The current situation and the role of the practice nurse in identification

and management

Cardiovascular Disease

• Prevalence• Risk factors• The ‘Gap’• Interventions• Practice-based skills

Content

• CVD – heart, stroke and vessel disease1

• Leading cause of death – 34% men, 39% women2

• One Australian death every 10 minutes from CVD1

• 18% of total burden of disease (DALYs) – exceeded only by

cancer (19%)2

• Ischaemic heart disease (IHD) and stroke are primary

causes of morbidity and mortality2

CVD Burden

1. National Heart Foundation of Australia. The shifting burden of cardiovascular disease in Australia.Access Economics, 2005. Available at: http://www.heartfoundation.org.au (Accessed April 2009).

2. National Heart Foundation of Australia. The burden of cardiovascular disease in Australia forthe year 2003. July 2007. Available at: http://www.heartfoundation.org.au (Accessed April 2009).

YLD = years lost due to disability

YLL = years of life lost

CVD Burden1

1. National Health Foundation of Australia. The burden of cardiovascular disease in Australia for the year 2003.July 2007. Available at: http://www.heartfoundation.org.au (Accessed Jan 2009).

Risk Factors

• Age – (M>45; F>55 or post-

menopausal)

• Gender (M > F)• Ethnicity

– Aboriginal, Torres Strait Islander, Maori and Pacific Islander

• Family history (first degree relative <60 years)

• Psychosocial factors

Risk Factors1

1. National Health Foundation of Australia. The shifting burden of cardiovascular disease in Australia. Access Economics, 2005. Available at: http://www.heartfoundation.org.au (Accessed Dec 2008).

Non-modifiable• 7 modifiable risk factors

account for >65% of CV deaths and CVD burden– smoking, hypertension,

dyslipidaemia, alcohol, physical inactivity, overweight, low fruit and vegetable intake

• Diabetes is a significant modifiable risk factor

Modifiable

Shift in Lifestyle Causes of CVD?1

Why fat distribution pattern is important• Free fatty acids contribute

to atherosclerosis and insulin resistance in peripheral tissues

• Visceral fat also releases inflammatory mediators that act on the liver to increase insulin resistance; our body tries to overcome this ‘resistance’ by secreting more insulin, further contributing to atherosclerosis and other metabolic disturbances – the metabolic syndrome

Modified LDL initiates inflammatory atherosclerosis2

• Oxidised LDL deposited in vessel wall stimulates a response that is counteracted by HDL

• Atherosclerotic process featuring inflammation is a self-perpetuating vicious cycle that tends to progress

1. Mazzone T et al. Lancet 2008; 371: 1800–9; 2. Aviram M. Atherosclerosis 1993; 98: 1–9.

Asia Pacific Cohort Studies Collaboration1

• Meta-analysis: 26 prospective studies; 96,224 individuals

• Participants grouped in the highest fifth of triglyceride levels compared with those belonging to the lowest fifth

1. Asia Pacific Cohort Studies Collaboration. Circulation 2004; 110: 2678–86.

Risk Factor Burden in Australia1

1. AIHW. Living dangerously. 2001.

The CV Gap

• The evidence-treatment gap1

– failure to attend/identify (diagnosis problem)

– failure to intervene appropriately/sufficiently (management problem)

– failure to adhere to treatment (treatment compliance problem)

• The demographic gap – greatest burden of CVD falls on2

– Aboriginal and Torres Strait Islander peoples

– rural residents

– low socio-economic status

What is the Gap?

1. NHFA and CSANZ. Position statement on lipid management 2005.2. National Health Foundation of Australia. The shifting burden of cardiovascular disease in Australia. Access Economics, 2005. Available at http://www.heartfoundation.org.au (Accessed Dec 2008).

Ethnicity Gap1

1. AIHW. Heart, stroke and vascular diseases – Australian facts 2004.

Socio-economic Gap1

1. AIHW. 2006. Socioeconomic inequalities in cardiovascular disease in Australia: current picture and trends since 1992.

Bridging the Gap

Lifestyle Interventions1

• SNAP– Smoking

– Nutrition (overweight/obesity)

– Alcohol

– Physical activity

• Tailor to patient needs

• Provide encouragement

• Provide written instructions

• Review progress regularly

1. RACGP. SNAP: a population health guide to behavioural risk factors in general practice. Oct 2004. Available at: http://www.racgp.org.au/guidelines/snap (Accessed 14 Jan 2008).

Hypertension1

• ACE inhibitors• Angiotensin II

receptor blockers• Calcium channel

antagonists• Beta blockers• Diuretics

Pharmacological Interventions

Dyslipidaemia2

• Statins• Fibrates• Bile acid sequestrants• Cholesterol absorption

inhibitors• Nicotinic acid

Diabetes3

• Sulphonylureas• Alpha-glucosidase

inhibitors• Biguanides• Meglitinides• Thiazolidenidiones• Incretin mimetics• Insulin

1. Heart Foundation. Hypertension Management Guide for Doctors. 2004. 2. National Health Foundation of Australia. The shifting burden of cardiovascular disease in Australia. Access Economics,

2005. Available at: http://www.heartfoundation.org.au (Accessed Dec 2008).3. American Diabetes Association. Other Diabetes Medications. Available at: http://diabetes.org/utils (Accessed Mar 2009).

Benefits of Intervention

1. Adapted from National Prescribing Service. New Zealand Cardiovascular Risk Calculator.

Practice-based Skills

Apply Appropriate Parameters1

Prevalence of central obesity in Singapore

1. Adapted from Tan C. Diabetes Care 2004; 27: 1182–86.

Pro

po

rtio

n o

f p

op

ula

tio

n (

%)

Pro

po

rtio

n o

f p

op

ula

tio

n (

%)

Diet Treatment1

Energy balance• Energy density

– energy (calories)/gram

• Nutrient density– nutrients/calorie

• To get enough micro-nutrients – simply eat a variety of

nutrient dense foods, i.e. fruit, veg, complex CHO, NOT sugar

• But we often prefer to eat energy dense foods, i.e. fat and alcohol, hence three possibilities:

– exercise, or

– get obese (and insulin resistant), or

– diet and miss out on protective nutrients

1. Bowman. J Am Coll Nutr 2002; 21: 268–74.

Laboratory Reports1

• Full blood count – RBC, WBC, haemoglobin, haematocrit, MCV, WCD, platelets

• Lipids (TC, TG only. HDL & LDL separate)

• Plasma glucose (fasting)

• Liver functionBe careful:

“reference intervals”

1. Simay A. Public Health 2005; 119: 437–41

Follow-up

• Continuity of care is essential for “bridgingthe gap”

• Awareness of high-risk patients – high absolute CV risk– ethnicity or low socio-economic status

– poor compliance

• Recall systems can assist in appropriatefollow-up

Summary

• Despite substantial reductions in the incidence of CVD and associated mortality, further gains are possible

• The Practice Nurse can play a crucial role in the identification of patients at risk of CVD, and reduce thatrisk through:

– specific interventions, counselling and education

– implementation of assessment and recall systems

– assessment of adherence to agreed actions

– awareness of individual circumstances impacting a patient’s ability to make necessary changes

– community liaison