CHD (coronary heart disease) is a common disabling disease and a leading cause of mortality in the UK and developed world. CHD is a preventable disease that kills more than 110,000 people in England every year. More than 1.4 million people suffer from angina and 275,000 people have a heart attack annually. CHD is the biggest killer in the country (DOH 2000). Identification and management of risk factors in the development of CHD have significant potential for improving health.
A fifty-year-old man visited me for a routine checkup. He appeared to be healthy. As part of the check up, I asked him if he had ever experienced any chest pain. He described experiencing occasional central chest pain. He said the chest discomfort was accompanied with feeling of dizziness, shortness of breath and tingling in fingers. It usually occurred during an evening walk, which he took after dinner.
The chest pain lasted for a very short time and disappeared if he stopped walking for a short while. The patient was of moderate build and appeared healthy and well hydrated. His height was 165cm and his weight was 85KG. His BMI was 31. The BMI of more than 30 suggests that the patient is obese. He smoked 30 cigarettes a day and consumed alcohol in excess of 30 units a week. His vital signs were as follows. Blood pressure, 145/89mm Hg, pulse 80 beats/min. Urinalysis showed no protein or glucose. He had no ankle oedema.
The patient had a family history of coronary heart disease. His father was diagnosed with coronary heart disease at 60 years of age. He subsequently underwent triple bypass surgery. The patient's paternal grandfather died of a heart attack at the age of sixty.
The patient is married. He is employed as a bus driver. Although he enjoys his work, he works long hours and takes few holidays. His wife accuses him of being a chronic workaholic who is always under considerable stress. The patient's age, gender, family history, and social history placed him at high risk for coronary heart disease
Significant findings include the patient's age, gender, and family history of coronary artery disease, and lifestyle, which includes stress, overwork, and very little physical activity.
Blood tests for fasting lipid profile, urea and electrolytes, full blood count, creatinine kinase and fasting blood glucose were carried out the following day with the patients consent. I also performed an ECG which showed no significant changes. He was referred for an exercise treadmill test, the results of which were within normal limits. He returned for review the following week. Blood results showed elevated serum cholesterol, LDL and triglycerides and low HDL with normal liver and kidney function and abnormal blood glucose.
A repeat fasting glucose was also raised and a glucose tolerance test was later performed. He was found to have an impaired glucose tolerance which was to be monitored on an annual basis. He was also found to be slightly anaemic with a haemoglobin of 12.1g/dl. The patient had a high relative risk of heart disease. I then assessed his absolute heart disease risk using the Joint Committee Chart. With a systolic BP of 140 and serum total cholesterol to HDL ratio of 4.5, his risk was >20% over the next 10 years.
It is important to detect the risk of coronary atherosclerosis at an early stage and to treat the patient with inexpensive interventions like diet restriction, aerobic exercise, healthy lifestyle, stress reduction technique and disease prevention.
The patient's condition was initially managed by modifying the associated risk factors. I did this by advising on a low fat diet, regular aerobic exercise, relaxation therapy and medication in the form of a statin to help lower his serum cholesterol. He was also referred to the Stop Smoking service to help him to give up smoking. He was very proactive in his approach to lifestyle changes and was keen to improve his overall health status.
I gave him advice surrounding his lifestyle choices, using research based practice.
Risk factors for CHD include personal and genetic, which are unalterable, and factors related to lifestyle, which can be influenced. The main risk factors relating to lifestyle are accepted as cigarette smoking, alcohol, raised blood pressure, elevated serum cholesterol, inappropriate dietary intake, physical inactivity and obesity (Shaper et al, 1981 and Gandhi, 1997).
The link between dietary intake and coronary heart disease is widely known. (Sivers 1996). On my third consultation with the patient I took a diet history, his wife was also present at the consultation as she felt that her input would be valuable. He was quite knowledgeable about food groups but had a high intake of saturated fats. Together we set realistic and attainable goals for his approach to diet that included increasing his fruit and vegetable intake to the recommended 5 portions a day and reducing his salt intake. We also talked about reducing his intake of fats by advising on grilling foods in preference to frying and choosing low fat alternatives when available. I also advised that he increases his consumption of oily fish such as trout, mackerel and sardines. We also discussed his sugary food intake; especially in view of his impaired glucose tolerance test He was keen to address this. I also advised him to increase his intake of starchy foods to help fill him up, rather than eating larger portions, which he previously had been doing.
He was referred to the Stop Smoking service, which he was keen to do, and over a period of 16 weeks he was able to completely stop his smoking. He was initially started on a nicotine replacement patch 21mg/24hours. He regularly attended the stop smoking service and also received counseling at the practice. He had never attempted to stop smoking before and initially struggled. I explained the cycle of change to him as suggested by Prochaske and DiClemente (1986), this helped him to understand his cyclical behaviour with respect to smoking cessation. Keys (1980) reported that the incidence of CHD among smokers was almost double that of non-smokers. Smoking is estimated to account for around 18% of all CHD deaths, and is the largest modifiable contributor to CHD deaths (The Scottish Office, 1996).
The relationship between alcohol and heart disease is still under discussion. However, the Department of Health (1993) class alcohol as a contributory factor as it can also lead to obesity. We therefore discussed moderating his alcohol intake and to keep within the recommended 21 units per week. (Drugs and Therapeutics Bulletin 2001)
The benefits of a physically active lifestyle in health promotion and disease prevention are well documented. (CMO, 2004). The patient admitted to getting less exercise than he should and was keen to address this. We discussed a healthy exercise plan that included regular walks, which he was already doing. After lengthy discussion I felt he would benefit from a structured exercise programme and a referral to Exercise Your Options Scheme was made.
Arteries provide oxygen-rich blood to the heart, brain, and other parts of the body. The inner lining of the arteries, the endothelium, can be injured due to high cholesterol levels, high triglycerides, high blood pressure, smoking and diabetes. When the endothelium is damaged, substances that flow through the arteries, such as fats, cholesterol, calcium, cellular waste products and other substances (collectively known as plaque), are deposited in the artery wall, and over time begin to build up. The build up of these substances causes the arteries to harden, narrow or become blocked. Depending on where the hardening or blockage occurs, other complications then follow.
The build up of plaque is known as atherosclerosis. As the plaque increases in size, the insides of the coronary arteries get narrower and less blood can flow through them. Eventually, blood flow to the heart muscle is reduced, and, the heart muscle is not able to receive the amount of oxygen it needs. Reduced or cut off blood flow and oxygen supply to the heart muscle can result in angina, shortness of breath, myocardial infarction and arrhythmias.
Endothelium is damaged by high cholesterol, high blood pressure, and cigarette smoking. A person such as the man described, who has all three of these risk factors is eight times more likely to develop atherosclerosis than is a person who has none. Physical inactivity, diabetes, and obesity are also risk factors for atherosclerosis.
The patient's ECG and stress test were normal; however, his laboratory tests and family history suggest that he is at high risk for atherosclerosis. The presences of the high LDL together with the low HDL and high triglycerides put him at an increased risk for myocardial infarction and make him a candidate for interventive therapy. He was consequently commenced on 40mg Simvastatin daily.
His blood pressure was monitored monthly and in accordance with the British Hypertension Society Guidelines, and because his 10 year CHD risk was 20% he was commenced on Lisinopril 5mg daily. There is evidence to suggest that hypertension control has greatly contributed to the reduction of the death rate from CHD. (ALLHAT 2002)
The patient's occasional chest pain could be due to the stress and strain of overwork. Anxiety can lead to physical symptoms of hyperventilation like chest pain, palpitation, and shortness of breath. These symptoms often get confused with symptoms of angina or heart attack.
The patient was advised to attend for repeat lipids periodically between 6-12 weeks after initiation of therapy and to continue to monitor lipid levels every six months, which is in accordance with current recommendations. (BNF 2007)
Gibbs (1988), described a reflective cycle, that shows how refection on actions is a cyclical process. I used this process when reflecting on my own practice. I felt the advice I gave was appropriate and was happy with the approach I used with the patient
The author thinks that her approach to this gentleman was appropriate and hopefully will produce a positive outcome. Since he was first seen in the clinic he has greatly improved his overall health status. He is no longer smoking and gets regular exercise. He feels that his diet has improved but he could still do more, as he finds this the most difficult of his lifestyle changes. I would, in future, make more referral to the dietetics service as they can offer invaluable help to individuals requiring more than average input in making positive adjustments to their dietary intake. This gentleman is very keen to address his health and has shown good concordance to his medication and changes in his lifestyle. I see him regularly and I am very pleased with the outcome. I feel appropriate advise and referral was given. I would change very little about the way this patient was managed.
With secondary and primary prevention fewer patients will need hospital admission for exacerbation of symptoms. Influencing lifestyle and must be undertaken sensitively and with offer of practical help (Bennett, 1992). Once CHD has been diagnosed continuing advice must be given on risk factors to reduce subsequent exacerbation or complications. A randomized trial on nurse run clinics in Scotland suggested that such clinics are effective at reducing risk factors in this group (Campbell et al, 1998). Nurses are particularly good at helping reduce cholesterol levels (Cowburn 1995). I am currently involved in doing an audit on the patient practice to find patients at risk of coronary heart disease. I then intend to do a complete health assessment on them to establish their relative and absolute risk and continue to give advise according to guidelines and policy.