Engaging patients in managing cardiovascular risk
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Once a patient understands that they have a higher risk of a cardiovascular event occurring, the next step is to engage them in participating in their healthcare and making lifestyle changes to reduce this risk.
Treatment needs to be tailored to the individual taking into account their beliefs and attitude towards modifying their cardiovascular risk.
The guidelines recommend:
- Drug therapy and lifestyle modification initiated simultaneously for people whose CVD risk is greater than 20%
- Lifestyle modification initiated three to six months prior to initiating drug treatment for patients whose CVD risk is 15-20%
However for some patients with less than 20% risk it may be appropriate to initiate drug treatment simultaneously with lifestyle interventions if you consider outcomes will be better, for example if they are unlikely to undertake lifestyle measures or the addition of a prescription is likely to better engage them in addressing their cardiovascular risk.
It is unrealistic to expect patients to make all lifestyle changes at once. Changes are more likely to occur if each patient prioritises lifestyle changes and sets realistic targets.
All health targets should be S.M.A.R.T:2
Specific - a specific target would be: “I’m going to go for a 30-minute walk everyday in my lunch break”, rather than: “I’m going to exercise more”.
Measurable - targets must be able to be measured. The target above of a 30-minute walk every lunch time is able to be measured, it is clear if it has been done or not.
Achievable - do not set unrealistic targets. For example setting a target weight loss of 20 kg in two months is unrealistic and will most likely fail and reduce the patient’s confidence. Setting a lower target such as 500 g a week is more achievable and if exceeded, will increase the patient’s confidence.
Rewarding - targets that are rewarding increase confidence in ability to achieve goals.
Time bound - goals are more likely to be carried out if a specific time to achieve them has been agreed in advance.
Smoking increases the risk of coronary, cerebral and peripheral arterial disease.3 This effect is dependent on the lifetime exposure to tobacco smoke i.e. the amount of tobacco smoked daily and the duration of smoking.4
All Māori who smoke should be encouraged and supported to stop
Māori are equally as motivated and just as likely as non-Māori to have made a quit attempt in the past year. Māori can be encouraged to quit smoking using nicotine replacement therapy (NRT) and programmes such as Aukati Kai Paipa, a smoking cessation support programme delivered by Māori for Māori that takes a whanau based approach to smoking cessation. The programme reports that quit rates for Māori are significantly better for Aukati Kai Paipa than conventional programmes.
Aukati Kai Papa: www.auahikore.org.nz
The risk of cardiovascular disease declines rapidly after smoking is stopped.
Assess current behaviour: How many cigarettes does the patient smoke? Do they want to stop?
Advise about the benefits of changing behaviour: The latest New Zealand guidelines for smoking cessation suggest advising every patient who smokes, about the benefits of stopping smoking, at least once a year.
Advise that it is never too late to stop and tell patients that the benefits of smoking cessation include:
- Within two days of quitting your ability to smell and taste improves
- Within three months of quitting your circulation improves
- You will save money
- You will set a good example for your children
Agree on patient-centred goals to change behaviour: A first step to engaging patients in reducing or stopping smoking may be to encourage a smoke-free house and car.
Arrange follow-up and support: Make a follow up appointment to ask about current smoking status. Support involves prescribing medicines including nicotine replacement therapy which is now able to be prescribed by all GPs and practice nurses.
Obesity, particularly abdominal obesity, increases cardiovascular risk.
Weight reduction results in lower blood pressure, lower LDL cholesterol and triglycerides, and higher HDL cholesterol.
An initial goal may be a small change in weight over a set time, achieved by introducing changes in diet and physical activity.
A healthy diet is good for the heart and can modify other risk factors. A diet rich in fruit and vegetables and low in saturated fat is beneficial for preventing and managing cardiovascular disease.
Key targets for dietary modification
- Limit dietary intake of fat, particularly saturated fat
- Replace saturated fats with unsaturated fats
- Increase the intake of fresh fruit and vegetables to at least five portions a day
- Regularly eat fish (at least two servings per week)
- Limit intake of salt
- Limit alcohol to less than 21 units per week for men or less than 14 units per week for women
Dietary changes, while recommended for an individual, often need to be adopted by a whole whanau in order for change to take place, therefore expectations of this change need to be realistic and culturally acceptable.
Approach dietary modification in a step wise manner; a recommended approach is:
Assess current behaviour: what does the patient currently eat? For example, find out the components of a patients diet that may be contributing the most fat.
Advise about the benefits of changing behaviour: Advise patients about the key targets for dietary modification listed above but provide some suggestions. Encourage any healthy suggestions the patient makes for changing their diet.
Agree on patient centred goals to change behaviour. Initial goals may be to replace some foods with healthier alternatives. For example:
- Replace white bread with grain bread
- Replace butter with margarine
- Replace fruit juices or soft drinks with water, or low fat milk
- Replace full fat milk (‘blue top milk’) with lower fat milk (‘light blue’ or ‘green’ top milk)
Or provide some food cooking and preparation tips:
- Cut fat off meat
- Grill instead of frying
Arrange follow-up and support. Make a follow up appointment to assess changes in diet. Provide simple written material to reinforce messages when a patient gets home. Material that is personalised can be shared with whanau.
A sedentary lifestyle is associated with an increased risk of cardiovascular disease.3 Being physically active can also modify other risk factors, for example, reduce weight, lower blood pressure and increase the level of protective HDL cholesterol.
In general, Māori like other indigenous cultures, place great emphasis on the spoken word and eloquence is traditionally valued. Be careful when using medical jargon (e.g. myocardial infarction for heart attack) and ordinary words that have a specialised meaning in a medical context (e.g. ‘the patient is complaining of a headache’ can be taken by the patient to mean the GP does not believe them).
Māori are less likely to question a GP so it is important to check on their understanding in different ways. Open questions and the involvement of whanau can assist with this. Everyone, regardless of background has a preference for receiving information in a particular way. Information may need to be delivered in a number of ways to check that the patient has understood what is being communicated.
When discussing cardiovascular risk and the actions that can be taken to reduce the risk, it may be appropriate to include other whanau members. Rather than just educating the patient there are benefits in investing time in educating all members of the whanau. Any actions or changes will be most successful if they are understood and adopted by the entire whanau.
Although these education sessions may take a bit longer than the average consultation it can be an excellent investment of time and energy. Not only may the patients CVD risk be lowered, but other whanau members can similarly benefit.
Best health outcomes for Māori: Practice Implications. Available from:
Provide advice about physical activity that is patient centred, achievable and measurable; a recommended approach is:
Assess current behaviour: Ask about current levels of activity including activities that the patient may not associate with exercise. For example, ask about method of getting to work or time each week spent gardening or gathering kaimoana (seafood).
Advise about the benefits of changing behaviour: Advise patients that physical activity can be accumulated throughout the day. Three ten minute bouts of exercise per day are equivalent to one 30 minute session. Activities that can be incorporated into everyday life, such as brisk walking, using stairs and cycling, are recommended as people may be more likely to participate in these activities.
Agree on patient-centred goals to change behaviour: An initial goal may be a small but agreed and measurable increase in exercise, for example these activities may be done at least three times per week:
- Walk to school or shops
- Get off the bus one stop earlier than usual
- Use the stairs instead of the lift
- Park a block away from work and walk
Group activities may encourage some people to engage in physical activity because the social aspect can be enjoyable.
Arrange follow-up and support: Set measurable goals that can be evaluated at follow-up.
Consider issuing a Green Prescription or referring patients to a local sports trust.
Te Hotu Manawa Māori provides Māori specific resources for lifestyle intervention www.tehotumanawa.org.nz
- New Zealand Guidelines Group. The assessment and management of cardiovascular risk. December 2003. Available from www.nzgg.org.nz (accessed June 2008).
- The New Zealand Heart Foundation. A practical guide to management of CVD risk 2007.
- JBS 2: Joint British Societies Guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91:1-52.
- SIGN (Scottish Intercollegiate Guidelines Network). 97: Risk estimation and the prevention of cardiovascular disease. Available from www.sign.ac.uk/pdf/sign97.pdf (Accessed June 2008).
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