Primary Care Pharmacy June 2000 Vol 1 No 3 p65-66

Viewpoint

Patient perspectives of coronary heart disease

By Eve Knight

A patients' association representative puts forward a lay view on CHD and suggest ways in which pharmacists might help

To learn that they are suffering from coronary heart disease (CHD) comes as a huge shock to most people. To realise gradually that, in most cases, the plan is disease management and symptom suppression rather than a cure can be a very hard pill to swallow. Once over the initial shock, patients are keen to learn more about any choices they may have, who can help them and how they can help themselves.
However, just what is a patient? People are all different, complex individuals from many varied backgrounds and cultures. The only thing they may have in common is that they have CHD. Thus, patients have to be treated as individuals and given choices. To make an informed choice, they must first have the right information and then someone to discuss this with.
Coming home from a general practitioner or specialist appointment, having been told that they need to make significant changes to their lifestyle (give up smoking, lose weight, take more exercise, cut down on fats, reduce salt intake, eat more fruit and vegetables, limit alcohol, take a pill to reduce cholesterol, one or two for high blood pressure and maybe a diuretic just to round it all off ), can seem like the end of life as they know it.
Once a patient has a cardiac problem, there is plenty of advice around and a great deal to read, but the information is not consistent, particularly from the media. Red or white onions? low fat or no fat? red wine or white wine? fish but not prawns? The only consistent piece of information seems to be to give up smoking but by then most people are so confused they think: "Why is this one right?" or "Why bother?"

Eve Knight: pharmacies provide information and reassurance

What can pharmacists do?

Pharmacists have a very real part to play for people at every stage of CHD helping those with symptoms of the disease, those who have had an episode and are looking for secondary prevention, and those with a high risk of developing the disease. It is not necessary for patients to be constantly at their doctors to be monitored. In fact, in many cases, people prefer a demedicalised environment, such as the community pharmacy. They feel more comfortable and able to talk and ask advice and, rightly or wrongly, they feel that the pharmacist has more time.
All forms of monitoring should be available at the pharmacy - blood pressure, cholesterol, weight, INR. Lifestyle advice can be given, and by pharmacists taking the time to get to know the individual, it becomes easier to provide the motivation needed for that patient to make any necessary changes to their lifestyle. Support and constant encouragement are essential in order to achieve long-term results. The local pharmacy can also be the place where carers and families can access information - they often feel frightened and isolated and do not know who to turn to.
A three-way alliance can be formed between pharmacist, patient and GP. The patient should be able to discuss their diagnosis and treatment, the risks and benefits with both health care professionals and greater concordance should be achieved. For people who have not had an episode of CHD but who have several risk factors that need treating, an alliance such as this can be a vital step forward in their treatment.
A large number of people who are diagnosed with high blood pressure and increased cholesterol levels have had no outward symptoms whatsoever. They have been feeling fine and the diagnosis may have been made at a routine health check or when they attended for something completely different and relatively trivial. Suddenly they are having to take life-long medication, which may be producing unacceptable side effects. Often, the patient has not been told that there are numerous anti-hypertensive drugs or that it is possible to change drugs and find one that suits them better. The risks of high blood pressure and increased cholesterol levels have not been explained to them sufficiently and they may be inclined to discontinue medication.
The pharmacist can become the vital link in this three-way chain by giving information and advice and encouraging the patient to return to the GP if there are side effects.

Monitoring CHD

Another important aid is regular monitoring. Patients cannot see whether their blood pressure is being lowered by their drugs unless it is monitored, they did not feel ill before they started taking their medicine, so how can they feel better? GPs often tell the patient to come back in three months but this is too long a gap. Problems and discouragement can set in long before then and this is where the pharmacist's role becomes so important.
The second stage of non-compliance is at about six months. If hypertension has not been properly explained, many patients decide that they have been taking a drug long enough and must be "cured" and will stop taking their medicine.
In the case of secondary prevention, it is essential that it is explained to the patient why they are taking a drug. Medicines are given to improve or free the patient from symptoms, to modify risks but not necessarily to be a cure. It is important to explain the need, in some cases, for more than one drug for a condition. Patients need to know why they are being given the drug, what the results should be and roughly how long before any improvement may be noticed. They need to be told what possible side effects there may be, what alternatives there are if the drug does not agree with them and what they can do to help themselves in the way of lifestyle changes.
Community pharmacies should be part of a seamless service that offers a totally holistic approach to care for the patient. They should be a place where people can be helped to help themselves. There is a real need to adopt a multi-disciplinary approach, which encompasses the patient, the GP and the pharmacist, forming a partnership, which will improve concordance, thereby improving outcome and quality of life for the patient.
We must aim to reach the stage where all sides are sharing the same perspective. It must be clear that we are all working together for a better quality of life for those with CHD - that we are working for the patient.