67 CHAPTER 14

Prevention of cardiovascular disease Professor Andrew Haines, MD, FRCGP, MRCP, Dr David Patterson, MD, FRCP Dr Mike Rayner, MA, PhD Ms Karen Hyland, SRD

SUMMARY 1. Major risk factors for coronary heart disease (CHD) are smoking, blood pressure and blood cholesterol and they interact in a multiplicative fashion. Family history of premature coronary heart disease and lack of exercise also contribute. Obesity increases risk probably mainly by its effect on blood cholesterol and blood pressure. Heavy alcohol consumption is a risk factorfor stroke. 2. Prevention may be opportunistic or in specially organized clinics, the latter being less likely to result in the attendance of high risk individuals. 3. Worthwhile reductions in cigarette smoking can be achieved by brief advice and follow-up. Literature on smoking and other aspects of prevention is available from the district health education department. 4. Risk scores can be used to calculate the risk of coronary heart disease. They can help to indicate the advisability of measurement of blood cholesterol and to focus limited resources on those at highest risk by helping to define a 'special care group'. 5. Indications for measuring blood cholesterol are: a family history of premature coronary heart disease or hyperlipidaemia, personal history of coronary heart disease, clinical evidence of raised lipids (xanthelasma, corneal arcus under 50, xanthomas at any age), a high risk of coronary heart disease according to a risk score. Many would also include those under treatment for hypertension and diabetes. 6. Dietary advice can moderately reduce blood cholesterol. The proportion of calories from fat should be reduced from the current average of around 40% to a maximum of 33%. Dietary advice should be tailored to the patient's current diet. An increase in vegetables and fruit can be generally advocated. 7. Regular exercise has a worthwhile role to play in prevention. Rapid walking, jogging and swimming may all be suitable, as may be heavy gardening and housework. 8. A small proportion of patients may require lipidlowering drugs. These include resins (cholestyramine and colestipol), fibrates (eg bezafibrate and gemfibrozil) and more recently HMG CoA inhibitors (eg simvastatin). The HMG CoA inhibitors produce large falls in cholesterol and may become first line drugs in future. Because of the current controversy about the effect of lipid-lowering drugs on total mortalitv, many believe that they should be reserved for

FFPHM

those at the highest risk, for example patients with familial hypercholesterolaemia or with pre-existing coronary heart disease and a high plasma cholesterol (>7.8 mmol/L). 9. The special care group defined by the practice should be offered regularfollow-up. Other patients can be followed up by recording riskfactors in medical records and by monitoring them opportunistically during subsequent consultations.

Introduction The UK has a high mortality from cardiovascular disease compared with most other Western countries. Recent figures suggest that there has been a moderate reduction in deaths from coronary heart disease particularly in younger age groups (OPCS, 1991). Deaths due to stroke continue to decline. The evidence linking major risk factors such as smoking, blood cholesterol and blood pressure to coronary disease is persuasive. Diabetes also increases risk. Alcohol excess is a risk factor for hypertension and stroke and probably for sudden death. Moderate alcohol consumption, however, may protect against coronary heart disease (Rimm et al., 1991). Obesity is a risk factor for coronary heart disease particularly when body fat is centrally distributed. It operates at least partly through its association with blood pressure and cholesterol (Donahue et al., 1987). There is reasonably good evidence that regular exercise may play a role in prevention (Berlin and Colditz, 1990). Blood coagulation may have an important role to play in causing events and is currently the subject of research. A family history of premature coronary disease (before age 55) in one or more first degree relatives also increases risk. Risk factors interact with each other in such a way that their effect is multiplicative (Tunstall-Pedoe, 1989). South Asian communities in the UK have a 20% higher mortality from coronary heart disease than the indigenous population. Afro-Caribbeans have a higher mortality from stroke and hypertension but lower mortality from coronary heart disease than whites (Marmot et al., 1984). Although the primary prevention of cardiovascular disease is an important goal, it is also necessary to intervene in those who already have evidence of ischaemic heart disease with the aim of preventing further episodes. There is evidence that coronary artery disease may be halted and even reversed in some patients with aggressive lipid-lowering regimes or changes in lifestyle (Patterson and Treasure, 1991). Since around 90% of the population consult their general practitioner over 5 years, general practice is the most appropriate place for programmes aimed at preventing cardio-

68

vascular disease. Patients consider that general practitioners should be involved in preventive activities (Wallace et al., 1987).

Organization The two main approaches are either opportunistic case finding or screening clinics. Opportunistic case finding takes advantage of the high probability that patients will consult their general practitioner at least every few years. It has the advantage that costs are low and patients may be particularly receptive to advice if the intervention is related to the condition for which they consult. The disadvantages include the possible inappropriateness of case finding in some consultations, and the lack of time in a busy surgery. Screening clinics have the advantage that the doctor or nurse can give undivided attention to prevention. The disadvantages are that response rates to invitations to attend may be relatively low and many who are at high risk may not attend. One possible compromise between these two organizational approaches is to use the routine consultation to undertake a brief assessment of risk or as an opportunity to invite patients to attend a session oriented specifically to prevention for a check-up. Practical advice about starting these activities as well as health education material and training should be available in most districts from the primary care facilitator or practice nurse adviser at the family health services authority (FHSA) or from the local health promotion unit. Practical guidelines for running health checks are given in Appendix 1. Risk assessment Inevitably primary care teams have only limited time and resources to devote to cardiovascular prevention; therefore some way of apportioning time to individual patients is necessary. All those seen at health checks can be given brief general advice about healthy lifestyle. A recent study suggests that about 75% of patients aged 35-64 need advice or treatment as a result of one or more risk factors for coronary heart disease (ICRF, 1991). Special care can only be given to patients at highest risk. The minimum special care group consists of those who have recognized coronary heart disease or who are receiving treatment for hypertension, hyperlipidaemia or diabetes. These will constitute about 1 in 8 of the middle-aged population of an average practice. In addition, those who have multiple risk factors are also at high risk. The Dundee coronary risk disk (for availability see Appendix 2) has been developed to give an estimate of risk based on the multiplicative effect of smoking, blood pressure and blood cholesterol. In the case of those who have not had a blood cholesterol performed, an estimated cholesterol can be used based on the average value for an individual of the same age and sex (Tunstall-Pedoe, 1991). Other scores, such as that from the British Regional Heart Study, have also been devised (Shaper et al., 1987). This takes into account pre-existing coronary heart disease and diabetes (see Appendix 2). An action plan for preventing coronary heart disease in primary care has been proposed based on the use of a risk score (Coronary Prevention Group and British Heart Foundation Working Group, 1991).

Indications for performing a blood cholesterol (for which a non-fasting sample can be used) are: 1. A family history of premature (age 7.8 mmol/L) 3. Clinical evidence of raised lipids - xanthelasma, or corneal arcus, under the age of 50, xanthomas at any age 4. A personal history of coronary heart disease 5. Those at high risk of coronary heart disease according to their risk score or rank. For instance, the risk disk can be used to calculate risk rank, and those with risk ranks above or close to the threshold for special care using estimated blood cholesterol should have a sample taken (see Appendix 2) 6. Many would include patients under treatment for hypertension or diabetes; an alternative is to include them in risk scoring systems and to test for cholesterol if they are at high risk according to the overall score. Record keeping Several standard forms have been designed for keeping records of cardiovascular risk factors. One example is the Oxford heart attack and stroke risk card developed by the Oxford Project for Prevention of Heart Attack and Stroke (available from the HEA Primary Care Unit, Oxford - see Appendix 3). Family history can be recorded using a method such as that described by Zander (1977) if several members are affected.

Smoking Advice from general practitioners is of proven benefit in reducing cigarette smoking. As smoking probably contributes to the deaths of about 100 000 people out of a total of nearly 600 000 British deaths each year, it is the single most important risk factor to focus on. Randomized trials have shown that interventions in general practice, even those of a very brief nature, have a measurable impact on numbers of people giving up smoking. The success rates range from about 5% in studies using minimal intervention and up to 20-30% in studies employing more intensive interventions (Russell et al., 1979; Russell et al., 1987). Behavioural approaches to helping patients to give up smoking have been advocated, including negotiating a contract for smoking cessation which is then signed by the patient, discussing strategies for dealing with high risk situations such as when a patient is offered a cigarette, and setting aside money saved from stopping smoking for a specific purpose, which is seen as a reward by the patient. Tips to help people 'stop' smoking are as follows: 1. Help patients prepare for giving up by planning for a definite 'stop' date. 2. Reassure smokers that any weight gain which may occur after stopping smoking poses far less of a risk than continuing to smoke. 3. Give written information to patients (available from district health education departments or primary care facilitator).

69

4. Discuss reasons for any previous failed attempts to give up. This may enable patients to plan different tactics on the next occasion. 5. The use of nicotine gum is a useful adjunct for some patients - it is contra-indicated in those with clinical coronary heart disease. Nicotine patches are still being evaluated at the time of writing but appear to be useful.

Hypertension The treatment of hypertension is dealt with in the guidelines on this topic (Chapter 6). Dietary advice Reductions in blood cholesterol levels, weight and blood pressure can sometimes be achieved by dietary measures, but a recent review of major trials suggests that a general lipid-lowering diet only reduces plasma cholesterol by up to 4% with more intensive dietary intervention resulting in a reduction of 10-15% (Ramsay et al., 1991). However, the effectiveness of dietary interventions could be improved by increasing the primary health care team's knowledge of nutrition, enhancing their counselling skills and developing systems for monitoring and evaluation. Fats The major non-genetic determinant of raised blood cholesterol level is diet. The association is closest with saturated fat intake which should ideally be reduced to a maximum of 10% (COMA, 1991). An increase in consumption of n-6 polyunsaturated fat (the type of polyunsaturated fat found in vegetable oils and spreads) also helps to reduce total cholesterol levels, while an increase in consumption of n-3 polyunsaturated fat (from fish) probably does not reduce blood cholesterol levels but it may lead to a reduction in coronary risk through beneficial effects on blood clotting pathways. Reducing dietary cholesterol (the main source of which is eggs, shellfish and offal) has only a small effect on blood cholesterol levels. Substituting monounsaturated (for example, olive oil) for saturated fat may reduce blood concentrations of LDL cholesterol giving a beneficial effect on risk. In some studies blood cholesterol levels are related to total fat intake but it is unlikely that this association is independent of saturated or polyunsaturated fat intake. On the other hand most of the fat in the UK diet is saturated and therefore a reduction in total fat intake is an indirect route to reducing saturated fat intake. Furthermore reducing total fat intake is important when seeking to lose weight and reductions in blood cholesterol are to be expected with weight loss. It is therefore advisable to reduce total fat intake to a maximum of 33% of calories (including calories from alcohol; 35% excluding alcohol) (COMA, 1991). There is no simple way of turning targets for fat and saturated fat intake into advice about changes in food consumption. Advice about foods has to be tailored to what the patient actually eats. Suggested dietary changes and questions about diet are given in Appendix 4.

Complex carbohydrates and dietary fibre If the patient is not overweight it is not necessary to reduce energy intake. Calories from saturated fat should be replaced with unsaturated fat and partly with complex carbohydrate. Sugar should be avoided because high intakes are strongly associated with dental caries and possibly with obesity. Since most people eat too little fruit, vegetables (including potatoes), bread, pasta and rice, an increased intake of all these foods would be advisable. An increased consumption of dietary fibre - particularly soluble fibre (the main sources of which are oats, fruit, vegetables) may help to reduce blood cholesterol levels, but it is unclear whether this effect is independent of associated changes in fat intake. Methods of providing advice Patients with very high blood cholesterol or severe obesity (see below) should be referred to a dietitian. There is a range of literature and other materials, for example videos, games, computer programs, aimed at the general public containing information on dietary change which may be a useful adjunct to verbal advice. Such materials are available from district health education departments, primary care facilitators and from some national organizations listed in Appendix 3. A personal health record card for patients has been piloted and may be purchased by family health services authorities and from the Health Education Authority. However, an expectation that information automatically leads to increased knowledge and then to changes in behaviour is too simplistic. Advice tailored to the personal circumstances of the patient is essential. In addition to baseline information about the patient's current diet, factors such as beliefs about perceived likelihood and seriousness of disease, and attitudes towards the costs and benefits of making dietary changes must also be ascertained, as these may affect compliance.

Obesity Obesity is best measured using the body mass index (BMI: weight in kg divided by height in metres squared). Grade 1 obesity is defined as a body mass index between 25-29.9, grade 2 as body mass index 30-39.9. Only a few patients in any practice are grade 3 obese (40 plus). The chart devised by Garrow (1981) (which may be available from the local primary care facilitator) is particularly valuable for measuring the severity of obesity. Achieving and maintaining weight loss in established obesity is often difficult. It is important to try to prevent the weight gain that occurs in many young adults as they age, and to advise those with mild obesity how to avoid further weight gain. In treating obese patients it is important to discourage patients from having unrealistic expectations about the rate of weight loss. Although in the first few weeks weight loss can be quite rapid because of the loss of glycogen with its associated water, the rate of decrease in weight slows down as fatty tissue is lost. The optimum rate of weight loss at this stage is between 0.5 and I kg per week. A higher rate of weight loss may result in loss of lean tissue and is undesirable. Longterm weight loss and maintenance of weight reduction is the goal. Patients should receive verbal and written advice about

70

changes they can make to their diet (see Appendix 4). All patients with grade 3 obesity should be referred to a dietitian. The referral of those with grade 2 obesity will clearly depend on availability of dietetic advice. The most important changes are: 1. A reduction in fat 2. A reduction in sugar and foods containing a lot of 'hidden sugar' such as soft drinks and snacks 3. A reduction in alcohol.

Exercise Regular exercise has a worthwhile part to play in prevention. It is reasonable to aim for at least 20 minutes of exercise three times a week. The exercise shouid be vigorous enough to cause shortness of breath. Rapid walking, jogging or swimming may all be suitable forms of exercise as may heavy gardening and housework. Progress may be monitored by counting the pulse rate during or immediately after exercise although reliability may be difficult to achieve. The pulse during the first 15 seconds after exercise should not be greater than a rate in beats of 200 less the patient's age, less a further 20 if he/she is unfit (FHAG et al., 1986). Previously sedentary individuals should not increase their level of exercise more quickly than at about 10-weekly intervals; they should be aware of symptoms of distress and situations in which they should exclude themselves from vigorous activity. Erratic participation may be more risky than regular activity and it is important that individuals know the symptoms of angina and stop if it occurs. Indications that exercise is too stressful are listed in Appendix 5. Exercise should not be undertaken during an episode of asthma or chest infection or when an individual may be dehydrated such as following an episode of gastro-enteritis, or when feverish. Specific advice needs to be given to those who have cardiorespiratory illness or arthritis and locomotor problems.

Management of raised blood cholesterol The indications to perform a blood cholesterol are listed under risk assessment. There is no justification at present for routine population screening for plasma cholesterol. The relative risk of coronary heart disease in patients with a raised cholesterol is higher at younger ages, but the absolute risk increases with age, at least up to age 65 and probably beyond, because the incidence of coronary heart disease rises with age. It is probably reasonable to treat high concentrations of blood cholesterol up to age 65. Treatment may also be offered to individuals aged 65 and over who are symptomatic. Coronary disease is rare in populations with a plasma cholesterol below 5 mmol/L but even below this level there is an association between cholesterol and coronary heart disease. The majority of the UK population has a cholesterol level above this and it may therefore be appropriate to give advice to the whole adult population. In the population at large, a 1% reduction in plasma cholesterol is predicted to lead to a 2% reduction in the incidence of coronary heart disease (OMAR and NIH, 1985). Triglycerides are probably not an important independent risk factor for coronary heart disease in the general population. It is useful to measure

them in patients with very high levels of cholesterol (Appendix 6) to enable classification of the lipid disorder. In these cases the sample must be taken with the patient fasting. The great majority of patients with raised cholesterol in general practice will be treated solely by dietary means. Much of the dietary advice can be provided by the primary care team with adequate training but patients at highest risk may require referral to a dietitian. Reducing plasma cholesterol in patients with elevations of other risk factors may be particularly efficacious because of their multiplicative effect. Guidelines for the interpretation of blood cholesterol are given in Appendix 6 and these can be adapted for use with a risk disk. Patients should not be started on drug treatment to lower cholesterol unless they have had lipoprotein analysis including HDL cholesterol, as this may contribute to the raised total cholesterol although its effect is protective. This should be done on a fasting sample. Factors to be taken into account before starting a lipid-lowering drug include: the need for several measurements of blood cholesterol, age, family history, other risk factors, effects of diet, patients' wishes and cost.

Drug treatment for lowering plasma cholesterol Although studies of a number of lipid-lowering drugs have shown that they reduce coronary events, no study has demonstrated a reduction in total mortality, perhaps because of inadequate study size. Some have suggested that there should be a moratorium on the use of cholesterol-lowering drugs (Smith and Pekkanen, 1992). In view of the uncertainty about the impact of lipid-lowering drugs on total mortality, many feel that they should be reserved for those at highest risk, eg patients with familial hypercholesterolaemia or those with a raised plasma cholesterol (>7.8 mmolfL) and pre-existing coronary heart disease. Some would also include patients at very high risk according to a risk score. There are now a range of drugs for reducing plasma cholesterol. Bezafibrate, fenofibrate and gemfibrozil are fibric acid derivatives related to clofibrate but probably with less adverse effects. They are particularly useful in cases of mixed hyperlipidaemia (in which triglycerides and cholesterol are raised). Cholestyramine is an ion exchange resin which works by binding to bile acids in the intestine. It is generally rather unpleasant to take and often causes gastro-intestinal upset. If tolerated it can be effective and it is best to start with small doses. Supplemented vitamins A, D, and K should be given and other drugs taken at least one hour before cholestyramine. Colestipol is an alternative to cholestyramine. Probucol is a relatively new agent which may prove useful but there is as yet no direct evidence that it reduces the incidence of coronary heart disease. Nicotinic acid may also be effective but frequently causes flushes, which can however be prevented by aspirin taken beforehand. Simvastatin and pravastatin act by inhibiting a key enzyme involved in hepatic cholesterol synthesis (HMG CoA inhibitors). Reductions of about 30-40% in LDL cholesterol may be obtained. (For summary of drug treatment see Appendix 7.) Treatment should aim to keep blood cholesterol below 7.8 mmol/L. Lower levels are desirable particularly if the patient is at high risk according to a risk score. The HMG CoA inhibitors may well attain greater prominence in the future but for the moment should

71

be reserved for second-line treatment. Some general practitioners will wish to supervise treatment with lipidlowering drugs themselves but others will prefer to refer patients particularly in the case of young patients with a family history of coronary heart disease. Aspirin Aspirin reduces the risk of cardiovascular events by around 20% in those who already have evidence of coronary or cerebrovascular disease. Provided there is no contraindication (eg peptic ulcer, cerebral haemorrhage, bleeding disorder) it is reasonable to give aspirin 300 mg daily. Recent evidence suggests that a lower dose of 75 mg daily may be equally effective with a lower frequency of gastro-intestinal side-effects (SALT Collaborative Group, 1991). The evidence on the value of aspirin for primary prevention is equivocal and does not currently justify widespread use in individuals without evidence of cardiovascular disease.

Follow-up The 'special care' group should be offered regular follow-up, perhaps 3-4 months initially. Subsequently the frequency will depend on response to intervention, wishes of the patient and workload. The other patients can be followed up by using subsequent consultations (for whatever reason) as an opportunity to monitor changes in risk factors.

Audit points 1. Proportion of adult patients with risk factors recorded in notes - blood pressure, smoking, alcohol, weight (body mass index), exercise patterns. 2. Evidence that appropriate indications for the measurement of blood cholesterol have been used and that patients have been followed up where necessary. 3. Evidence that appropriate dietary advice has been given in relation to plasma cholesterol level and that drug treatment has been reserved for those at highest risk (in general those with a sustained blood cholesterol of at least 7.8 mmol/L following dietary intervention particularly if they are at very high risk by virtue of family history, pre-existing coronary heart disease or other risk

factors). 4. Changes in major risk factors following advice (Note: this does not necessarily imply that any changes are due to the intervention). References Berlin JA and Colditz GA (1990) A meta-analysis of physical activity in the prevention of coronary heart disease. American Journal of Epidemiology 132, 612-28.

Committee on the Medical Aspects of Food Policy (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. London, HMSO. Coronary Prevention Group and the British Heart Foundation Working Group (1991) On an action plan for preventing coronary heart disease in primary care. British Medical Journal 303, 748-50. Donahue R, Abbot RD, Bloom E et al. (1987) Central obesity and coronary heart disease in men. Lancet 1, 821-4. Fitness and Health Advisory Group, Health Educational Council and Sports Council (1986) Exercise: Why Bother? London, HEC. Garrow JS (1981) Treat Obesity Seriously. Edinburgh, Churchill Livingstone. Imperial Cancer Research Fund OXCHECK Study Group (1991) Prevalence of risk factors for heart disease in OXCHECK trial: implications for screening in primary care. British Medical Journal 302, 1057-60. Marmot MG, Adelstein AM and Bulusu L (1984) Immigrant Mortality in England and Wales 1970-78. OPCS Studies of Medical and Population Subjects No. 47. London, HMSO. Office of Medical Applications of Research, National Institutions of Health (1985) Lowering blood cholesterol to prevent heart disease. Journal of the American Medical Association 253, 2080-6. Office of Population Censuses and Surveys (1991) OPCS Monitor DH2 91/2. 13 August. Patterson DLH and Treasure T (1991) The culprit coronary artery lesion. Lancet 308, 1379-80. Ramsay LE, Yeo WW and Jackson PR (1991) Dietary reduction of serum cholesterol concentration: time to think again. British Medical Journal 303, 953-7. Rimm EB, Giovanucci EL, Willett WC et al. (1991) Prospective study of alcohol consumption and risk of coronary disease in men. Lancet 338, 464-8. Russell MAH, Wilson C, Taylor C et al. (1979) Effect of general practitioners' advice against smoking. British Medical Journal 2, 231-5. Russell MAH, Stapleton JA, Jackson PH et al. (1987) District programme to reduce smoking: effect of clinic supported brief intervention by general practitioners. British Medical Journal 295, 1240-5. SALT Collaborative Group (1991) Swedish Aspirin Low-dose Trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebro vascular ischaemic events. Lancet 338, 1345-9. Shaper AG, Pocock SJ, Phillips AN et al. (1987) A scoring system to identify men at high risk of a heart attack. Health Trends 19, 37-9. Smith GD and Pekkanen J (1992) Should there be a moratorium on cholesterol-lowering drugs? British Medical Journal 304, 431-4. Tunstall-Pedoe H (1989) Who is for cholesterol testing? British Medical Journal 298, 1593-4. Tunstall-Pedoe H (1991) The Dundee coronary risk disk for management of change in risk factors. British Medical Journal 303, 744-7. Wallace PG, Brennan PJ and Haines AP (1987) Are general practitioners doing enough to promote healthy lifestyle? Findings of Medical Research Council's general practice research framework study on lifestyle and health. British Medical Journal 294, 940-2. Zander LI (1977) Recording family and social history. Journal of the Royal College of General Practitioners 27, 518-20.

72 APPENDIX 1 GUIDELINES FOR HEALTH CHECKS These Guidelines for Health Checks have been adapted from Wycombe Primary Care Prevention Project: Clare Blakeway-Phillips Theo Schofield, Peter Havelock Wycombe Primary Care Prevention Project Sefton House, 113 Totteridge Road High Wycombe HP1 3 6EY Tel: 0494-464404

Aims of the health check 1. To screen patients for the presence of factors which put them at risk, particularly from arterial disease and cancer 2. To promote the adoption of a healthier lifestyle by all patients 3. To enable patients to make choices about their lifestyle and to take control of their own health.

I. 2. 3. 4.

Structure of health check Agreeing the agenda Information collection Negotiation and counselling Follow-up.

3. Negotiate: explore possibilities of change: opportunities, barriers, support. Select and agree appropriate goals. Involve the patient in the management. 4. Support: provide positive reinforcement. Use available resources. Arrange appropriate follow-up. Record agreed goals and follow-up date.

Follow-up Negotiate a follow-up where indicated and fix a firm date. The special care group should be seen at least three-monthly at first with subsequent follow-up depending on degree of change, patients' wishes and workload. If the patient's alcohol intake, smoking or weight are risk factors and goals have been agreed, follow-up may also be helpful. An appointment for this could be made in a health promotion clinic, or it may be done opportunistically during consultations. If the patient has been referred to the doctor as a result of the check, ensure that follow-up is not overlooked. At follow-up appointments: make repeat measurements, review achievement of the agreed goals and explore any problems that the patient has encountered. Consider other risk factors and set new goals for the future. Always reinforce and reward success.

APPENDIX 2 RISK SCORES

1. Agreeing the agenda * Establish why the patient has come for a health check and whether there are any particular concerns he/she wishes to discuss * Explain that you need to collect some information systematically and that you will have time before the end to discuss it. * Mention the limited time you have available at the outset. This might help to focus attention during the interview and terminate it when necessary.

2. Information collection Collect and record information given to you by the patient according to the structure of the record card and then perform and record the results of your examination. Indicate that you will return to discuss risk factors when the information gathering is complete. Briefly reinforce healthy lifestyles.

3. Negotiation and counselling You should now have established your patient's initial concerns and have elicited some additional risk factors. If no risk factors have been recorded, reinforce healthy lifestyles and encourage maintenance. If a number of risk factors are present, agree which to discuss first. Choose areas which the patient recognizes as a problem and in which he/she is most willing and able to achieve early changes. If the risk score is used, decide whether the patient fits into a special care group.

Stages in effective counselling I. Explore: the nature of the patient's health problems: symptoms, risk factors, lifestyle; and the patient's ideas and concerns about his/her health: knowledge and awareness, personal risks, benefits of change, personal control. 2. Explain: react to the patient's ideas: reinforce positive. Achieve a shared understanding: counter negative.

British Regional Heart Study Score A relatively simple scoring system has been devised for use in general practice which relies on measurements that can readily be made with even the most limited facilities. It is derived from a study of 7735 men aged 40-59 years and serves to define a high-risk group of individuals among whom over half (54%) of the major coronary heart disease events (acute myocardial infarction or sudden cardiac death) are likely to take place during five years of follow-up after screening. 7.5 x number of years spent smoking ('smoking years')

+4.5 x systolic blood pressure (average of two readings) +265 if a man recalls a doctor diagnosis of coronary heart disease +150 if current angina (chest pain on exertion) +80 if parent died of 'heart trouble' +150 if diabetic A score of 1000 marks the cut-off point for the 'high-risk' group, representing the top 20% of the overall distribution of the risk score. It is suggested that this group should receive 'special attention' from the doctor. For men aged over 60 and postmenopausal women a score of 1200 should be used. Younger men (30-40) who score >800 should be regarded as likely to have a high risk by the time they enter middle age.

Simple plastic disks to help in adding the score are available from: Lederle Laboratories, Gosport, Hampshire P013 OAS and Servier Laboratories, Fulmar, Slough SL3 7HH. Dundee coronary risk disk score and rank The Dundee coronary risk disk gives two measures of modifiable risk - a score and a rank. A low score is good and a high score is bad, and it is a measure of the patient's risk of coronary heart disease in relation to his/her sex and age group. The risk rank indicates the individual's risk in relation to a queue of 100

73 individuals of the same sex and age group. A high rank (low number) is unfavourable and vice versa. The practice can decide at what rank to allocate patients to a special care group. For example, if the decision is to provide special care to the top 10% of those at risk aged, say 40-59, then all those with a risk rank of 10 or above should be included in this group. The rank chosen will depend on the resources available and the size of the clinical risk group. The risk disk is available from: Risk-Disk CVEU Ninewells Hospital Dundee DDI 9S4 Note: If patients with treated hypertension are included in either score on the basis of their current blood pressure, this will somewhat underestimate their risk because treatment reduces but probably does not abolish the excess risk of coronary heart disease due to hypertension.

APPENDIX 4 DIET

Questions about diet Source: Oxcheck protocol. Imperial Cancer Research Fund, General Practice Research Group University of Oxford, Department of Public Health and Primary Care. Fibre rating:

Less than 20 20 to 40 More than 40

Low fibre intake Moderate fibre intake High fibre intake

= =

=

1. About how many pieces of bread or rolls (or Chapattis) do you eat on a usual day? Are they usually white, brown, or wholemeal? [Choose only 1, if possible] Less than 1-2 l aday aday

APPENDIX 3 USEFUL ADDRESSES HEA Primary Health Care Unit The Churchill Hospital Headington Oxford OX3 7LJ Tel: 0865 226061

Health Education Authority Hambledon House Mabledon Place London WCIH 9TX ASH (Action on Smoking and Health) 109 Gloucester Place London WIH 3PH Tel: 071 935 3519

QUIT (National Society of Non-Smokers) 102 Gloucester Place London WIH 3DA Tel: 071 487 2858 The Sports Council 16 Upper Wobum Place London WC I H OHA Tel: 071 388 1277 British Heart Foundation Head Office 102 Gloucester Place London WC I H 3DA Tel: 071 935 0185

Coronary Prevention Group 102 Gloucester Place London WCIH 3DA Tel: 071 935 2889 British Dietetic Association 7th Floor Elizabeth House 22 Suffolk Street Queensway Birmingham B I I LS Tel: 021 634 5483

Whitebread Brown or granary bread Wholemeal bread

1 2 3

4 7 8

3-4 5 or more aday aday

9 15 18

13 22 26

2. About how many times a week do you have a bowl of breakfast cereal or porridge? What kind do you have most often? [Choose 1 only, if possible]

Less than 1-2 3-5 6 or more I a week a week a week a week Sugar type: Frosties, Coco Pops, Ricicles, Sugar Puffs Rice/com type: Corn Flakes, Rice Krispies, Special K

0

0

1

2

Porridge or Ready Brek Wheat type: Shredded Wheat, Weetabix, Puffed Wheat, Fruit 'n Fibre, Nutri-grain, Oat Krunchies, Start Muesli type: Alpen, Jordan's

1

2

5

7

Bran type: All Bran, Bran Flakes, Sultana Bran, Team (high in sugar and calories!!)

2

5

12

18

3. About how many times a week do you eat a serving of the following foods? Less than 1-2 3-5 6 or more 1 a week a week a week a week

Rice, spaghetti, or noodles Potatoes Peas Baked beans, dried beans, or lentils Other vegetables (any type) Fruit (fresh, frozen, canned) Total fibre score =

0 0 1

1 1 3

3 3 8

4 5 12

1 0 0

4 1 1

10 2 3

15 3 5

74 6. About how many pats or rounded teaspoons of margarine or butter do you usually use in a day, for example on bread, sandwiches, toast, potatoes, or vegetables? ............ pats x 4 for margarine or butter = ............ pats x 2 for low fat spread

Less than 30 = Low fat intake = Moderate fat intake 30-40 More than 40 = High fat intake 4. About how many times a week do you eat a serving of the following foods?

Fat rating:

3-5 6 or more Less than 1-2 1 a week a week a week a week Cheese (any except cottage) Beef, pork or lamb Beefburgers or sausages Bacon, meat pies, processed meat Chicken or turkey Fish, not fried Any fried food: fried fish, chips, cooked breakfast, samosas Cakes, pies, puddings, pastries Biscuits, chocolate or crisps

2 2 2

6 6 4

9 9 6

2

8 5 2

0 0

0

5 3 1

1

2

6

9

1 1

2 2

5 4

8 6

Total fat score = 7. What sort of fat do you use:

Unsaturated fat rating: 5 or less 6 to 9 More than 9

Low unsaturated fat Moderate unsaturated fat High unsaturated fat

On bread or For For baking vegetables? frying? or cooking? Butter, ghee, dripping, lard, or solid cooking fat Hard or soft margarine (eg Blue Band, Stork, supermarket own brands)

1

1

1

2

2

2

3

3

3

4 3

4 3

4 3

Polyunsaturated/sunflower margarine or low fat spread (eg Gold, Outline) Pure vegetable oil (eg sunflower, soya, corn, peanut, olive)

5. About how much milk do you yourself use in a day, for drinking or in cereal, tea, or coffee? What kind of milk do you usually use? [Choose 1 only, if possible]

None

Less than About a About a 1 pint '/4 pint 1/4 pint 1/2 pint or more Full cream (silver top) or Channel Islands (gold top)

Semi-skimmed (red-top) Skimmed (blue-top)

1 0 0

3 1 0

6 3 0

Total unsaturated fat score =

12 6 0

DIET PLAN

The following diet plan has been developed by Anne Heughen, Paula Hunt and Paul Roderick.

Healthy eating diet plan Food stuff

Eat plenty

Eat in moderation

Not advised - special occasions

Bread Cereal

Good source offibre. Can be filling Wholemeal - flour, bread, pasta Granary, wheatgerm bread Brown - flour bread rice

White - flour, bread, rice, pasta Crackers Muesli (added sugar)

Fried rice

Try and have these 4-6/week: Chicken (without skin) Turkey, veal, rabbit, game 3-4 oz Lean - ham, pork, bacon - beef, mince uncooked ) - liver, kidney - lamb

Sausages, meat pies, pasties Heart Meat fat, chicken skin Pate, duck, goose Fatty bacon Beef burger, corned beef Tinned luncheon meat

Try and have fish 1-2/week at least: All white fish (eg cod, haddock) All oily fish (eg trout, herring) Shell fish (eg prawns) Fish fingers

Fried fish - home or shop Fried roe Fried scampi Taramasalata

Sugar-coated cereal Fancy bread, eg croissant

Crispbread, Ryvita Chapati Oat/bran cereal Muesli (unsweetened) Whole grain cereal Meat/poultry

Fish

75 Diet plan continued Vegetables Good source fibre, vitamins All fresh, frozen, tinned vegetables Salads Beans (eg baked, butter, haricot) Lentils Baked potatoes (with skin)

Stir fry vegetables, oven chips Chips and roast potatoes cooked in an unsaturated oil - up to 1-2/week

Other chips Roast potatoes Crisps Deep fried snacks

Biscuits Cakes Puddings Savoury dishes

Low fat and diet yoghurt Puddings made with skimmed milk

Homemade fruit-based pudding, tea bread made with small amounts of unsaturated oil Scones, currant buns, malt bread Plain biscuits Low fat ice-cream, jelly, sorbet Boiled sweets, pastilles, peppermints Pizza

Other pastry/pudding, cakes, biscuits Chocolate, toffee, fudge Chocolate-coated bars (eg Mars) Butterscotch, coconut bar Ice-cream, lemon curd, peanut butter Other sweets, sugar Samosas, suet dumplings Quiche

Fruit

All fresh, frozen and stewed fruit Dried fruit Tinned fruit in natural juice

Tinned fruit in syrup

Avocado Olives

Egg, milk, dairy products

Skimmed milk Low fat cheese (eg cottage) Low fat yoghurt Ricotta, Mozarella Fromage frais (1% low fat)

Semi-skimmed milk Eggs (4-6/week) Brie, Camembert, Edam Half-fat cheese Hard, blue and cream cheeses 2-3/week as main course only Soya milk Fromage frais (8% creamy) 1-2/week Greek yoghurt

Whole milk Evaporated milk Cream Whole milk yoghurt Condensed milk Non-dairy creamer (eg Coffeemate)

Allfats should be limited Margarine high in unsaturated fat (eg sunflower and soya) Low fat spread (eg Gold) Cooking oil high in unsaturated fat

Butter

Fats

Drinks

Tea,coffee Fruit juice (unsweetened) Mineral water Oxo, Bovril, Marmite Slimline Sugar free drink

Preserves, soups, Vegetable-based soup sauces Clear soup Herbs, spices, mustard Pepper, vinegar Pickle, chutney

Suet, lard, dripping Ghee Margarine/oils of unknown content and not labelled high in unsaturated fat Hydrogenated fats and oils

Alcohol no more than 14 units per week - female 21 units per week - male Ordinary fizzy drinks, squashes Sweetened drinks

Milk drinks, malted drinks

Salt Peanuts Packet soups French dressing Meat and fish paste Jam, marmalade Sauces made with oil high in unsaturated fat

Cashew nuts Pate Cream soups Salad cream, mayonnaise

Eat in moderation

Not advised - special occasions

Good source offibre. Can be filling

Fried rice Sugar-coated cereal Fancy bread, eg croissant Muesli (added sugar)

Diet plan -weight reduction Food stuff Bread Cereal

Eat plenty

White flour, bread, rice, pasta Wholemeal flour, bread pasta Granary, wheatgerm bread Brown flour, bread, rice -

-

-

Crispbread, Ryvita Chapati, cracker Oat/bran cereal Muesli (unsweetened) Whole grain cereal

76

Diet plan -weight reduction continued Food stuff

Eat plenty

Eat in moderation

Not advised - special occasions

Meat/Poultry

Try and have these 4-6/week: Chicken (without skin) } oz Turkey, veal, rabbit, game Lean - ham, pork, bacon - beef, mince 2 oz - liver, kidney 2 - lamb J

Sausages, meat pies, pasties Heart Meat fat, chicken skin Pate, duck, goose Fatty bacon Beef burger, corned beef Tinned luncheon meat

Fish

Try and have fish 1-2/week: All white fish (eg cod, haddock) All oily fish (eg trout, herring) Shell fish (eg prawns) Fish fingers

Fried fish- home or shop Fried roe Fried scampi Taramasalata

Beans (eg baked, butter, haricot) Lentils Baked potatoes (with skin) Stir fry vegetables

Chips

Low fat and diet yoghurt Low fat ice cream Puddings made with skimmed milk

Jelly Sorbet Pizza

Biscuits Pastry/pudding, cake, buns, scones Chocolate, toffee, fudge Chocolate-coated bars (eg Mars) Butterscotch, coconut bar Ice-cream, lemon curd, peanut butter Sweets, sugar Samosas, suet dumplings Quiche

Vegetables

Good source offibre, vitamins All fresh, frozen, tinned vegetables Salads

Biscuits Cakes Puddings Savoury dishes

Roast potatoes Crisps Deep fried snacks

Fruit

All fresh, frozen and stewed fruit Tinned fruit in natural juice

Tinned fruit in syrup Dried fruit

Avocado Olives

Egg, milk, dairy products

Skimmed milk Low fat cheese (eg cottage) Low fat yoghurt Ricotta, mozarella Fromage frais (1% low fat)

Semi-skimmed milk Eggs (4-6/week) Brie, Camembert, Edam Half-fat cheese Soya milk Fromage frais (8% creamy) 1-2/week

Whole milk Evaporated milk Cream Hard, blue and cream cheeses Whole milk yoghurt Condensed milk Non-dairy creamer (eg Coffeemate) Greek yoghurt

Allfats should be limited, Maximum 4 oz/or 100 g spreading fats and cooking oils per week Margarine high in unsaturated fat (eg sunflower and soya) Low fat spread (eg Gold) Cooking oil high in unsaturated fat

Butter Suet, lard, dripping Ghee Margarine/oils of unknown content and not labelled high in unsaturated fat Hydrogenated fats and oils

Fats

Drinks

Tea, coffee Fruit juice (unsweetened) Mineral water Oxo, Bovril, Marmite

Alcohol no more than 14 units per week - female 21 units per week - male Milk drinks, malted drinks Ordinary fizzy drinks, squashes Sweetened drinks

Slimline

Sugar-free drink Preserves, sauces

soups,

Vegetable-based Clear soup

Salt Pickle

Herbs, spices Mustard Pepper Vinegar

Chutney Packet soups Sauces made with skimmed milk French dressing

soup

Meat and fish paste

Jam, marmalade

Peanuts Cashew nuts Pate, cream soups Salad cream, mayonnaise Other sauces

77 APPENDIX 5

EXERCISE: INDICATIONS OF STRESS The following are symptoms and signs which develop occasionally during exercise and which need to be heeded. Appropriate advice follows for each.

Symptoms: Advice:

'Fluttering' pulse, palpitations in chest or throat, burst of rapid heartbeats, sudden very slow pulse. Stop activity. Investigation is indicated before exercise is resumed. There is the possibility that a dangerous abnormal heart rhythm is occurring during exercise.

Symptoms: Advice:

Pain or pressure in centre of chest, arm or throat during or following exercise. Stop activity. Investigation is indicated before exercise is resumed. Symptom exercise.

Symptoms: Advice:

Dizziness, lightheadedness, sudden inco-ordination, confusion, cold sweat, glassy stare, pallor, blueness or fainting. Stop exercising immediately, lie down with feet up or put head down between legs until symptoms pass. Investigate before next exercise sessions. Symptoms suggest cerebral ischaemia, albeit transient.

Symptoms: Advice:

Very rapid rate that persists for more than 5 or 10 minutes after stopping exercise. Reduce vigour of activity and advise build up more slowly to maximum activity level. If condition persists, investigate.

Symptoms: Advice:

Extreme breathlessness lasting more than 10 minutes after exercise. Reduce vigour of activity, and advise a more gradual 'build-up' and a longer 'cool down'.

Symptoms: Advice:

Nausea and vomiting immediately after exercise. Exercise less vigorously and cool down over a longer period. Symptom indicates insufficient oxygen to intestines.

Symptoms: Advice:

Prolonged fatigue even 24 hours after exercise or newly developed insomnia. Reduce intensity of exercise and build up more gradually. Exercise is probably too vigorous.

Symptoms: Advice:

Stitch in side (under ribs) while exercising. This indicates spasm of diaphragm which is not serious. Sit, leaning forward, to push abdominal organs up against the diaphragm.

may

indicate myocardial ischaemia during

In conclusion, the benefits of regular vigorous exercise far outweigh the risks of damage or injury; these risks can be minimized by gradually increasing the level of activity and heeding any unexpected symptoms.

Prepared by: Fitness and Health Advisory Group to the Sports Council and Health Education Council, August 1986. Available from: Sports Council, 16 Upper Woburn Place, London WC1H OHA.

APPENDIX 6

RISK FACTORS FOR CORONARY HEART DISEASE AND TREATMENT STRATEGIES Adapted from: Oxfordshire Guidelines for Shared Care.

Interpreting the cholesterol result

Risk category for coronary heart disease Total serum cholesterol

One additional modifiable risk factor

Pre-existing coronary heart disease or multiple risk factors

Low Low Moderate

Moderate Moderate High Very high

mmolsfl 7.8

High * Coronary heart disease risk is related to the number and degree of risk factors present. * Overall risk is greatly increased if multiple risks are identified (multiplicative rather than additive).

78 Treatment strategies for hypercholesterolaemia Risk category Low Moderate High Very high

0

Diet

Drugs

Healthy eating Lipid lowering Lipid lowering Lipid lowering (dietitian)

None None Rarely Probably

Diet (healthy eating or lipid lowering) is always the first step. Very few patients with total cholesterol 6.6-7.8 need drugs. Risk of coronary heart disease for given cholesterol is less in women than in men. The extent to which risk is reduced by intervention diminishes with increased age in both sexes. The extent to which patients will be referred to dietitians will depend of course on local availability. Check HDL cholesterol and triglycerides before starting drug treatment. Secondary hypercholesterolaemia may occur in several conditions including hypothyroidism, obstructive liver disease and chronic renal failure.

APPENDIX 7 DRUG TREATMENT FOR HYPERLIPIDAEMIA Plasma lipid raised Cholesterol

Cholesterol and triglyceride

Lipoprotein accumulation (Fredrickson type) LDL (type Ila)

Treatment First line

Second line

Combination of choice

Resin

Statin or nicotinic acid

Resin and statin or resin and nicotinic acid

(a) VLDL and LDL (type IIb)

Fibrate

Nicotinic acid or statin

(b) VLDL remnants and chylomicron remnants

Fibrate

Resin and nicotinic acid or resin and statin

LDL = Low density lipoprotein VLDL = Very low density lipoprotein Note: Combinations of a fibrate and a statin may lead to serious side-effects.