Cardiovascular disease (CVD) is the cause of significant morbidity and mortality across the UK and is also linked to premature mortality. Nurses working in general practice play an important role in identifying those at risk of developing CVD and implementing person-focused risk reduction strategies. The NHS Health Check programme was introduced in 2009 to facilitate the early identification of people at high risk of CVD so that appropriate advice could be given, and action taken to reduce future cardiovascular events (Waterall et al, 2015). In 2019, Public Health England set out its CVD ambitions, and identified the importance of detecting atrial fibrillation (AF), hypertension and dyslipidaemia, and fine tuning the management of these risk factors to reduce CV events (Waterall, 2019). In this article, we discuss why CVD risk reduction is so important and demonstrate how to carry out a risk assessment and support people to address their risk factors. By the end of this article, you should have a greater awareness of:
- The role of NHS Health Checks in CVD risk reduction
- Risk assessment tools and what they tell us
- Risk factors for developing CVD
- Lifestyle interventions that reduce CVD risk
- The appropriate use of pharmacological management.
NHS Health Checks
The NHS Health Check programme was designed to identify people with risk factors for CVD and ensure that they had access to the support and medication they might need to reduce that risk (Waterall, 2019). Anyone between the age of 40 and 74 years who does not have a pre-existing diagnosis of CVD is eligible for one of these health checks, which will include an assessment of risk factors and an individualised calculation of the likelihood of them suffering a cardiovascular event over the next 10 years, based on their particular measurements (blood results, body mass index, blood pressure), smoking history, medical history and family history. Although the programme has demonstrated some success with respect to the identification of high risk people who may not have been found prior to the programme's inception, it is still estimated that less than half of the eligible population has attended for a check (Iacobucci, 2019). General practice nurses (GPNs) could be instrumental in encouraging people to attend Health Checks and helping people to understand the potential benefits of risk assessment and reduction strategies. GPNs could also carry out opportunistic checks on people who are being seen for another reason if recent blood test results are available.
Risk assessment tools
The use of validated risk assessment tools allows an individual's chances of having a stroke or heart attack in the next 10 years and beyond to be estimated. GP computer systems will include risk assessment tools such as QRisk but calculations can also be made by visiting the QRisk (https://qrisk.org/three/) or JBS3 website (http://www.jbs3risk.com/). QRisk 3, like its predecessor, QRisk 2 (https://qrisk.org/2017/) is based on data gathered from GP practices in the UK and includes the risk factors that have been identified through this database as being important when calculating CVD risk. QRisk 3 includes the risk factors from QRisk 2 such as age, sex, family history of CVD, smoking history, the presence of atrial fibrillation or chronic kidney disease and measurements such as body mass index, blood pressure (BP) and lipid levels, along with additional risk factors such as erectile dysfunction, migraine and serious mental illness, which were identified through further data collection since QRisk 2 was published. Either system can be used, however, and few practice systems have QRisk 3 built into them.
If the individual is estimated to have a CVD risk score of 10% or more over the next 10 years, they will need pharmacological therapies aimed at reducing their blood pressure and/or lipid levels (Hippisley-Cox et al, 2008). People at all levels of risk, including those with a risk score of less than 10%, will be offered lifestyle advice based on their individual needs (National Institute for Health and Care Excellence [NICE], 2015).
It could be argued that using cut-off points such as 10% may be too simplistic and that decisions should also reflect people's relative risk and their heart age. For example, Steve (Caucasian), age 40 years, is an IT manager, who smokes 10/day. His BP is 142/90 mmHg, he has a total cholesterol to HDL ratio of 5.8, and a BMI of 22.2. His QRisk score is a fairly reassuring 4.2% however, his relative risk, compared to someone of the same age is 3.3 – in other words his risk of having a cardiovascular event is over three times higher than his peers. Based on the JBS3 calculator, his heart age is 46 – a full 6 years older than he is. As a result, Steve will benefit from a discussion about how to reduce his risk through lifestyle changes, even though his overall risk score is less than 10%. Explaining his relative risk and his heart age might motivate Steve to change, whereas having a QRisk score of 4% might have given him a misplaced sense of security.
Risk factors
Risk factors for CVD are divided into those that cannot be changed, such as age, sex and family history, and those that are modifiable, such as smoking and body mass index. Key contributing factors to the development of atheroma include hypertension, dyslipidaemia, smoking, poor diet and obesity (Waterall, 2020). Deprivation is also an important risk factor which is factored into the assessment by including a post code as part of the risk calculation (Lang et al, 2016).
Once the risk assessment has been completed, the focus will often move to managing the risk factors that are most closely linked to CVD risk, such as hypertension and dyslipidaemia, along with smoking. According to NICE, hypertension should be suspected if an individual has a clinic blood pressure of 140/90 mmHg or more with home readings of 135/85 mmHg or greater (NICE, 2019). The decision to treat an individual's BP will depend on any comorbid conditions they might have (such as diabetes or chronic kidney disease) or their CVD risk score. Hypertension is mostly asymptomatic so clinic and home measurements should be checked in all eligible individuals. If stage 1 hypertension is subsequently diagnosed (clinic BP 140/90 mmHg to 159/99 mmHg and subsequent ambulatory or home readings ranging from 135/85 mmHg to 149/94 mmHg) the individual should be offered support to make lifestyle changes. In those with pre-existing conditions or a risk score of 10% or more, medication should be offered. Often two or more drugs are required to achieve the recommended target BP (Mancia et al, 2019). In stage 2 hypertension (clinic BP of 160/100 mmHg to 179/119 mmHg subsequent ambulatory or home BP average of 150/95 mmHg or higher) medication is always recommended (Mancia et al, 2019).
Dyslipidaemia is another important risk factor which should be managed based on the profile of the patient (ie if there is evidence of familial hypercholesterolaemia), or on the overall CVD risk score being 10% or more (NHS England/Accelerated Access Collaborative, 2020). People with established CVD will always be advised to take a statin (NHS England/Accelerated Access Collaborative, 2020). When calculating CVD risk the ratio of total cholesterol to HDL cholesterol is used, but when looking at the treatment target, the non-HDL cholesterol should be 2.5 mmol/mol or less – this is equivalent to an LDL-cholesterol of 1.8 mmol/mol or less and is in line with European guidelines which also recommend that high risk individuals on statins should aim for an LDL-cholesterol of <1.8 mmol/L (Mach et al, 2020).
The PHE CVD ambitions document from 2019 (Waterall, 2019), as mentioned above, also includes the detection of AF as an important way to reduce future stroke risk.
Manual pulse checks can be carried out as part of a CVD assessment to improve the detection of AF. If an abnormal pulse is noted, an electrocardiogram (ECG) should be carried out as soon as possible to capture the evidence. If AF is diagnosed, stroke risk should be assessed and those at increased risk (CHA2DS2-VASc score of 2 or more) should be offered an anticoagulant (NICE, 2021).
Additional risk factors included in QRisk 3 include the presence of, and treatment for, serious mental illness, as people with SMI have a 53% higher risk of having CVD and 85% higher risk of death from CVD (NHS England, 2019). Erectile dysfunction is also included in QRisk 3 as evidence has linked ED with CV events (Jackson et al, 2010).
Lifestyle interventions
GPNs have an important role to play in supporting people at any level of risk to make lifestyle changes to reduce the possibility of a CV event in the future. They are ideally placed to advise on areas such as healthy eating, weight loss, physical activity, smoking cessation and alcohol intake. However, it is important to stay up to date with current evidence and opinions in order to engage with people effectively. For example, there is currently a significant level of interest in low carbohydrate diets and research suggests that these can help with weight loss and also impact on lipid levels (Nordmann et al, 2006). For some people, especially those with or at risk of diabetes, the very low calorie diet approach may be an option (Lean et al, 2018). There is renewed debate on the different benefits of aerobic, cardiovascular activity versus weight or resistance training (Schroeder et al, 2019). High intensity interval training may also appeal to people with less time to invest in physical activity (Kuehn, 2019). The message, then, is to stay open-minded and informed about what might help people to live healthier lives.
Smoking cessation is one of the most important and cost-effective interventions known to improve health (Duncan et al, 2019). Smoking cessation should be encouraged and supported by all healthcare providers and up-to-date training can be accessed via the National Centre for Smoking Cessation and Training: https://www.ncsct.co.uk/
Pharmacological management of CVD risk
Whether prescribers or not, GPNs will also be able to advise on medication, reviewing and optimising pharmacological interventions to ensure that research is put into practice in order to optimise outcomes. Guidance on prescribing in hypertension can be found via the NICE guidelines algorithm (NICE, 2019). Lipid lowering therapy for primary prevention usually starts with atorvastatin 20 mg, with the dose being uptitrated in order to reach target. In some cases ezetimibe may be added to a statin to improve lipid management (NHS England/Accelerated Access Collaborative, 2020). There is a new injectable PCSK9 inhibitor, inclisiran, and another new oral lipid-lowering therapy, bempedoic acid, for use in those who need more intensive treatment (Tibuakuu et al, 2020; Lamb, 2021). Smoking cessation therapies should also be used to support quit attempts, and varenicline or dual nicotine replacement therapies offer the best outcome for most people (Tulloch et al, 2016).
The future
It is anticipated that a direct enhanced service (DES) for CVD will be launched later this year, refocusing on the importance of sound evidence-based management (NHS England, 2020). Primary Care Networks may be encouraged to appoint CVD leads – nurses, pharmacists or GPs – to ensure that the DES is implemented in a meaningful and targeted way for the populations they serve. The Primary Care Cardiovascular Society (https://pccsuk.org/) is looking at how it can support people with an interest in CVD to deliver first class care through the development of a network of primary care CVD champions to share knowledge, expertise and best practice throughout the health service.
Conclusion
Nurses working in general practice play an important role in identifying those at risk of developing CVD and implementing person-focused risk reduction strategies. Risk assessment tools are useful but it can be argued that decisions should also reflect people's relative risk and their heart age. Once the risk assessment has been completed, the focus will often move to managing the risk factors that are most closely linked to CVD risk, such as hypertension and dyslipidaemia, along with smoking. Nurses can support people at any level of risk to make lifestyle changes to reduce the possibility of a CV event in the future, and it is essential to keep up to date with evidence to engage with people most effectively. Nurses are also instrumental in reviewing and optimising pharmacological interventions to ensure that research is put into practice in order to optimise outcomes for people at risk of CVD.
Useful resources:
- National Centre for Smoking Cessation and Training: https://www.ncsct.co.uk/
- Primary Care Cardiovascular Society: https://pccsuk.org/
- QRisk 3 calculator: https://qrisk.org/three/
- JBS3 calculator: http://www.jbs3risk.com/
- Health Matters: preventing cardiovascular disease: https://www.gov.uk/government/publications/health-matters-preventing-cardiovascular-disease
Key Points:
- NHS Health Checks offer a structured and evaluated method for assessing CVD risk in the population
- Risk assessment tools allow risk to be estimated on an individual basis, with 10 year risk, relative risk and lifestyle risk all helping to inform decision making and motivation to change
- There are multiple jigsaw pieces of CVD risk factors, some modifiable, other not. The focus of CVD reduction is on tackling modifiable risk factors in an evidence-based and person-focused way
- This will involve a combination of lifestyle interventions and pharmacological management
CPD reflective practice:
- How could you encourage more patients to take up the offer on an NHS Health Check in your surgery?
- In some cases, cut-off points for cardiovascular risk scores such as 10% may be too simplistic. Why is that?
- How can you ensure you stay up to date with research into lifestyle interventions to ensure you are following the latest evidence?