NHS Health Checks in Community Pharmacy

1. NHS Health Checks in Community Pharmacy Joanne Haws RN BSc (Hons) Nurse Consultant in Cardiovascular Disease Chair, Cardiovascular Nurse Leaders Primary Care Cardiovascular Society Clinical Lecturer in Cardiovascular Disease Education for Health, Warwick

2. Smoking

3. Easily available, cheap, energy dense foods!

4. Inactivity

5. Aims of session To be aware of current evidence based guidelines and DH Vascular Risk programme To understand the risk factors To be familiar with the investigations and assessment required to calculate CVD risk & tools available To be aware of non-pharmacological and pharmacological management options To know when to refer back to general practice To understand the importance of communicating risk To gain knowledge of motivational strategies to help support self care Ask what students would like to get out of the day Ask what students would like to get out of the day

6. The Problem�. Cardiovascular disease continues to be the biggest killer in the UK today Almost 200,000 deaths per year One in three premature deaths Half of these CHD A quarter stroke Most can be prevented/delayed

8. Putting prevention first National vascular checks programme Commenced 04/09 Comprehensive CV risk assessment to be offered to all aged 40-74 PCT delivery

9. Cardiovascular Disease

10. It�s all atheroma�. Common aetiology Systemic disease Risk factors Common treatment aim Prevention of events

11. Modifiable & non-modifiablerisk factors Linked to process of atherosclerosis INTERHEART study (Yusuf et al, 2004) Modifiable risk factors Non modifiable risk factors Certain risk factors contribute to development or exacerbation of CVD - linked to process of atherosclerosis Level of any one risk factor e.g. BP or waist circumference on its own insufficient to estimate the overall CVD risk. INTERHEART study (Yusuf et al 2004) showed 9 potentially modifiable risk factors account for over 90% of the risk of MI worldwide; in both sexes, at all ages and in all ethnic groups. 2 most important risk factors were smoking & abnormal lipids. Certain risk factors contribute to development or exacerbation of CVD - linked to process of atherosclerosis Level of any one risk factor e.g. BP or waist circumference on its own insufficient to estimate the overall CVD risk. INTERHEART study (Yusuf et al 2004) showed 9 potentially modifiable risk factors account for over 90% of the risk of MI worldwide; in both sexes, at all ages and in all ethnic groups. 2 most important risk factors were smoking & abnormal lipids.

12. Cardiovascular risk factors Non-modifiable: Modifiable: Age Smoking Gender Hypertension Family History Obesity Ethnicity Hyperlipidaemia Socio-economic status Salt intake Alcohol intake Diet Diabetes Physical activity Psychosocial factors

13. NHS Health Checks Programme

14. VASCULAR PROGRAMME

16. JBS2 CVD risk prediction charts

18. Levels of risk <10% risk over the next 10 years - classed as low CVD risk 10-20% risk over the next 10 years - classed as moderately increased CVD risk >20% estimated risk over the next 10 years - classed as high risk.

19. Red Flags Blood pressure >160/100 mmHg Cholesterol >7.5 mmol/l

20. Smoking Strong association with CVD Smoking as few as 3 per/day doubles risk of MI or death Level of risk falls to that of non-smokers within 5 years Best quit success with counselling and pharmacological therapy Stopping smoking improves health and reduces the risk or progression of smoking-related diseases, bringing substantial, immediate health benefits - see later. Cigarettes are the only legally available consumer product which kills people when used exactly as intended! Stopping smoking improves health and reduces the risk or progression of smoking-related diseases, bringing substantial, immediate health benefits - see later. Cigarettes are the only legally available consumer product which kills people when used exactly as intended!

21. Poor diet Low fruit and vegetable intake Takeaway and convenience foods High saturated fats High sugar High salt Excessive portion size Discuss why diets have changed and impact of this � modern lifestyle Discuss why diets have changed and impact of this � modern lifestyle

22. Alcohol intake Low to moderate intake is associated with a lower risk of CVD Heavy alcohol is associated with high risk for hypertension and stroke Drinkers of more than 35 units/wk double their risk of mortality Binge drinking strongly associated with a large rise in BP Women drinking more than ever before. Alcohol intake above the recommended levels & binge drinking both associated with risk of an increased BP, haemorrhagic stroke & arrhythmias. Red Wine � raises HDL anti thrombotic effect & positive effect on endothelial function. Drinking moderate amount & being physically active better than not drinking at allAlcohol intake above the recommended levels & binge drinking both associated with risk of an increased BP, haemorrhagic stroke & arrhythmias. Red Wine � raises HDL anti thrombotic effect & positive effect on endothelial function. Drinking moderate amount & being physically active better than not drinking at all

23. Physical activity Essential part of weight maintenance If maintained BP can be reduced by 3.8 to 2.6 mmHg, systolic and diastolic 30 minutes - on five or more days/wk Reduces the risk of CHD by more than 18%, the more is undertaken If no exercise is taken studies show that people are 30% more likely to become hypertensive. Mention cycling, brisk walking, running and swimming - any effect from physical activity is only related to current not historic exercise. Benefit is lost when physical activity discontinued. Therefore vital any programme of activity is planned with the patient & is sustainable. Pedometers useful?Mention cycling, brisk walking, running and swimming - any effect from physical activity is only related to current not historic exercise. Benefit is lost when physical activity discontinued. Therefore vital any programme of activity is planned with the patient & is sustainable. Pedometers useful?

24. Hypertension Approx 12% of population Rule of halves applies Usually primary/essential Risk not disease unless untreated Essential part of risk management QoF risk assessment

25. High Cholesterol 45% of MI�s associated with raised cholesterol 3 x risk of those with normal lipids Lipid profile important Affected by diet High cholesterol unlikely to be managed by diet alone

26. Familial Hypercholesterolaemia Affects 1 in 500 Over 280 LDL receptor mutations identified One of the most common genetic disorders Causes raised cholesterol levels and premature death from CHD Treatable once the patient is identified

28. Diabetes = high CVD risk Blood pressure Cholesterol Blood glucose How many times do you hear a person with diabetes say, �I�ve stopped having sugar in my tea�? Are we getting the message of CVD risk & the importance of blood pressure and cholesterol control as well as blood sugar?How many times do you hear a person with diabetes say, �I�ve stopped having sugar in my tea�? Are we getting the message of CVD risk & the importance of blood pressure and cholesterol control as well as blood sugar?

29. Diabetes Patients can go up or down from the IGR status. Patients with no MI but diabetes has the same risk as a non diabetic patient whose had an MIPatients can go up or down from the IGR status. Patients with no MI but diabetes has the same risk as a non diabetic patient whose had an MI

30. Definition of Metabolic Syndrome Central obesity (waist circumference = 94cm for European men and = 80cms for European women) and any two of the four factors below: ? Trigs = 1.7 mmol/L or treatment for this ? HDL < 1.03 mmol/L in men, < 1.29 mmol/L in women or specific treatment for this ? BP =130/85 or treatment of previously diagnosed hypertension ? FPG = 5.6mmol/L or diagnosed T2 diabetes International Diabetes Federation, 2004 Metabolic syndrome - not a specific disease but cluster of factors putting individual at risk of CVD. Affects 1/4 of worlds population, 2x likely to die from/ 3x likely to have a heart attack or stroke, 5x risk of developing T2 diabetes. If BMI over 30 waist circumference measurement not needed as considered a risk factor. ASK � What�s thought to have contributed to increasing numbers of individuals with metabolic syndrome? = Progressive increase in portion sizes, Commercially prepared food - high in salt, simple sugars and saturated fats, Sedentary lifestyles & Reliance on cars. Metabolic syndrome - not a specific disease but cluster of factors putting individual at risk of CVD. Affects 1/4 of worlds population, 2x likely to die from/ 3x likely to have a heart attack or stroke, 5x risk of developing T2 diabetes. If BMI over 30 waist circumference measurement not needed as considered a risk factor. ASK � What�s thought to have contributed to increasing numbers of individuals with metabolic syndrome? = Progressive increase in portion sizes, Commercially prepared food - high in salt, simple sugars and saturated fats, Sedentary lifestyles & Reliance on cars.

32. Obesity - BMI BMI = Wt (kg) Ht (m)2 < 20 underweight 20-24.9 normal 25-29.9 overweight 30-39.9 obese >40 severely (morbidly) obese. Now recognised that BMI is badly flawed as a diagnostic tool and waist measurement best predictor of CVD risk. Abdominal or central obesity was shown to place middle aged men at a much higher risk of CHD even in the absence of other major risk factors such as diabetes or hypertension. Unfortunately this is not taken into account by QOF. What do students measure? Now recognised that BMI is badly flawed as a diagnostic tool and waist measurement best predictor of CVD risk. Abdominal or central obesity was shown to place middle aged men at a much higher risk of CHD even in the absence of other major risk factors such as diabetes or hypertension. Unfortunately this is not taken into account by QOF. What do students measure?

33. Obesity � measurement Mention metabolic syndrome hereMention metabolic syndrome here

34. Management of CVD Risk

35. Interventions Smoking cessation Blood pressure control Lipid management Weight management Increase physical activity Healthier diet Psychosocial support

36. NICE/BHS Guidelines 2006

39. Lipid modification NICE guidance update May 2008 Cardiovascular risk assessments Primary prevention � no target Secondary Prevention � 4 & 2 Simvastatin first line High intensity statins for ACS patients

41. Risk perception Difficult to predict The risk of continuing that behaviour is? How might they go about changing it? What resources are available to help? Give them time to think about their risk.

42. Resistance to change Resistance can be a result of: You trying to take control Assuming they are ready to change before they are You suggesting which issue should be addressed The issue being raised too abruptly or inappropriately Trying to hurry the consultation.

45. Contact Joanne Haws Nurse Consultant in CVD Joanne.haws@sky.com 07786 341397