Preventive Cardiology: A practical manual

239 Pages·2009·1.2 MB·English

by  Catriona Jennings, Alison Mead, Jennifer L Jones, Annie Holden, Susan Connolly, Kornelia Kotseva, David Wood

Preventive
Cardiology: A
Practical Manual
C.S. Jennings
Cardiovascular Specialist Research Nurse
Cardiovascular Medicine, National Heart and Lung Institute,
Imperial College London
A.C. Mead
Specialist Dietitian
Imperial College Healthcare NHS Trust and National Heart and
Lung Institute, Imperial College London
J.L. Jones
Specialist Physiotherapist
Cardiovascular Medicine, National Heart and Lung Institute,
Imperial College London
A.M. Holden
Physical Activity Specialist
Cardiovascular Medicine, National Heart and Lung Institute,
Imperial College London
S.B. Connolly
Consultant Cardiologist, Imperial College Healthcare NHS Trust
Honorary Senior Lecturer, National Heart and Lung Institute,
Imperial College London
K.P. Kotseva
Consultant Cardiologist
Imperial College Healthcare NHS Trust, Senior Clinical Research
Fellow, Cardiovascular Medicine, National Heart and Lung Institute,
Imperial College London
and D.A. Wood
Garfi eld Weston Chair of Cardiovascular Medicine
National Heart and Lung Institute, Imperial College London
1
1
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iii
Contents
Detailed contents iv
Foreword viii
Preface ix
Summary of lifestyle, risk factor, and therapeutic
targets xii
Abbreviations xiv
Part 1 Background and multidisciplinary family-based
cardiovascular assessment
1 Rationale for preventive cardiology programmes 3
2 The nurse-led multidisciplinary team 19
3 Identifi cation and recruitment 33
4 Comprehensive multidisciplinary family-based
cardiovascular assessment 39
Part 2 Application of the assessment fi ndings to manage
lifestyle and cardiovascular risk factors
5 Changing lifestyles 105
6 Smoking cessation 117
7 Principles of dietary intervention 123
8 Physical activity and exercise 145
9 Principles of managing weight loss 167
10 Blood pressure, lipids, and glucose 179
11 Cardioprotective drug therapies 193
12 Erectile dysfunction 197
13 The health promotion workshop programme 203
14 Data management, quality assurance, and audit 209
Index 211
iv
Detailed contents
Foreword viii
Preface ix
Summary of lifestyle, risk factor, and therapeutic targets xiii
Abbreviations xiv
Part 1 Background and multidisciplinary family-based
cardiovascular assessment
1 Rationale for preventive cardiology programmes 3
What is preventive cardiology? 4
What is a high-risk patient? 6
What is cardiovascular risk? 8
How to assess risk 9
JES4: SCORE risk estimation system 10
JBS2: CVD risk prediction chart 12
Why families too? 16
2 The nurse-led multidisciplinary team 19
The core team in a preventive cardiology programme 20
The role of the nurse in a preventive cardiology programme 24
The role of the dietitian and physiotherapist in a preventive
cardiology programme 26
Role of the cardiologist, general practitioner, and other
physicians 28
Input of other disciplines to the preventive cardiology
programme 30
Conclusion 32
3 Identifi cation and recruitment 33
Priority groups for CVD prevention 34
The practicalities of recruitment 34
DETAILED CONTENTS v
4 Comprehensive multidisciplinary family-based
cardiovascular assessment 39
Principles of the multidisciplinary assessment of high-risk
families 40
Assessment of lifestyle 42
Assessment of smoking 44
Assessment of diet and weight 48
Assessment of physical activity and exercise 60
Assessment of other cardiovascular risk factors 78
Assessment of psychological and social factors 84
Family history of coronary heart disease 100
Part 2 Application of the assessment fi ndings to manage
lifestyle and cardiovascular risk factors
5 Changing lifestyles 105
Changing lifestyles 106
An approach to facilitating behavioural change 110
6 Smoking cessation 117
The challenge of helping high-risk patients to stop smoking 118
Tobacco treatments 120
7 Principles of dietary intervention 123
Principles of dietary intervention 124
What is a cardioprotective diet? 126
Fats 128
Fish and oily fi sh 130
Fruit and vegetables 132
Carbohydrate and fi bre 134
Protein 136
Alcohol 138
Salt (sodium chloride) 140
Stanol and sterol esters 141
Dietary cholesterol 142
Dietary interventions to improve risk factors 143
vi DETAILED CONTENTS
8 Physical activity and exercise 145
Introduction to exercise programming 146
Exercise prescription and physical activity advice 147
Delivery of a supervised exercise component 148
Monitoring exercise intensity 154
Health and safety 163
Home exercise programming 164
9 Principles of managing weight loss 167
The causes of obesity 168
The principles of energy balance 170
Setting targets for losing weight 172
How to reduce calorie intake 174
Other interventions for obesity 176
10 Blood pressure, lipids, and glucose 179
Lifestyle modifi cation and the management of blood pressure 180
Treatment protocol for blood pressure 182
Treatment protocol for lipid management 186
Treatment protocol for glucose management 190
11 Cardioprotective drug therapies 193
Antiplatelet therapy 194
Beta-blockers 194
ACE inhibitors 194
Lipid lowering therapies 194
Calcium-channel blockers 194
Diuretics 194
Anticoagulation 195
12 Erectile dysfunction 197
Background 198
Assessment of the patient with ED 199
Management 200
DETAILED CONTENTS vii
13 The health promotion workshop programme 203
The health promotion workshop group 204
Learning outcomes of the workshops 206
Characteristics of the workshop facilitator 208
14 Data management, quality assurance, and audit 209
Clinical activity 210
Data quality 210
Audit 210
Index 211
viii
Foreword
Modern cardiovascular medicine has witnessed a transformation in the
acute management of vascular patients, giving more years to life. However,
salvaging the acutely ischaemic myocardium by primary angioplasty for
example is important but already too late in the management of coronary
patients. We need to address the underlying causes of the disease which
precipitated the acute event in order to reduce the risk of recurrent
disease.
The watch word is prevention. All patients with vascular disease should
be able to access a comprehensive preventive cardiology programme
addressing lifestyle, risk factor management, and cardioprotective drugs.
The multi-disciplinary team - nurses, dietitians, physiotherapists, physical
activity specialists, occupational therapists, psychologists, pharmacists and
others – need to work together with cardiologists and GPs to deliver such
preventive care.
This Care Manual in Preventive Cardiology serves the professional
interests of all members of the team by giving practical advice on every
aspect of prevention. Waiting until patients develop vascular disease will
be too late for some and the preventive cardiology team should extend
their services to those people who are at high risk of developing cardio-
vascular disease in the community. Prevention is always better than cure.
Professor Kim Fox
ix
Preface
The European and British guidelines on cardiovascular disease prevention
in clinical practice1,2 advocate that the care of all high-risk patients and
their families should embrace all aspects of cardiovascular prevention and
rehabilitation. High-risk patients are those who present with symptomatic
atherosclerotic disease and those who are asymptomatic but at high total
risk of developing atherosclerotic disease (see fi gure below). If preven-
tion initiatives are to have the greatest impact and be cost effective, they
should be targeted at these high-risk patients and their families.
Asymptomatic individuals at
risk of developing
symptomatic disease
People without
disease
Patients with
symptomatic
cardiovascular disease
High-risk patients and their families require multidisciplinary support to
achieve appropriate lifestyle change—quitting smoking, making healthier
food choices, and increasing physical activity—based on behavioural models
of change. Risk factor management in terms of controlling weight, blood
pressure, lipids and glucose and the use of prophylactic drug therapies,
such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhib-
itors, lipid modifi cation therapy, and anticoagulants, is also an integral part
of this approach. The traditional focus of cardiac rehabilitation on physical
rehabilitation for coronary disease is gradually evolving into a more com-
prehensive strategy for all atherosclerotic disease patients which addresses
all aspects of lifestyle, the management of other risk factors and the use of
cardioprotective drug therapies.
Beyond those with established cardiovascular disease, the next chal-
lenge is to reach those apparently healthy individuals who are at high risk
of developing cardiovascular disease. Both the European and the British
guidelines on cardiovascular disease prevention provide models for total
risk estimation (see risk estimation charts in this manual).