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2. METHODS

Chapter 10

Systematic Risk Factor Management And Clinical Assessment

Anne Merete Boas Soja & Marianne Frederiksen

10.1 Introduction

Systematic risk factor management and clinical assessment is one of the seven components of cardiac rehabilitation at Bispebjerg Hospital. This chapter describes the purpose of the planned follow-up consultations and how they are carried out.

Systematic risk factor management and clinical assessment

Illustration af Systematisk risikokontrol og -opfølgning


10.2 Evidence On The Effects Of Systematic Risk Factor Management And Clinical Assessment

There is solid evidence that treating modifiable risk factors among people with heart disease and people at high risk of cardiovascular disease can reduce the risk of cardiovascular disease. Denmark’s guidelines on pharmaceutical and nonpharmaceutical prophylactic treatment of patients with ischaemic heart disease, type 2 diabetes and patients at high risk of ischaemic heart disease (1–6) systematically review this evidence.


10.3 Purpose

The purpose of systematic risk factor management and clinical assessment is to ensure that the treatment goals set are achieved with the aim of improving patients’ quality of life and reducing their total morbidity and mortality in the long term.


10.4 Methods

The comprehensive cardiac rehabilitation programme considers reducing the risk factors for heart disease and clinical assessment as a task requiring interprofessional coordination. Clinical assessment in the programme is organized as consultations with a physician, since the physician has a key role as the professional responsible for pharmaceutical treatment. The consultations are conducted based on the same principles as the initial consultations, including preparation, patient-centred communication, continuity, documentation and quality assurance (Chapter 4).


10.4.1 Follow-up consultation with the physician

All patients are scheduled for a 30-minute follow-up consultation 3 months and 6 months after the 6-week intensive cardiac rehabilitation programme started. The patients have routine blood tests before each consultation (described in Danish at www.CardiacRehabilitation.dk). The physician knows each patient from the initial consultation and from the informal meetings in the programme and learns of progress in rehabilitation by reviewing the patient records and blood test results before the consultation. The consultation is conducted based on an interview guide for follow-up consultations (available in Danish at www.CardiacRehabilitation.dk).

Patients who have undergone percutaneous coronary intervention, patients who have undergone coronary artery bypass grafting and patients with an implantable cardioverter defibrillator are treated specially regarding patient information, physical activity, mental factors, rules concerning driving licences and pharmaceutical treatment. The Cardiac Rehabilitation Unit has prepared specific action plans to manage these groups of patients (available in Danish at www.CardiacRehabilitation.dk).

Cardiovascular symptoms
The physician asks the patient about trends since the last consultation. They discuss any new symptoms or recurrence of previous cardiovascular symptoms. The physician decides whether the symptomatic treatment is optimal and whether detailed assessment or referral to invasive investigations and treatment is needed in accordance with current guidelines (available in Danish at www.CardiacRehabilitation.dk).

Psychosocial well-being
At these follow-up consultations, patients have acquired some distance from the acute illness and have started a new life.The physician asks patients about their social life, sex life, relationship with spouse or cohabitant, children, friends and employment. The physician assesses whether patients who were in crisis have worked through the phases of the crisis or whether they may have developed depressive features. If depression is present or suspected, the physician refers patients to detailed assessment by a psychiatrist.

Alcohol
Many patients with alcohol problems comply less well with both behavioural and pharmaceutical recommendations. Suspected alcohol problems are discussed with patients, who are informed of the option for referral to treatment for alcohol dependence.

Pharmaceutical assessment
Each physician consultation systematically reviews pharmaceutical treatment. The physician assesses whether patients take the medicine as directed and whether there are any side-effects. Any uncertainty among patients on pharmaceutical treatment is discussed, and the physician updates the medicine forms and the medicine registration in the patient records. If the physician decides that the patient’s pharmaceutical treatment needs to be reviewed in detail, an appointment is made with the nurse.

Symptomatic pharmaceutical treatment: The physician ensures that patients’ symptoms are optimally treated and that patients are phased out on medicine that is no longer needed, such as diuretics. Denmark’s current guidelines for symptomatic pharmaceutical treatment and gradually increasing the dose (1–3;7) are followed.

Prophylactic pharmaceutical treatment: At every consultation, the physician ensures that patients are receiving and continue to take prophylactic pharmaceuticals. If there are side-effects, the physician decides whether to interrupt treatment and whether and when it will be resumed or whether another product should be chosen.The products in the following table are reviewed and prescribed depending on the diagnosis and comorbidity. Medicine is prescribed and dosed according to Denmark’s current guidelines on secondary prophylactic treatment (1–3;5–7), which are implemented in the local instructions of the Department of Cardiology (available in Danish at www.CardiacRehabilitation.dk).

Ideal goals for secondary prophylactic pharmaceutical treatment in the comprehensive cardiac rehabilitation programme
  Congestive heart failure
(7;8)
Ischaemic
heart disease

(1;2;5;9)
Type 2
diabetes

(3;10-12)
High risk
(5;6)
Thrombotic inhibition (13)
Acetylsalicylic acid 75 mg.
Clopidogrel bisulfate 75 mg

+
Optional b,c

+
Optional b,c

+

+
Optional c
Beta-blockers + + + Optional
Calcium antagonist
Optional when
beta-blockers
are not tolerated


ACE inhibitors + Optional + Optional
Angiotensin-II Optional Optional + Optional
Spironolactone +


Statins (5;14) + + + Optional
Antiplatelet treatment for atrial fibrillation or heart valve surgery (13)
Optional

Optional

Optional

Optional
a 150 mg of acetylsalicylic acid for previous stroke.
b 12-month supplement to acetylsalicylic acid following.
c When allergic to or intolerant of acetylsalicylic acid.


Systematic risk factor management
Systematic risk factor management means eliminating and managing as many risk factors for heart disease as possible simultaneously or consecutively depending on the motivation and resources of each patient. The physician achieves an overview of each patient’s risk factors at the initial consultation (Chapter 4). The physician also assesses the need for further assessment and follow-up and for prescribing tests and investigations. All risk factors are recorded in the joint patient records and in patients’ action plans. The treatment goals are also recorded so that both the physician and patient can determine the effect of rehabilitation activities. The treatment goals are based on Denmark’s current guidelines and are set in accordance with patients’ motivation, resources, diagnoses and overall risk (Chapter 4).

Blood pressure: At the initial consultation with the physician, all patients have their blood pressure measured in both upper arms while sitting and after resting in a calm environment for at least 10 minutes (6). The nurse ensures that the cuff is the correct size. The future measurements are performed on the arm that had the highest blood pressure. If arterial hypertension or white-coat hypertension is suspected or if the history indicates suspected dysregulation, blood pressure is measured for 24 hours. If the dose of antihypertensive drugs is being increased or new ones are being added, blood pressure checks are agreed after at least 14 days depending on whether the patient has other concurrent diseases.

The nurse increases the patient’s dose based on a detailed treatment plan formulated by the physician and also checks blood pressure. If the patient has mild hypertension and the physician does not believe that restricting salt intake, losing weight and exercise will lower blood pressure sufficiently, pharmaceutical treatment is started in accordance with Denmark’s current guidelines (6). Patients are treated with a maximum dose of one product if this is tolerated well before any new ones are added, to increase compliance.

Serum cholesterol: All patients with ischaemic heart disease and demonstrated arteriosclerosis are treated with statins regardless of their serum cholesterol concentration (5). Among patients with a high risk of heart disease, the physician assesses whether patients fulfil the criteria for starting stain treatment regardless of the serum cholesterol concentration (14).

To determine whether the treatment goals have been achieved, the serum cholesterol concentrations are determined at the follow-up consultations with the physician at 3 and 6 months. The results are compared with the initial values and the treatment goals. If the treatment goals have not been met, the physician ensures that the patients receiving pharmaceutical treatment take the medicine and the dose of statins is increased or supplemented by fibrate or nicotinic acid depending on the degree and type of hypercholesterolaemia and hypertriglyceridaemia. Patients who have not yet received statins are started on these.

Hyperglycaemia: Strictly controlling blood sugar levels has been shown to influence the rate of complications and survival among patients with both heart disease and type 2 diabetes (3). Chapter 11 describes how the comprehensive cardiac rehabilitation programme manages blood sugar levels.

Microalbuminuria: The presence of microalbuminuria is a sign that diabetes is starting to affect the kidneys. About 20–30% of all patients with type 2 diabetes and 10–15% of all elderly people without recognized type 2 diabetes have microalbuminuria (15). Microalbuminuria is associated with a two- to four-fold increased risk of cardiovascular disease, regardless of whether people have type 2 diabetes. For patients with type 2 diabetes, intensifying antihypertensive treatment and starting treatment to protect the kidneys are crucial, since 5–10% of patients progress to nephropathy each year. The comprehensive cardiac rehabilitation programme uses morning spot urine as a screening method. If two of three consecutive samples taken over several months show a ratio of albumin to creatinine exceeding 2.5 mg/mmol, the patient is defined as having microalbuminuria. Urine is collected for 24 hours to quantify any albuminuria.

Smoking: The physician informs patients that smoking over many years greatly influences the development of cardiovascular disease.The physician encourages ex-smokers to avoid starting again and explains to smokers that it never is too late to quit even though they have achieved some distance from the acute phase of heart disease. It is important to explain to smokers that most people who quit gain some weight but that this can be limited or avoided through physical activity. Some patients begin to smoke again at the follow-up consultations after 3 and 6 months, and the physician tries to motivate them to quit again and refers them to counselling with the nurse or another smoking cessation counsellor.

Physical activity: The physician informs patients about the significance of the relationship between physical activity and developing cardiovascular disease. The physician emphasizes that physical activity is as important a part of treatment as pharmaceutical treatment. At the follow-up assessment, the physician asks patients about their current level of functioning and assesses whether patients have regained their previous level of functioning and can manage as they did previously. The physician also assesses whether patients are physically active at least 30 minutes per day.

Weight: The physician explains that obesity is a risk factor for cardiovascular disease and emphasizes that losing weight is important to improve survival and the quality of life. The physician weighs patients at the follow-up consultations. This has turned out to have great psychological importance for patients in a weight-loss programme. Patients who achieve weight loss are praised. Patients who do not lose weight are offered more counselling from the dietitian.

Need for further assessment or follow-up
The current status and plan for the future are noted in the joint patient records and in the patient’s treatment plan. The patient is referred for relevant tests or examinations when detailed investigation or assessment is needed. In cooperation with the patient, the physician assesses whether consultations with other professionals in the Cardiac Rehabilitation Unit are necessary.


10.4.2 Concluding consultation

The concluding consultation with the physician uses 60 minutes to review the patient’s progress in the rehabilitation programme. The consultation is carried out based on an interview guide (available in Danish at www.CardiacRehabilitation.dk) so that the consultation includes all aspects of the programme.

Various factors may prevent some treatment goals from being fulfilled at the concluding consultation; a plan for future rehabilitation is made with the patient. Depending on the severity of the disease, how complicated the illness is and risk factor management, the physician determines where the patient will be followed up.

Most patients are referred to their general practitioner, who is sent an analysis of the patient’s entire rehabilitation programme, blood test results and recommendations on further treatment initiatives and need for consultation by the general practitioner.


References

(1) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(2) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(3) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(4) Forebyggelse af iskæmisk hjertekarsygdom i almen praksis [Prevention of ischaemic heart disease in general practice]. 2nd edn. Copenhagen, Danish College of General Practitioners, 2002.

(5) Færgeman O, Christensen B, Steen Hansen H, Jensen GH, Melchior TM, Nordestgaard BG et al. Sekundær og primær forebyggelse af koronar hjertesygdom med særligt henblik på dyslipidæmi [Secondary and primary prevention of coronary heart disease with a special focus on dyslipidaemia]. Copenhagen, Danish Society of Cardiology, 2000 (www.dadlnet.dk/klaringsrapporter/ 2000-07/2000-07_0.htm, accessed 22 March 2004).

(6) Abildgaard Jacobsen I, Bang LE, Borrild NJ, Feldt-Rasmussen BF, Steen Hansen H, Ibsen H et al. Hypertensio arterialis [Arterial hypertension]. Copenhagen, Danish Hypertension Society, 1999 (www.dadlnet.dk/klaringsrapporter/1999-09/1999-09-0.htm, accessed 22 March 2004).

(7) Kühn Madsen B, Johannessen A, Thomassen A, Egeblad H, Mortensen SA. Diagnostik og behandling af hjerteinsufficiens. Oversigt og vejledende retningslinjer [Diagnosis and treatment of congestive heart failure. Overview and guidelines]. Copenhagen, Danish Society of Cardiology and Danish Society of Internal Medicine, 1997 (www.dadlnet.dk/klaringsrapporter/1997-09/1997-09- 0.htm, accessed 22 March 2004).

(8) Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22(17): 1527–1560.

(9) Bertrand ME, Simoons ML, Fox KA,Wallentin LC, Hamm CW, McFadden E et al. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2002; 23(23): 1809–1840.

(10) Grundy SM, Howard B, Smith S Jr, Eckel R, Redberg R, Bonow RO. Prevention Conference VI: Diabetes and Cardiovascular Disease: executive summary: conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation 2002; 105(18): 2231–2239.

(11) European Diabetes Policy Group. A desktop guide to type 2 diabetes mellitus. Diabet Med 1999; 16: 716–730.

(12) American Diabetes Association. Clinical practice recommendations 2001. Diabetes Care 2001; 24(suppl 1): S33–S63.

(13) Godtfredsen J, Sandbjerg Hansen M, Elkjær Husted S, Pilegaard HK, Jespersen J. Antitrombotisk behandling ved kardiovaskulære sygdomme. “Trombokardiologi” [Antithrombotic treatment in cardiovascular diseases. “Thrombocardiology”]. Copenhagen, Danish Society of Cardiology and Danish Society of Clinical Biochemistry, 2002 (www.dadlnet.dk/klaringsrapporter/2002-05/2002- 05.HTM, accessed 22 March 2004).

(14) MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360(9326): 7–22.

(15) Donnelly R, Yeung JM, Manning G. Microalbuminuria: a common, independent cardiovascular risk factor, especially but not exclusively in type 2 diabetes. J Hypertens Suppl 2003; 21 Suppl 1: S7–12.


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© Cardiac Rehabilitation, Department of Cardiology Y, H:S Bispebjerg Hospital