New research shows how health management can help heart patients
The treatment of people with a history of heart disease is a key aim of the Government's Cardiovascular Health Strategy. Such a secondary prevention programme could reduce the number of deaths from heart disease in the Republic by 20 per cent.
There are two types of prevention of heart disease: primary prevention refers to the management of risk factors among patients with no evidence of previous cardiac problems; secondary prevention is the long-term management of risk factors among people who have already been diagnosed with heart disease.
The latter group includes patients with a history of a heart attack, or angina (cardiac chest pain) and those who have undergone procedures such as angioplasty (where a balloon or stent is used to reopen a blocked artery in the heart), or a full coronary bypass operation.
Secondary prevention aims to reduce avoidable deaths and illnesses by ensuring patients with cardiac disease do the following:
Stop smoking
Make healthier food choices: reduce fat, salt intake and increase fruit and vegetables.
Become physically active - walk for at least 30 minutes four to five times a week
Achieve an ideal weight for their sex and
height
Consume moderate amounts of alcohol
Have a blood pressure of less than 140/90mmHg; use appropriate medication
Have a total cholesterol of less than 5.0mmol/litre; use statins (see panel on drugs) if required
Use aspirin and other "preventer" drugs
The internationally accepted goals of secondary prevention are easily measured. However, several studies have shown that the management of these patients is less than ideal. For example, a Scottish study of almost 2,000 patients found half were not receiving optimum drug management and for almost two-thirds of patients, two aspects of their health behaviour (weight, exercise or smoking) would benefit from change. In Norway, 58 per cent of cardiac patients received aspirin, while only 20 per cent of those surveyed had cholesterol below the desired level of 5 mmol/litre.
How do we compare here in the Republic? Researchers at Trinity College Dublin, who reported their findings in the June issue of the Irish Medical Journal, examined the prescribing of secondary preventive treatments for 42,000 medical card patients.
The prescription rates for four therapies - ACE inhibitors (the Angiotensin Converting Enzyme inhibitors work by dilating the body's blood vessels); beta blockers; aspirin and statins - were calculated by health region. The rate of prescribing ACE inhibitors in some regions was double that of others. In addition, the study found age and sex inequalities in the treatment of heart disease: men were more likely to receive the preventive drugs while the elderly received less treatment with three of the four medications. The study provides clear evidence that the secondary prevention of heart disease could be significantly improved throughout the State.
A new study by Molly Bryne and Prof Andrew Murphy of the Department of General practice at NUI Galway sets out to provide figures on the current levels of secondary cardiac prevention in the State. Seen exclusively by The Irish Times prior to publication, the study looks at 1,600 patients both public and private in the Western and North Western Health Boards. It shows 3 per cent of the population have coronary heart disease and 14 per cent of these have survived a previous heart attack.
When the targets of secondary prevention were analysed, some of the results were surprisingly good. Almost 80 per cent of patients were receiving aspirin, while half were receiving lipid-lowering treatment. More than 60 per cent of patients had blood pressure readings within the target level. However, only 31 per cent of patients had cholesterol levels below 5.0mmol/litre and, of even more concern, no cholesterol reading was available for almost a quarter of those with established heart disease. One fifth of those studied were still smoking and 24 per cent had achieved their recommended weight.
Despite the infrastructural limitations of general practice in the Republic, the results compare reasonably well with international statistics of secondary prevention in heart disease. "While there is obviously room for some improvements, the fact that preventive levels, comparable to other countries with more resources have been achieved largely in the under-funded GMS population, is to be commended," Prof Murphy says.
Which is why the promised, but much delayed, cardiac secondary preventive programme in general practice is badly needed. Originally due this month, it is now expected to start in January; says Dr Sean McGuire, national programme director for Secondary Prevention of Cardiovascular Disease in Primary Care. Prof Murphy says: "This structured package of care to patients with established heart disease is a really important development and it is especially appropriate that it be delivered through general practice".
Twenty per cent of the State's GPs will participate in the initial phase of the programme, the funding of which is guaranteed. But despite its budgetary difficulties, the Government must continue to fund the programme until it is established countrywide; to do any less would be to create even more inequalities in the treatment of heart disease in the Republic.
The full NUIG secondary prevention of heart disease study will be available fromwww.nuigalway.ie/dgp