The Pharmaceutical Journal Vol 267 No 7169 p510-525
13 October 2001

BPC 2001 summary

Hospital pharmacists and the NSF for CHD

Millions of pounds worth of statin therapy are thrown down the drain each year because patients are not titrated to an optimum dose, said Professor DAVID UPTON, chief pharmacist, University Hospitals of Leicester, during his presentation at the hospital pharmacy session on how pharmacists can help implement the National Service Framework for coronary heart disease.

The framework is a blueprint whose aim is to iron out inequalities in care across the country, with clear standards and a modernisation agenda which will meet the expectations of well informed consumers. The target is to reduce the death rate from heart disease by 40 per cent by 2010. The big challenge for all health care practitioners is collecting data to monitor progress against these standards.

According to Professor Upton, pharmacists can become involved in smoking cessation clinics and the promotion of healthy eating. The best time for pharmacists to be involved is while the patient is still in hospital after an acute cardiac event.

For high risk patients, the hospital pharmacist can ensure that aspirin and a statin have been prescribed. Community pharmacists should also be involved to make sure treatment is continued. At the moment there are discrepancies between patient records held in hospital and community practice. Professor Upton’s team had piloted a scheme whereby information on patients’ discharge medication was faxed through to selected community pharmacies.

Pharmacists can be involved in managing risk factors, such as elevated blood pressure and diabetes, and ensuring that patients are on the drugs that they should be, at the most effective dose, and that treatment targets are being met.

Patient group directions for paramedics to administer thrombolytics have been drawn up. These will dramatically reduce the time between an emergency call and treatment being started for acute coronary syndromes. As soon as patients are admitted to accident and emergency, cardiac nurse practitioners, also working under patient group directions, administer reteplase.

After revascularisation, patients often no longer need pre-existing drug therapies. Frequently however, as soon as patients are discharged they are restarted on drugs that are no longer appropriate under repeat prescribing systems at doctors’ surgeries. Professor Upton has designed a form with spaces for the hospital doctor to fill in, stating what therapy has been initiated during the patient’s admission, what needs to be continued and what therapy has been discontinued. It is about to be used in his area. Pharmacists need to improve the communication across the interface, not only with GPs but also with community pharmacists.

Pharmacists also want, and need to have, a role in the palliative care of patients with heart failure, he said.

Pharmacists in Leicester have had a lot of input into the discharge process and in cardiac rehabilitation. They have contributed to individual patient care plans, educating patients before discharge on effective management of their medication, produced booklets in relevant languages for the significant Asian population and talked to ethnic groups.

One of the cardiac surgeons in Leicester has set up a website, (www.yourheart.com) that patients undergoing cardiac rehabilitation can access.

NSF for CHD in a hospital setting

Dr ERWIN RODRIGUES, consultant cardiologist and clinical director, Aintree Cardiac Centre, said: “What we are trying to do is develop seamless care for the patient.” More than half the people with an acute myocardial infarction die before they reach hospital. However, if they are treated immediately with a defibrillator, outcomes are good.

“To reduce mortality, we need to take the hospital outside the geographic constraints of the building and consider a pre-hospital phase in the management of acute MI,” said Dr Rodrigues.

Nowadays, ambulance crews give patients cardiopulmonary resuscitation and defibrillation in the home or street. Patients also receive oxygen, pain relief with intravenous opiates, and aspirin before they are transferred to hospital.

Complete myocardial necrosis can occur within six to 12 hours so it is vital to start thrombolysis as soon as the patient reaches hospital. Streptokinase is the first-line agent but alteplase is reserved for patients aged below 75 with an anterior MI.

Audit results at his hospital compared treatment times for MI when carried out by a thrombolysis nurse in casualty with those not carried out by a thrombolysis nurse. Without such a nurse, MI was treated in under 30 minutes in 54 per cent of cases, and in under 45 minutes in 80 per cent of cases.

When patient are assessed and treated by a thrombolysis nurse, these percentages improve to 87 per cent being treated in under 30 minutes and 100 per cent being treated within 45 minutes.

Heart failure

DAVID THORNTON, pharmacist, Aintree Cardiac Centre said pharmacists are in a good position to identify patients with heart failure who might require investigations such as echocardiography or drug treatments such as diuretics.

The use of certain drugs, for example, ACE inhibitors, b-blockers and spironolactone, can reduce hospital admissions — an important factor in a city such as Liverpool with one of the highest death rates from heart disease in the UK.

Like the previous two speakers, Mr Thornton said that pharmacists have a vital role to play. Pharmacists can educate — not only patients giving advice on life style, blood pressure control and diabetes control — but also doctors and nurses with computer aided learning and formal teaching.
—Contributed by Diane Langleben, editor of Hospital Pharmacist.

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