Primary Care Pharmacy June 2000 Vol 1 No 3 p67-69

Medicines resource management

NSF for coronary heart disease

By Lee Furniss, MSc, MRPharmS

Some pharmaceutical issues covered by the new national service framework for CHD are discussed in this article

After much waiting and speculation, the national service framework (NSF) for coronary heart disease (CHD) has finally arrived. It consists of 12 standards of care which cover the whole spectrum of management of CHD, from prevention through to surgical interventions of established disease. There are standards for both primary and secondary care, and heart failure is included in the framework. By implementing the NSF, the incidence of other arterial disease (eg, of the brain and legs) will also be reduced.
This article will look at two of the standards that are directed at the general practitioner (GP). In particular, selected pharmaceutical issues will be discussed, with the aim of stimulating debate among primary care pharmacists.

The primary health care team

Standards three and four are concerned with preventing CHD in high-risk patients and it is here that primary care is specifically mentioned. GPs and the primary health care team should identify all people with either established cardiovascular disease or who are at significant risk of it but who have no symptoms. These patients should be offered appropriate advice and treatment to reduce their risks based on the secondary and primary prevention criteria shown in Table 1.¹
There are many ways in which the primary care pharmacist, as a member of the primary health care team, can maximise these interventions and demonstrate the added value of pharmacy input.

Lifestyle measures

A number of lifestyle alterations may be made by patients to decrease their risk of CHD.

Smoking Smoking cessation is of paramount importance in the treatment and prevention of many diseases and it is central to the NSF. An "immediate priority" is for smoking cessation clinics to be introduced into all health authorities by April, 2001.¹
This is an area in which community pharmacists have been intimately involved for many years. It is an important part of health promotion to which they can make a real contribution. Some innovative community pharmacies are targeting large places of work in their area for smoking cessation programmes and also local communities at high risk of CHD (eg, the Bengali community). It is an area which is ripe for pharmacy practice research.
Bupropion had not been launched at the time of writing but it seems to be more effective than nicotine patches.² It is likely to be available only on prescription but whether on an FP10 or a private prescription is still unknown. The carefully managed entry of this drug is crucial for primary care groups.

Other lifestyle measures Community pharmacists can improve their health promotion role to patients by giving evidence-based advice. Changes in diet have been shown to reduce mortality post-myocardial infarction (MI). Eating oily fish twice each week and adopting a Mediterranean-style diet (ie, replacing red meat with poultry and eating more fish, fruit, vegetables and olive oil) have both been shown to be beneficial.3 The evidence for low-fat and high fibre diets in this area is less robust.3 In primary prevention, increased fruit and vegetable intake reduces the risk of MI and stroke, although the evidence comes from cohort studies.3 The results could be confounded by the fact that people in higher socio-economic groups, who have healthier lifestyles and suffer less CHD, eat more fruit and vegetables. The use of antioxidants is questionable.3 Interventions such as weight reduction, increasing aerobic exercise and dietary salt restriction all help to lower blood pressure, which is a risk factor for CHD.3

Eating more fruit and vegetables is beneficial

Evidence-based medicine

Drugs also play a part in coronary heart disease prevention.

Antiplatelet drugs The role of antiplatelet treatment in people with no symptoms of cardiovascular disease is uncertain.³
Aspirin is still the "gold standard" in secondary prevention and is a comparatively cost-effective intervention.⁴ It appears that doses of 75mg daily give a favourable balance of risks and benefits, as the risk of gastrointestinal bleeding is dose dependent.⁵ There is often debate over which preparation to use - soluble or enteric-coated. However, use of an enteric-coated formulation may not be less harmful than plain aspirin.⁶
Clopidogrel appears to be a safe and effective alternative to aspirin,³ although there have been reports recently of thrombocytopenic purpura occurring soon after starting therapy with this drug.⁷

Hypertension treatment The recommendation to reduce blood pressure to below 140/85mmHg is in line with the advice of the British Hypertension Society. There is potential for the community pharmacist to measure blood pressure opportunistically but this should be carried out in a systematic manner (eg, repeated measurements over time with assessment of other risk factors).
It is important that blood pressure monitoring results are put into context for the patient and do not result in unnecessary extra work for local GPs. Collaboration with the local practice may allow development of a joint protocol and demonstrate the value of GPs working with community pharmacists.
The largest evidence base for antihypertensive treatment is with thiazide diuretics and beta-adrenoceptor blocking drugs (beta-blockers). These reduce morbidity and mortality with minimal adverse effects.³ Anecdotally, some clinicians feel that newer antihypertensives (eg, angiotensin converting enzyme inhibitors [ACEIs] and alpha-adrenoceptor blocking drugs) are better tolerated but this is not supported by clinical trial evidence.^8,9

Cholesterol Blood cholesterol is an important risk factor for CHD but should be considered in combination with other risk factors. Blood cholesterol measurement alone is a relatively poor predictor of individual CHD risk.⁴ That aside, the NSF requires all those with existing CHD and those with a greater than 30 per cent risk of CHD over 10 years to be started on a statin to lower their blood cholesterol to less than 5 mmol/L or by 30 per cent (whichever is greater). cholesterol should be measured on more than one occasion before initiating treatment.⁴
Charts and computer programs are available to calculate CHD risk. The effect of a low-fat diet on cholesterol lowering is disappointing^3,4 but statin use should be combined with dietary measures and the control of other risk factors (eg, hypertension, smoking).¹⁰
When choosing statins, the dilemma is whether to pick a cheaper agent that lowers cholesterol effectively (and assume a class effect in terms of clinical outcomes) or to go with the evidence-based choices.
Statins have other antiatherothrombotic effects besides lowering cholesterol,¹¹ which may be clinically important, and any differences can only be assessed through morbidity and mortality studies.
It is important that cholesterol levels are checked two to three months after commencing a statin. The dose should be adjusted and the patient's concordance checked if the required cholesterol level is not achieved. Annual checks should take place when the patient is stabilised. Monitoring of liver function is also important.¹⁰
As with all long-term treatments, concordance is vital if statin treatment is to be used successfully; the community pharmacist is ideally placed to communicate with the patient on their treatment and on coronary heart disease in general.

Post-myocardial infarction

The following drugs should be started in hospital but it is important that primary care pharmacists know the rationale for their use and the correct length of treatment. In addition, knowledge of the evidence base for these drugs is important when guidelines are being drawn up across the primary/secondary care interface.

Beta-blockers Provided there are no contraindications, all patients should be prescribed a beta-blocker.^12,13 Continued benefit has been reported for up to six years³ and some researchers suggest indefinite use,^12,13 which seems reasonable if angina or hypertension is still present.
Which beta-blocker to use is an area of debate. Some reviews suggest there is no difference between those available³ and atenolol is commonly recommended.¹² Others suggest that metoprolol, timolol or propranolol have a stronger evidence base and that of atenolol has been inadequately evaluated.¹⁴ Sotalol should not be used post-MI because of its arrythmogenic effect.¹³

ACE inhibitors There is strong evidence from systematic reviews that ACEIs should be used indefinitely in patients who have left ventricular dysfunction or who have clinical evidence of heart failure.^3,12,13 It is not clear whether ACEIs exert a class effect post-MI.¹² Short-term trials (up to four to six weeks post-MI) have used captopril, enalapril or lisinopril and trials over longer periods (years) have used ramipril and trandolapril.¹³ The Heart Outcomes Prevention Evaluation (HOPE) study suggests that the use of ramipril in patients with normal left ventricular dysfunction is beneficial but this evidence is not as robust as it comes from a single trial.
The angiotensin-II receptor antagonists are not licensed for use in heart failure.

Conclusion

Healthcare professionals eagerly awaited the arrival of the NSF. There are many medicine management issues within it for pharmacists - particularly for those in primary care. These pharmacists need to add their voices to the debates that go on and ensure that evidence-based approaches to patient care take place.
This article has merely touched upon some of the many areas of discussion. It has made no mention of the organisational issues to which pharmacists can contribute (eg, audit), but these are equally important. Often the medication record is the starting point for GPs to develop systems of care for their patients with CHD. Primary care pharmacists are in a unique position to be able to contribute to many areas included in this NSF. CHD is a disease that accounts for much morbidity and mortality; together we can beat it.

Mr Furniss is the liaison pharmacist for the North Islington primary care group, London

References