Closing gaps in monitoring heart health

Amanda Lyons

4/11/2019 1:11:11 PM

Two large-scale studies have highlighted how surveillance of heart conditions can be boosted in general practice, aiding in prevention and management.

Checking heart rate
Two large-scale heart health studies presented at GP19 help GPs identify gaps in monitoring patients for CVD.

‘Heart disease is Australia’s leading single cause of death. So if you are 45 and over, or 30 and over if you are Aboriginal or Torres Strait Islander, the best chance of reducing your risk starts with seeing your GP for a Heart Health Check.’
That is Natalie Raffoul, discussing her recent presentation, ‘Assessment and management of absolute CVD [cardiovascular disease] risk in an Australian primary care setting’, at GP19.
Ms Raffoul believes the research shows the importance of placing a greater emphasis on absolute CVD risk assessment and prevention in general practice.
‘Absolute CVD risk assessment is the most effective, evidence-based approach to guide decision-making around initiating medicines and ensures that high-risk patients are getting the right support they need to lower their risk of CVD,’ she said.
The research derived its information from MedicineInsight, a large-scale national general practice data program, providing access to de-identified health records from the clinical information systems of more than 3300 GPs in 705 general practices across Australia.
‘We looked at how often CVD risk factors are being assessed in more than 350,000 Australian patients aged 45 and over without heart disease,’ Ms Raffoul said.
‘Assessing CVD risk in the primary prevention setting requires up-to-date blood pressure and cholesterol levels, yet close to half of Australians 45 and over did not have a cholesterol recorded in the last five years, and a third didn’t have a blood pressure recorded in the last two years.’
Ms Raffoul highlighted recent policy changes relating to CVD that are relevant to primary care community, including a new interim Heart Health Check Medicare Benefits Schedule item, the inclusion of CVD risk factors in the 2019 Quality Improvement Practice Incentive Program and government funding for the update of national absolute CVD risk guidelines.
She emphasised the benefits such changes will bring to all patients, especially those most at risk.
‘The Medicare-funded Heart Health Check provides GPs and practice nurses with an opportunity to regularly assess and manage CVD risk factors within this population,’ Ms Raffoul said.
By contrast, another heart health study presented at GP19, ‘A retrospective cohort study of heart failure in the Australian primary care setting (SHAPE)’, focused on the management of patients who have already experienced heart failure.
The largest ever heart failure observational study conducted in Australia, SHAPE examined the de-identified health records of 1.93 million adult patients.
‘It’s a real landmark study, because up until now we didn’t know how many people in Australia had heart failure,’ Professor Andrew Sindone, cardiologist and lead author of the research, told newsGP.

Cardiologist Professor Andrew Sindone wants to ensure all heart failure patients are identified in medical records so they receive the optimal treatment and medication. 

In addition to identifying that heart failure is likely to affect more than 270,000 Australians, SHAPE found that fewer than one in five patients with heart failure had the condition identified in the diagnosis section of their medical records.
Professor Sindone is concerned this gap in recording may lead to heart health going overlooked.
‘GPs may not realise their patients have heart failure, even though they are managing the diuretics and ACE inhibitors,’ he said.
‘So they may treat their blood pressure or swelling in the legs with a diuretic, but are not thinking, “It looks like heart failure, they need to go and see the cardiologist”.
‘I think the number of patients being referred to cardiologists with possible or probable heart failure is not enough.’
Dr Jo-Anne Manski-Nankervis, University of Melbourne academic and member of the RACGP Expert Committee – Research (REC–R), agrees is important to identify this population in general practice.
‘We need to understand why there is relatively low recording of heart failure. Optimising the recognition of heart failure has the potential to  assist with optimising management and health outcomes,’ she told newsGP.
SHAPE found that patients with heart failure who were attending general practice tended to present differently from patients who present in cardiology, in ways that can make them more difficult to detect.
‘A very small proportion had diabetes, high blood pressure, lung disease, kidney problems or ischaemic heart disease, whereas the sorts of patients who are in the big trials with heart failure have far more conditions and problems,’ Professor Sindone said.
‘[Primary care patients] are also a bit younger than patients who are leaving hospital with heart failure, so it’s definitely at the mild end of the spectrum.’
Dr Manski-Nankervis believe that while heart failure can be difficult to diagnose, identify these patients is vital to ensuring they receive the most appropriate treatment.
‘There is good evidence for the use of medications such as beta blockers and ACE inhibitors in people with reduced left ventricular ejection fraction heart failure,’ she said.
‘There is some evidence that people with heart failure have better outcomes if a cardiologist is involved in care.’
Professor Sindone is concerned about the effect gaps in medical records can have on patients’ medications.
‘We were surprised that significant numbers of patients were not on heart-failure-disease-modifying medication,’ he said.
‘They were on medications I call band-aids, that help the symptoms but don’t really help the underlying condition. So diueretics or digoxin, but not significant proportions of ACE inhibitors, beta blockers or spironolactone, which are the chief medications.
‘Also, significant numbers of patients were on medications that actually make things worse in heart failure, like non-steroidal anti-inflammatories, tricyclic antidepressants which are contra-indicated because they can cause fluid retention or abnormal heart rhythms or things like that.’
Professor Sindone urges the importance of recording heart failure in a patient’s medical records to reduce poor outcomes, and also suggests GPs keep it in mind as a possibility among older patients.
‘If you see someone who’s short of breath, has some swelling in the legs, is feeling tired, or is not able to do the things they used to do before, think about heart failure and further investigations, like a chest X-ray or an echocardiogram. Or sending them to see a cardiologist for an opinion as to why they may be having these symptoms,’ he said.

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Dr Ian Mark Light   5/11/2019 9:44:58 AM

With regard to calculation of risk over five years there is the Australian cardiovascular risk charts calculating risk based on a persons sex systolic blood pressure total cholesterol:HDL ratio smoker or non -smoker diabetic and without diabetis .
High risk is between 3-6% year risk over 5 years .
Low risk is between 5-9% per 5 years .

A 45 year old male smoker diabetic systolic blood pressure 160 and over with a cholesterol :HDL ratio 6 -7 has a 25-29% risk of cardiovascular event over 5 years
If he can become non -diabetic stop smoking and get his blood pressure down to 140 systolic and cholesterol :HDL ratio to 4 his risk is 5-9% over 5 years .
Risk reduced by one fifth to one third .