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Are you prepared for CVD prevention in a post-COVID world?
By Natalie Raffoul, Manager, Risk Reduction, Heart Foundation
Source: APNA Primary Times Summer 2021 (Volume 21, Issue 2)
General practices face a backlog of patients in need of preventative and chronic-disease-related cardiovascular care. During a period of competing priorities, including the COVID-19 vaccine rollout, the prevention of cardiovascular disease (CVD) and the role of practice nurses has never been so critical.
Finding ways to integrate opportunistic CVD screening into vaccination programs whilst supporting systematic recall of eligible patients is critical to addressing risk factors before they lead to overt disease. Practice nurses play an important role in leading preventative activities in their general practices, and driving health-promotion initiatives and recall programs to support routine screening in at-risk patient populations.
Wave of chronic diseases on the horizon due to COVID-19
Two years on from the start of the COVID-19 pandemic, it is becoming clearer that the devastating mortality and morbidity inflicted by the virus may be followed by a wave of chronic diseases in years to come (1). The COVID-19 pandemic has seen patients postpone or forgo a wide variety of health services, ranging from emergency treatment of acute conditions to routine check-ups, including the Heart Health Check (2).
In fact, at least 27,000 fewer Heart Health Checks were delivered between March 2020 and July 2021 because of the pandemic. These checks could have prevented up to 350 heart attacks, strokes and cardiovascular-related deaths over 5 years (3).
Clinical assessment and management of CVD risk is suboptimal
Almost 580,000 adults are living with coronary heart disease, which remains the leading cause of death in Australia (4).
The Australian ‘Guidelines for the Management of Absolute Cardiovascular Disease Risk’ recommend regular cardiovascular screening for adults aged 45 to 74 years without a history of CVD (5). Yet, adherence to the peak CVD-prevention guidelines in Australia remains suboptimal (6).
Based on recently published data from the first year of the Practice Incentives Program Quality Improvement (PIP QI) Measures, information is lacking for 50% of eligible Australians on the four risk factors that enable absolute CVD-risk assessment – tobacco smoking status, diabetes type or HbA1c result or fasting glucose tests, blood pressure and lipid levels (7).
Reduced screening in primary care can lead to avoidable cardiovascular events and deaths in high-risk individuals. One-third of patients with no prior CVD presenting to a Queensland hospital with acute coronary syndrome were found to have a high absolute CVD risk score and, of these, only one in five were on appropriate guideline-recommended pharmacotherapy (8).
Best-practice CVD risk assessment and management
Absolute CVD risk assessment estimates the cumulative risk of multiple, and sometimes synergistic, risk factors to predict a heart attack or stroke event (Fig. 1). Current Australian guidelines recommend the use of a validated Framingham-based risk-prediction algorithm to estimate an individual’s risk of a CVD event over a 5-year period (5).
International guidelines are increasingly emphasising the place of risk calculators as a starting point, not as the final arbiter, for decision-making in the primary prevention of CVD. Risk-enhancing factors, as labelled by the 2019 American College of Cardiology/American Heart Association Guidelines on the Primary Prevention of CVD, can help guide decisions about preventative interventions in select individuals (9). Some of these factors are family history, metabolic syndrome, chronic inflammatory conditions, high-risk ethnicity and elevated lipid biomarkers, such as lipoprotein(a).
The Heart Foundation, on behalf of the Australian Chronic Disease Prevention Alliance, is currently leading an update to the 2012 absolute CVD risk guidelines and risk calculator.
"We can do something about it. We can intervene in those people at high risk or who have had an event already."
- Ralph Audehm, GP and academic
Life-saving CVD risk assessment made easy
In an effort to help GPs, practice nurses and other primary care professionals re-engage with patients about their heart health, the Heart Foundation has developed the Heart Health Check Toolkit: http://www.hrt.how/toolkit.
This digital resource provides a range of tools and easy-to-use templates all in one place to streamline the systematic implementation of Heart Health Checks via a whole-of-practice approach.
CVD risk assessment and management templates are now embedded in popular GP software, including Best Practice and MyGPMP tool on Topbar, and are also available in Rich Text Formats.
Figure 1. The recommended approach to CVD risk assessment and management according to Australian absolute CVD risk guidelines (5). a. Adults with any of these conditions do not require absolute CVD risk assessment using the risk equation because they are already known to be at clinically determined high risk of CVD and should be managed accordingly.
Anecdotal feedback from general practices across Australia indicates that structured processes to support CVD screening in primary care help to prioritise prevention. Systematic identification and recall of high-risk individuals create the biggest return on investment as it relates to CVD events prevented. The clinical assessment and management of CVD risk is subsidised by the Heart Health Check MBS items 699 and 177 and incentivised through the PIP QI program.
- KE Mansfield, R Mathur, J Tazare and AD Henderson, ‘Indirect acute effects of the COVID-19 pandemic on physical and mental health in the UK: a population-based study’, Lancet, 2021, 4(4):e217–e230.
- K Sutherland, J Chessman, J Zhao et al., ‘Impact of COVID-19 on healthcare activity in NSW, Australia’, Public Health Res Pract, 2020, 30(4):e3042030.
- Heart Foundation, ‘Fears 27,000 heart checks missed in pandemic could lead to wave of heart disease: new data’, Heart Foundation website, September 2021, accessed 1 November 2021. https://www. heartfoundation.org.au/media-releases/ heart-checks-missed
- Australian Bureau of Statistics, National Health Survey 2017-18, ABS, Canberra, 2018.
- National Vascular Disease Prevention Alliance, ‘Guidelines for the management of absolute cardiovascular disease risk’, Heart Foundation website, 2012, accessed 29 October 2021. https://www. heartfoundation.org.au
- CM Hespe, A Campain, R Webster et al., ‘Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed’, Med J Aust, 2020, 213(7):327–328, doi:10.5694/ mja2.50756.
- Australian Institute of Health and Welfare (AIHW), Practice Incentives Program Quality Improvement Measures: National report on the first year of data 2020-21 (Cat. no. PHC 5), AIHW, Canberra, 2021.
- A Bailey, R Korda, J Agostino et al., ‘Absolute cardiovascular disease risk score and pharmacotherapy at the time of admission in patients presenting with acute coronary syndrome due to coronary artery disease in a single Australian tertiary centre: a cross-sectional study’, BMJ Open, 2021, 11:e038868, doi: 10.1136/ bmjopen-2020-038868.
- DK Arnett, RS Blumenthal, MA Albert et al., ‘2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines’, Circulation, 2019, 140(11):e596–e646, doi:10.1161/CIR.0000000000000678.