history of ischaemic heart disease for subjects attending and not attending the education sessions. There were few differences, but those attending the sessions were older. There was no significant age difference in the overall rate of surgical intervention between the two groups. There was no significant age difference between genders.
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Table 2
shows the number of individuals with BP>160 mmHg systolic or >90 mmHg diastolic according to whether or not they were receiving medication for BP control. Data for men and women are displayed separately, as the rates of intervention varied with gender. BP was measured in 715 (99%) of the 722 who attended the sessions. Of those who did not attend, BP recordings were available for 244 (83.3%) of 293 individuals. There was no significant difference between mean BP recorded from the sessions and mean BP documented in the medical records. Analysing the whole group, 259 men (37.5%) and 156 women (48.1%) had a systolic BP>160 mmHg or a diastolic BP>90 mmHg. Women were more likely to have been prescribed BP-lowering medication, with 48% overall, compared with 39% for the men (p=0.006), but a significantly higher percentage of women had a BP>160/90 mmHg (p=0.013). Approximately half the subjects with BP>160/90 mmHg were receiving BP-lowering medication.
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Cholesterol was very poorly recorded in the medical notes, with levels documented for 121 men (17.5%) and 86 women (26.5%). Thus cholesterol was documented in significantly more women (p=0.001). Table 3
shows the number of men and women who had their cholesterol measured at the education sessions divided into groups according to their cholesterol level, for cholesterol levels of <5.2 mmol/l, <6.5 mmol/l and >6.5 mmol/l. Cholesterol was measured in 706 (97.8%) of the 722 subjects who attended the sessions. Only a third of men and a quarter of women had cholesterol levels below 5.2 mmol/l. Mean cholesterol was lower in the men at 5.6 mmol/l (SD 1.1) than in the women at 6.1 mmol/l (SD 1.3) (p=0.001). In men, there was no significant difference between the mean cholesterol in those who had had their cholesterol previously documented in the medical records and those who had not. In women the mean cholesterol for the documented group was 5.8 mmol/l (SD 1.2) compared with 6.3 mmol/l (SD 1.4) for the undocumented group (p=0.01). In summary, a minority of the subjects had had their cholesterol documented, and even if it had been measured it was being undertreated. Although women were more likely to have had their cholesterol documented, their mean level of cholesterol was still higher than that of the men.
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The majority of subjects that attended the study gave details of lifestyle factors that can modify CHD risk. Table 4
shows measures of modifiable lifestyle risk factors together with body mass index (BMI) for those attending the sessions. As women smoked less, drank less and took less exercise than the men, data are presented by gender. A significant number were still smoking and drinking more than the recommended quantity of alcohol. The majority of men and women had a BMI>25 kg/m2. Women were significantly more overweight than men, with mean BMIs of 27.9 kg/m2 (SD 5.1) and 26.9 kg/m2 (SD 4.1), respectively. There were significantly more smokers in the non-attending group: 36 (18.8%) compared with 76 (10.5%) in the attending group (p=0.004). The majority of subjects said they had received dietary and lifestyle advice, but a frequent comment was that this had been inadequate and had been given informally.
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Information on aspirin usage was available on all subjects. As patients were specifically asked if they took regular aspirin, this includes patients who were self-medicating. There was no gender difference between rates of prescription. Table 5
shows the number and percentage of patients taking aspirin according to the diagnostic category of ischaemic heart disease or surgical intervention used. Overall, only 577 (56%) were taking aspirin, with slightly better rates in those who had had previous myocardial infarctions or coronary artery bypass grafting.
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In summary, none of the possible secondary prevention measures were optimal, with significantly worse management in the women. At the end of the education sessions, patients were asked to complete a short questionnaire about the usefulness of the evening. Overall, 461 (98%) of 471 felt that the evening had been useful and would make a significant difference to their risk of coronary heart disease; 45 (9.6%) felt the evening could be improved, with a variety of suggestions, many of which related to providing more information at an earlier stage of their disease; and 432 (91.7%) felt that the information given had been appropriate to their needs.
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Discussion |
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Our results demonstrate that within the sample group of general practices studied, there is huge potential for improvement in secondary prevention of CHD. Every measure of modifiable risk studied was being managed suboptimally. Management was significantly worse in the women.
By inviting subjects to attend an education session, we are introducing bias into the study, as this group of subjects are likely to be more motivated than those that did not attend. We have evidence of this in the comparison of smoking rates, which is higher in the non-attending group. A possible contradiction to this is the data on diabetes, with the prevalence being higher in the non-attending group than those attending. It is likely that this is because a structured series of education sessions has already been established for this group, and that they felt that they had little to gain by attending further education sessions. The structure of the education session used in this study closely follows that already established for diabetes education17 where it has been shown to be of benefit. The General Practices involved in this study were all highly motivated, with an interest in prevention of CHD, and the standard of secondary prevention is likely to be, if anything, better in these practices than overall. It is therefore likely that we are over-estimating preventative practice, and that the overall situation is worse than we have shown.
The British Hypertension society advises a target blood pressure of <160 mmHg systolic and <90 mmHg diastolic for patients with established CHD.18 Although blood pressure had been checked in the majority of subjects, only half of the subjects had a blood pressure below the recommended level and only half of those with blood pressure above the recommended level were receiving treatment for hypertension. We have shown a significant gender difference in the treatment of hypertension with women more likely to be given medication but as we have shown a significantly higher proportion of women were hypertensive, this suggests that the women are being undertreated. In the setting of a group education session it was impossible to follow closely the British Hypertension Society guidelines18 for the measurement of blood pressure, possibly leading to an overestimate of blood pressure, but when mean blood pressure from the sessions was compared with blood pressure measured under more standard conditions in the GP surgeries, there was no significant difference.
Management of cholesterol was also poor. Again men were less likely to have cholesterol checked than women, but mean cholesterol was still lower for the men than the women, suggesting that although cholesterol was being checked it was not being acted upon. British Hyperlipidaemia Association guidelines recommend treating a cholesterol >5.2 mmol/l in patients with established CHD.19 Nearly 2/3 of subjects studied had a cholesterol above this level, and the majority of these had not previously had their cholesterol checked.
Lifestyle measures can significantly contribute to reduction in cardiovascular mortality in established CHD. Evidence is available that stopping smoking, taking more exercise, losing weight, drinking less alcohol, and eating a more favourable diet can all play a part in secondary prevention of CHD.7–12 To modify these risks most effectively requires proper education, and this requires time. Within the group studied, there was considerable room for improvement in lifestyle measures. Again we have shown gender differences in how this advice is received and acted on. Women were less likely to smoke and drank less alcohol, reflecting the pattern in the general population, but were less likely to take exercise and were more overweight than the men. Although the majority said they had been given dietary advice, they also commented that it had been inadequate. The presence of a dietitian able to tailor specific advice to the individual was considered very helpful.
Although aspirin significantly reduces vascular events, and has a significant part to play in the prevention of CHD,3 only half of the subjects were taking it. This may partly reflect inability to tolerate aspirin in some subjects, but as the ASPIRE study reported13 rates as high as 85% in those who had recently suffered a MI, it seems likely that there is considerable potential for improvement in prescribing rates in primary care.
The poor results do not reflect a lack of awareness of possible secondary prevention measures in general practice, but rather the time available to spend educating and reviewing patients' CHD risk on an individual basis. Part of this missed opportunity to prevent CHD may be due to the inability or unwillingness of patients to follow the advice given, but we need at least to ensure that this advice is given in the first place, and that it is documented. Further work is needed to distinguish whether the failure of secondary prevention is due to poor provision of information or reluctance to adopt the advice by patients. Previous studies of nurse-led patient assessment of cardiovascular disease in primary care have shown variable success, but these studies only involved education on lifestyle measures, and did not involve assessment of patient medication.20–22 The use of a structured group education session with multidisciplinary input is a means of providing the relevant information to a number of people in a relatively short space of time, and formally documenting that this advice has been given. The information gathered from the session can then be fed back to the primary health care team to target those individuals who require specific interventions. At the end of the study the results were discussed with representatives of the practices involved. Each practice was furnished with the overall data anonymized practice-by-practice, but with their own practice identified. Thus they were given the information to make appropriate changes.
Although the gender differences in provision of secondary prevention care are striking, the reasons for this are not obvious. Previous work has suggested that prevention strategies may be more effective in men than women, and our data support this.23 It does not seem to reflect an unwillingness on the part of women to participate, as there were no gender difference in those attending or not attending the sessions. Further work is required to investigate and remedy this discrepancy.
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Acknowledgments |
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We thank the 14 medical practices that are participating in this project, Dr David Kerr and Dr Sally Flanagan for criticism of the paper. Funding was received from Merck Sharp and Dohme Ltd.
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References |
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1. Ramsay LE, Haq IU, Jackson PR, Yeo WW, Pickin DM, Payne JN. Targeting lipid-lowering drug therapy for primary prevention of coronary disease: an updated Sheffield table. Lancet 1996; 348:387–8.[Web of Science][Medline]
2. Anonymous. 1996 National Heart Foundation clinical guidelines for the assessment and management of dyslipidaemia. Dyslipidaemia Advisory Group on behalf of the scientific committee of the National Heart Foundation of New Zealand. N Z Med J 1996; 109:224–31.[Web of Science][Medline]
3.
Anonymous. Collaborative overview of randomised trials of antiplatelet therapy—I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. Br Med J 1994; 308:81–106.
4.
Browner WS, Hulley SB. Effect of risk status on treatment criteria. Implications of hypertension trials. Hypertension 1989; 13:151–6.
5. Anonymous. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344:1383–9.[Web of Science][Medline]
6.
Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford J, Cole TG, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med 1996; 335:1001–9.
7. Daly LE, Mulcahy R, Graham IM, Hickey N. Long term effect on mortality of stopping smoking after unstable angina and myocardial infarction. Br Med J 1983; 287:324–6.
8. Burr ML, Fehily AM, Gilbert JF, Rogers S, Holliday RM, Sweetnam PM, et al. Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet 1989; 2:757–61.[Web of Science][Medline]
9. de Lorgeril M, Renaud S, Mamelle N, Salen P, Martin JL, Monjaud I, et al. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet 1994; 343:1454–9.[Web of Science][Medline]
10.
Horgan J, Bethell H, Carson P, Davidson C, Julian D, Mayou RA, et al. Working party report on cardiac rehabilitation. Br Heart J 1992; 67:412–18.
11.
O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr, et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989; 80:234–44.
12.
Friedman LA, Kimball AW. Coronary heart disease mortality and alcohol consumption in Framingham. Am J Epidemiol 1986; 124:481–9.
13.
Bowker TJ, Clayton TC, Ingham J, McLennan NR, Hobson HL, Pyke SD, et al. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996; 75:334–42.
14.
Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. Br Med J 1998; 316:1430–4.
15.
Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. Br Med J 1998; 316:1434–7.
16. Whitelaw FG, Nevin SL, Milne RM, Taylor RJ, Taylor MW, Watt AH. Completeness and accuracy of morbidity and repeat prescribing records held on general practice computers in Scotland. Br J Gen Pract 1996; 46:181–6.[Web of Science][Medline]
17.
Miles P, Everett J, Murphy J, Kerr D. Comparison of blood or urine testing by patients with newly diagnosed non-insulin dependent diabetes: patient survey after randomised crossover trial. Br Med J 1997; 315:348–9.
18. Sever P, Beevers G, Bulpitt C, Lever A, Ramsay L, Reid J, et al. Management guidelines in essential hypertension: report of the second working party of the British Hypertension Society. Br Med J 1993; 306:983–7.
19.
Betteridge DJ, Dodson PM, Durrington PN, Hughes EA, Laker MF, Nicholls D, et al. Management of hyperlipidaemia: guidelines of the British Hyperlipidaemia Association. Postgrad Med J 1993; 69:359–69.
20.
Cupples ME, McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. Br Med J 1994; 309:993–6.
21.
Anonymous. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study. Family Heart Study Group. Br Med J 1994; 308:313–20.
22.
Anonymous. Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year. Imperial Cancer Research Fund OXCHECK Study Group. Br Med J 1994; 308:308–12.
23.
Field K, Thorogood M, Silagy C, Normand C, O'Neill C, Muir J. Strategies for reducing coronary risk factors in primary care: which is most cost effective? Br Med J 1995; 310:1109–12.
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