Cardiovascular disease prevention and management

It’s about the ‘before’

“Prevention needs to become part of everyday pharmacy practice rather than something that only happens during cardiovascular awareness campaigns,” says Darshan.

Remind customers that regular exercise can improve the efficiency of their heart and blood circulatory system, helping to lower cholesterol and maintain healthy blood pressure. Aerobic exercise like walking, swimming and dancing are good examples. This combination of diet and exercise will help customers to keep to a healthy weight – a crucial step towards limiting cardiovascular disease (CVD) risk as excess weight and body fat put significant pressure on the body.

“For someone who is overweight, even a modest, sustainable reduction can be a worthwhile goal to discuss with a healthcare professional. The important thing is to avoid extreme diets and focus on changes that can be maintained,” says Dr Lo Monaco.

Remember, too, that reducing alcohol consumption and stopping smoking are crucial for better cardiovascular health. The NHS recommends no more than 14 units of alcohol a week, spread out over three days or more. It also advises having several drink-free days each week and avoiding binge drinking, which increases the risk of having a heart attack.

It could be useful to display leaflets and posters in the pharmacy to visually depict how much a unit of alcohol actually is, as many people find it difficult to relate their glass of wine, for example, to a number of units. Stopping smoking is another thing to highlight during customer conversations. Smoking is a major risk factor for atherosclerosis (furring of the arteries) as well as a host of other circulatory diseases, so giving up will reduce these risks.

“Smoking deserves particular emphasis,” says Darshan. “Prevention has to be personalised and patient-centred. A generic leaflet is unlikely to change behaviour on its own. Pharmacy teams can ask what matters most to that person, address their ideas, concerns and expectations, identify one or two achievable changes, signpost or refer them to appropriate services that support their journey, and follow up when they next come into the pharmacy.”

Identifying risk

There will be instances where an everyday interaction, such as discussing lifestyle, may lead to identifying CVD risk in a patient. “Everyday interactions around blood pressure checks, smoking cessation, medicines and healthy lifestyle advice provide opportunities to encourage customers to ‘know their numbers’ and take up health checks,” says Emily McGrath, senior cardiac nurse at the British Heart Foundation. “With around five million people in the UK living with undiagnosed high blood pressure, early conversations can help identify those at risk and connect them with the right support.”

For example, a customer asking for advice on wellbeing products or for smoking cessation support should prompt a follow-up question about their overall health. “Community pharmacy has a major advantage in that we see people often before they consider themselves unwell,” Darshan says, adding that these routine interactions can become an opportunity to identify cardiovascular risk earlier.

Spotting risk factors in customers should be assessed by looking at the ‘bigger picture’ of their health profile. “For example, raised blood pressure should prompt us to consider the wider picture – like smoking status, cholesterol, diabetes risk, weight, kidney health, family history and, where appropriate, pulse rate and rhythm,” says Darshan. “This multi-organ approach places particular emphasis on finding people with undiagnosed or under-treated risk factors before they experience a heart attack or stroke. Many of these conditions are largely asymptomatic, so opportunistic case-finding is particularly important, and can be a real lifesaver,” he explains. “Pharmacy teams can help by recognising initial cues and referring the patient to the pharmacist or appropriate service.

“A practical community pharmacy CVD model can incorporate case-finding, ambulatory blood pressure monitoring, adherence support, lifestyle intervention and referral, with prescribing or treatment optimisation where appropriately trained and governed.”

In case of emergency

When CVD risk is identified in a patient, it’s important for pharmacy teams to have a clear plan in place. “The first principle is that pharmacy staff do not need to diagnose an emergency before escalating it,” explains Darshan. “They need to recognise when the presentation could represent something serious and act promptly.”

If pharmacy teams do suspect an emergency such as a heart attack or a stroke, they should escalate to 999 without hesitation.

“Symptoms that should immediately raise concern include new or severe central chest pain or pressure, particularly with breathlessness, sweating, nausea or pain spreading to the arm, jaw or back; sudden facial weakness, arm weakness or speech disturbance, which could indicate a stroke. The acronym of think FAST is particularly useful for pharmacy colleagues.”

The NHS advises a call to 999 if someone’s lips or skin are pale, blue or grey (on black or brown skin this may be easier to see on the palms of the hands) or if they have passed out and are not responding normally.

For a full list of red flags, visit nhs.uk/conditions to find dedicated pages for heart attack, heart failure, heart rhythm problems, stroke and more.

“Every pharmacy needs clearly understood clinical boundaries and escalation pathways,” Darshan says. “Your team should know not only what to look for, but who takes over via appropriate referral using mechanisms like SBAR-D narrative [a structured communication method used to report critical information clearly and concisely], whether the appropriate route is 999, NHS 111, same-day primary care or routine follow-up, and how that interaction is documented.”

Care beyond prescriptions

Some customers will be receiving medication for their cardiovascular condition at the pharmacy. These regular prescription collections give pharmacy teams an opportunity to check in with how patients are coping with their medicines. “I think one of the most valuable things we can do is move from simply supplying the medicine to understanding how the person is actually getting on with it,” says Darshan.

Questions pharmacy teams can ask include if they are experiencing any adverse effects, if they are finding the regimen easy or difficult to follow, if they are experiencing any swallowing difficulties, and if they have any concerns around remembering to take the medication. Open-ended questions may also be useful in starting the conversation.

“A non-judgemental conversation often identifies problems that would otherwise remain hidden or unaddressed,” says Darshan. “As pharmacy teams, we should be moving away from simply asking “Is the patient taking their medicines?” to a patient-centred approach of: “Are these medicines working for this person specifically, are they taking them safely, and is anything preventing us from achieving the best possible cardiovascular outcome?”

With pharmacy teams seeing customers regularly, the opportunities to influence heart health from the pharmacy counter cannot be understated.

Pharmacy teams have enormous scope to move cardiovascular care upstream, find risk earlier, have meaningful conversations about prevention, support people to get the best from their medicines and know when something needs urgent escalation. “The aim here is not simply to perform more checks,” says Darshan. “It is to turn everyday pharmacy contacts into opportunities to prevent the first heart attack or stroke.”