The ABC of CVD
A new coalition led by Public Health England and NHS England aims to educate the public on the A-B-C conditions that can lead to cardiovascular disease, and pharmacy has a key role to play
As the leading cause of death, cardiovascular disease (CVD) claims 17.9 million lives worldwide each year, and the equivalent of one death every four minutes in England.
The falling mortality rate from heart disease was the biggest cause of the increase in life expectancy between 2001 and 2016 in England, according to the Health Profile for England. But since 2011, the rate of increase in life expectancy has slowed for both sexes as improvements in heart disease mortality have plateaued. In 2016, 33,812 people under the age of 75 died from CVD. Morbidity is also a major issue for health and social care, with 6.8 million people in England living with cardiovascular conditions.
Public Health England (PHE) says this highlights the need for a renewed drive to prevent CVD deaths.
Poor cardiovascular health can cause heart attacks, strokes, heart failure, chronic kidney disease, peripheral arterial disease and the onset of vascular dementia.
In addition, millions of people are unaware that they are living with serious but treatable conditions such as atrial fibrillation (AF), high blood pressure and high cholesterol. These are known as the A-B-C conditions, which are the major causes of CVD.
Detecting and treating A-B-C conditions is very effective in preventing cardiovascular events, but the conditions themselves often carry no symptoms, meaning late diagnosis and under-treatment are common. Indeed, PHE says over five million people are currently living with undiagnosed high blood pressure in England alone.
Improving detection and treatment
Unsurprisingly, improving the detection and treatment of the A-B-C conditions has the potential to unlock considerable health gains.
A new coalition led by PHE and NHS England has announced the first ever national ambitions to do just this. The goal is to prevent 150,000 strokes, heart attacks and vascular dementia cases over the next 10 years, in line with the NHS Long Term Plan.
The aims of the coalition include recommendations for decision makers and frontline healthcare professionals on getting more people checked, and best practice for identifying and treating those already at risk. By 2029, PHE and NHS England want to:
- Detect and treat millions more people living with high blood pressure who are currently undiagnosed. Currently 6.8 million people (57 per cent) of those with high blood pressure have been detected and the aim is to increase this to 80 per cent
- Ensure 75 per cent of 40- to 74-year-olds have received a formal CVD risk check and have had their cholesterol levels recorded. Currently 7.6 million people (49 per cent) of those eligible for a formal check have received one
- Increase the proportion of 40- to 74-year-olds at high risk of developing CVD who are treated with statins from 35
to 45 per cent.
Independent PHE estimates show that if these ambitions were achieved within three years, at least 49,000 strokes and 32,000 heart attacks could be prevented and other conditions, including heart failure, transient ischaemic attacks, vascular dementia and angina, averted.
Over five million people are currently living with undiagnosed high blood pressure
Cardiovascular disease (CVD) is one of the conditions most strongly associated with health inequalities.
Public Health England (PHE) figures claim those who live in England’s most deprived areas, are almost four times more likely to die prematurely than someone in the least deprived.
Those in the most deprived communities are 30 per cent more likely to have high blood pressure – the biggest single known risk factor for heart attack and stroke. Furthermore, CVD is more common where a person is male, older, has a severe mental illness, or is of South Asian or Afro-Caribbean ethnicity.
PHE claims that delivering the NHS Health Check can ensure people at the greatest risk of disease are prioritised, helping to narrow the gap in health inequalities.
The A-B-C conditions can be quickly and easily detected through routine checks across community and healthcare settings, including in pharmacies.
“Community pharmacies play an important role in detecting serious heart and circulatory conditions by providing advice and support in managing preventable risk factors”, says Vanessa Smith, senior cardiac nurse at the British Heart Foundation (BHF).
For example, people aged between 40 and 74 can be encouraged to get their free NHS Health Check, which helps detect the early warning signs of CVD. Pharmacies can also deliver opportunistic pulse and blood pressure testing, and promote the Heart Age Tool (HAT), which was co-developed by the BHF, PHE and UCL, available on the NHS website. This is another way of helping customers understand the risks of heart disease and offers a way to encourage more participation in blood pressure testing.
If these tests reveal a CVD risk, pharmacy teams can explain what this means and help people access services provided locally or in the pharmacy that can prevent and delay the onset of CVD, such as:
- Stop smoking
- Weight management
- Physical activity
- Alcohol reduction
- NHS Diabetes Prevention Programme.
“Pharmacy staff can also make a difference by promoting and offering support on healthy diet changes to reduce cholesterol and encourage people to lead an active lifestyle to lower high blood pressure”, adds Vanessa.
Such advice can include:
- Eating a healthier diet in line with the Eatwell Guide, including reducing the amount of salt in the diet which can lead to high blood pressure
- Cutting down on excess alcohol consumption, which is a causal factor for conditions such as high blood pressure
- Being physically active, including at least 150 minutes of moderate intensity activity each week, in bouts of 10 minutes or more; 75 minutes of vigorous activity across a week; or a mixture of moderate and vigorous activity.
At Ace Pharmacy in Surrey, Alphega Pharmacy member and pharmacist Raju Patel (pictured below, right) has been using the NHS Health Check to identify and target customers either with or at risk of cardiovascular disease and the A-B-C conditions.
“Identification and targeting have become routine, and we have also briefed counter staff to engage with customers who purchase OTC medicines such as nicotine replacement therapy (NRT) products and offer the NHS Health Check”, she says. “Plus our dispensary staff identify eligible patients who walk in with prescriptions for unrelated conditions.”
Raju’s staff use three promotional initiatives to signpost people to the service and clinic:
- A poster in the window and on an A-board on the pavement outside the pharmacy that shows the criteria for eligibility, emphasises that the service is free and explains what tests are carried out as part of the service
- Leaflets displayed in the consulting room and in the health zone
- Verbal advice during consultations for the smoking cessation service.
Following the health check, customers are given a record booklet explaining the results in simple terms, along with the impact on the final risk factor, and full records are sent to their GP with their consent
“Leaflets are a great way to support any advice we offer, as they can be referred to by the patient at any time”, says Raju. “I often use this for low- and medium-risk patients, especially if their diet and lifestyle contribute towards the risk factors. We also offer a retest after five years, as per the NHS protocol, and referrals can be made in our local area, if needed, to any of the health improvement and lifestyle programmes in the Kingston Borough – for example Walk for Health, Cycle Kingston, Get Active, and a Park Run event.”
Raju adds: “High risk patients are referred to their GP who carry out more detailed blood tests, and although we do not run a follow-up clinic we are always available for further advice and support when requested.”
Feedback from customers who have had the check is “very positive, especially as a good majority aren’t aware of the factors affecting the overall cardiovascular disease risk and that it can be lowered by looking at making small changes in lifestyle, diet and physical activity levels”, explains Raju.
Raju’s advice for pharmacy teams wanting to engage a customer with a health check or other cardiovascular disease clinic is to make the most of every encounter.
“For example, when selling OTC medicines and offering advice on unrelated issues such as weight management programmes,” she says. “You can add a reminder note on prescriptions for eligible patients, encouraging them to book an appointment on the spot. Also inform local surgeries that you offer the health check, so they can refer any eligible patients to your pharmacy when they are unable to provide the service themselves.”
Eligible patients can also be recruited via stop smoking services. “Using the QRisk calculator can show patients the results of how their body is affected whilst they are still smoking, and what a ‘what if you stopped’ result would look like”, says Raju. “This has proved to be one of the best tools for recruiting an eligible patient who is currently a smoker.” She also recommends providing leaflets for the hard to reach, high-risk patients, such as South East Asian and Afro-Caribbean communities, who are more likely to benefit from the NHS Health Check service.
Although CVD mortality rates have almost halved over recent decades, there is no room for complacency in the efforts required to address the major challenges that CVD continues to play in individual lives, communities and society as a whole. Recommending customers make the most of the accessible services that community pharmacies offer will not only help them detect and manage their CVD risks, but will also help to reduce the pressures that CVD puts on all parts of the health and care system.