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Coronary heart disease: risk factor management pages 47-54 Multiple choice questions and submission instructions page 55 Practice profile assessment guide page 56
Coronary heart disease: risk factor management
NS271 Foxton J et al (2004) Coronary heart disease: risk factor management. Nursing Standard. 19, 13, 47-54. Date of acceptance: November 9 2004. Aim and intended learning outcomes The aim of this article is to provide an overview of coronary heart disease (CHD) risk factors and their management. After reading this article you should be able to: ■ Explain the rationale behind the treatment targets to reduce the incidence of CHD in the population. ■ Describe the risk factors for CHD. ■ Use the coronary risk calculator to identify people at high risk of developing CHD. ■ Identify those who are at moderate risk of CHD. ■ Discuss the role of lifestyle advice in the management of cholesterol. ■ Describe the drug therapy that may be used to reduce cholesterol. Incidence and prevalence CHD is the leading cause of mortality and morbidity in the UK and the single most common cause of premature death. Despite a fall in CHD mortality in recent years, the UK death rate is among the highest in the world at around 120,000 per year (British Heart Foundation (BHF) 2003). CHD, together with cancer and stroke, accounts for 35 per cent of life years lost before the age of 75 (BHF 2003). In addition, more than 1.5 million people in the UK are living with angina and 500,000 have heart failure (Department of Health (DoH) 2004) frequently, although not exclusively, caused by CHD. This high incidence is not unique to the UK and a similar pattern is being observed worldwide (Yusuf et al 2002). The World Health Organization (WHO) has predicted that by 2020, CHD will be the greatest cause of death and disability throughout the world (Tunstall-Pedoe et al 1999). The increasing number of people living with the disease is of concern to healthcare professionals. Strategies to prevent this are therefore of great importance. The National Service Framework (NSF) for CHD (DoH 2000a) laid the foundations for dramatic improvements in the prevention and treatment of heart disease, and 1.8 million people are now receiving lipid-lowering drugs, with lifestyle advice a key feature of primary and secondary prevention appointments. However, there is room for improvement and the NHS Improvement Plan (DoH 2004) sets an ambitious target to reduce death rates from CHD and stroke in the under-75s by at least 40 per cent by 2010. Pathophysiology CHD can develop at any age. Initially, an area of atheromatous plaque forms in the coronary artery. The mechanism for plaque formation is unclear, although the predominant view is that lipid accumulates under the lining of the coronary artery (Samar 1999). Because the lipid infiltrate is a foreign matter, white blood cells called macrophages engulf it, and create foam cells (Samar 1999). Smooth muscle cells then invade the area, which enlarges. It is not until the plaque obstructs more than 50 per cent of the lumen of the coronary artery that the flow of blood to the heart muscle, the myocardium, is reduced. This usually means that when resting, or undertaking minimal activity, the blood supply to the heart is adequate. However, when the heart requires a greater supply of oxygen, as occurs during exercise or emotional episodes, the blood supply cannot increase sufficiently and the person will experience chest discomfort. This is referred to as angina pectoris. Once plaque has
This article has been supported by an educational grant from:
In brief Author Julie Foxton RGN, RM, is senior nurse adviser, HEART UK, Maidenhead, Berkshire; Michaela Nuttall RN, DipN, MSc, is CHD Co-ordinator, Bromley Primary Care Trust, Kent; and Jillian Riley RGN, RM, BA(Hons), MSc, is head of postgraduate education for nurses and allied health professionals, Royal Brompton Hospital, and honorary lecturer, Imperial College, London. Email: firstname.lastname@example.org Summary Coronary heart disease is the leading cause of mortality and morbidity in the UK. Nurses have a pivotal role in the management of high-risk patients and the modification of risk factors. Key words ■ Cardiovascular system and disorders ■ Health promotion These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review. Online archive For related articles visit our online archive at: www.nursing-standard.co.uk and search using the key words above.
december 8/vol19/no13/2004 nursing standard 47
0mmol/l and low-density lipoprotein (LDL) 48 nursing standard december 8/vol19/no13/2004 . You may need to read the patient’s notes to find some of the details. which suggests that the ideal way to implement secondary prevention is through nurse-led clinics. additional risk factors include a family history of CHD. and use the calculator to assess his or her risk of developing CHD over the next ten years. However. compare your answers with the suggestions below. Risk factors A number of factors are thought to increase the likelihood of developing CHD. While nurses in almost all areas of care have the opportunity to assess and advise on CHD risk factors. This also helps to improve equity of care. These risk factors are common. efforts are being made to lower cholesterol levels in the population to a target level of 5. diabetes. hypertension and abnormal cholesterol levels. The nurse’s role The role of the nurse has extended to meet the changes in health care where increasingly the emphasis is on health promotion and disease prevention. and efforts should be made to increase awareness of how to reduce the likelihood of developing CHD both in the person who has identified risk factors and in the population as a whole (Yusuf et al 2004). who does not already have a diagnosis of CHD. TIME OUT 1 Write down.hyp.uk/bhs/Cardiovascular _Risk_Charts_and_Calculators. whereas moderate risk is calculated as a 10 per cent risk of developing CHD over the next ten years (Wood et al 1998). At this time the person will experience a myocardial infarction (MI). the NHS Plan (DoH 2000b). regardless of sex.0 mmol/l or less for total cholesterol. This is because many people who have CHD or who are at a high or moderate risk of developing the disease are cared for in primary care settings. there is now TIME OUT 2 Using a separate piece of paper for each risk factor identified above. the wall of the coronary artery is damaged and irregular in shape and platelets cluster around the obstruction. where patient concordance with therapy is poor. in no more than one paragraph. write down what you are currently doing to reduce that risk factor either in your own life or in a patient’s life. They include lifestyle advice as well as the prescription of advice regarding medication. lack of fruit and vegetables in the diet and lack of exercise (Yusuf et al 2004). The risk of developing CHD can be calculated using a risk chart. obesity. This is outlined in the documents Making a Difference (DoH 1999a). Consequently. physical inactivity and smoking. cholesterol.0mmol/l (Williams et al 2004). High risk is identified where the risk is calculated as 30 per cent or higher. Diabetes and obesity are also increasing in the UK (BHF 2003).htm Consider a patient you have cared for over the past week. level of less than 2. abdominal obesity. for example. This may seem hard to achieve – certainly among some sections of the patient population and in some areas of the country. Government policies to improve the health of the individual and the population have emphasised that nurses have a significant contribution to make. Nurses can proactively implement preventive strategies and advise on many aspects of health promotion. This means that while nurses are ideally placed to provide information. The nursing profession can assist the shift in responsibility for health to patients by empowering people to improve their health outcomes. Sometimes platelet aggregation can be sudden causing an abrupt and total occlusion of the coronary artery.ac. there is an inability to tolerate therapy or where sections of the community are unable or unwilling to access medical services – but the most recent British Hypertension Society guidelines go further and suggest a total cholesterol of less than 4. For those people with CHD. diabetes. thereby increasing the risk (Yusuf et al 2004). the advice given can be more consistent and evidence-based through the application of local and national guidelines. Once you have done this. This forecasts the risk of developing CHD over the next ten years.Health promotion formed. This reduces the size of the lumen still further and consequently the blood supply is also reduced. In CHD the proactive role of the nurse has been further reinforced by the publication of the NSF for CHD (DoH 2000a). The three major risk factors are smoking. and Shifting the Balance of Power in the NHS: Securing Delivery (DoH 2001). They are increasingly using clinical guidelines to ensure a higher quality of care (Puffer and Rashidian 2004). Modification of risk factors There are a number of ways in which the risk of developing CHD can be modified. hypertension. for example. Some risk factors are modifiable. ethnic group or age and are frequently not found in isolation. TIME OUT 3 Look at the risk calculator on the following websites: www. it is particularly pertinent for nurses working in primary care and the community. The nurse’s role is pivotal in helping to address this increase. your own definition of CHD. Abnormal cholesterol levels are a major risk factor for CHD and are responsible for at least 46 per cent of all new cases of CHD (BHF 2004).
these products should be used as described as a constant circulating level of stanols or sterols is required to achieve maximum efficiency and effectiveness. They inhibit the absorption of cholesterol in the intestines and may achieve total cholesterol reductions of up to 14 per cent (Miettinen et al 1995). it is also important to incorporate regular. In people with a body mass index (BMI) greater than 25kg/m2 (calculated by dividing weight in kilos by height in metres squared).200-1. Box 1. Various benefits are associated with weight loss (Box 1). Targeted CHD prevention is also advocated by the joint British recommendations on CHD prevention (Wood et al 1998). Reduction of waist circumference is associated december 8/vol19/no13/2004 nursing standard 49 . yoghurts and spreads. These show that nurseled secondary prevention clinics can improve secondary prevention of CHD risk factors. Wright et al (2001) also found that nurse-led risk factor management is acceptable to patients. fried food and lard (Tang et al 1998). List this patient’s risk factors for CHD. They are safe and tolerable and are contained in a variety of ready-to-buy products ranging from milk and milk drinks. It is recommended that weight reduction is required when waist circumference is more than 102cm in men and more than 88cm in women (Lean et al 1995). Cupples and McKnight 1999. CHD is the main cause of excess mortality (British Nutrition Foundation (BNF) 1999). but steam frying or using a vegetable oil high in polyunsaturates. There is less evidence that nurse intervention is effective for those people who are at high or moderate risk of developing CHD but have not been diagnosed with CHD. Therefore. Three of the trials were in primary care in the UK and one in secondary care in the United States (US). fruit.600kcal per day. Plant sterols and stanols are sourced from either wood pulp products or soya bean distillates. 15 per cent low-density lipoprotein and 30 per cent triglycerides Increase of 8 per cent high-density lipoprotein (Blenkinsopp 2004) TIME OUT 4 In Time Out 3 you calculated a patient’s risk of developing CHD over the next ten years. with improvements in cardiovascular risk (Han et al 1997). Unlike BMI. rice. diabetes and high triglyceride and cholesterol levels. Strategies should be considered that gradually reduce weight by about 0. waist measurement can give a better indication of android obesity (central distribution of excess adipose tissue) (Donahue et al 1987). full-cream milk. ■ Fried food should be discouraged. However. Lifestyle and pharmacological interventions and goals for those people at high risk of CHD are similar to those for people with CHD. moderate exercise into a daily routine. wholegrain bread. Murchie et al 2003). This is in part because obese or overweight individuals are more likely to have hypertension. sugar and alcohol is helpful but. Under each risk factor. rapeseed and sunflower oils. targeting health promotion activities at high-risk individuals should be considered the first step. ■ Use low-fat spreads – suggest considering a low-fat spread that contains plant stanol/sterol esters. cereals.Health promotion evidence of benefits from four randomised controlled trials of nurse-led secondary prevention (Allen et al 2002. identify some of the ways in which you might help him or her to reduce this risk. Benefits of 5-10kg weight loss Mortality 20-25 per cent fall in overall mortality 30-40 per cent fall in diabetes-related deaths 40-50 per cent fall in obesity-related cancer deaths Blood pressure 10mmHg fall in diastolic and systolic pressures Diabetes Up to a 50 per cent fall in fasting blood glucose Reduces risk of developing diabetes by more than 50 per cent Lipids Fall of 10 per cent total cholesterol. referral to a dietician or nutritionist should be considered. poultry. fatty cheese. fish. These and other plant stanol/sterolcontaining foods may be useful adjuncts in lowering cholesterol levels. to achieve a healthy body weight. exercise and behavioural changes. Moher et al 2001. ■ Consider eating more vegetables. The Cochrane Library reviewed multiple risk-factor interventions for primary prevention of CHD and concluded that effective interventions on a general population basis would be mostly ineffective and costly (Ebrahim and Davey Smith 1999). moderate fat intake by eating less fatty meat. which does not take into account body fat distribution. Weight control is important and can be achieved in a variety of ways. and other abnormalities of clotting that increase the risk of thrombus formation or MI (Meade et al 1993). Lifestyle management Weight loss There is a twofold increase in the risk of developing CHD in people who are obese or overweight.5kg per week through a combination of diet. skimmed or semi-skimmed milk. lean meat or pasta. such as sunflower or rapeseed oil or one containing plant sterols or stanols could be considered (see below). grilled food. Eating less fat. For those who are obese. Dietary advice Nurses can also advise on a healthy diet (Figure 1) which may include the following: ■ Calorie intake – 1.
Health promotion Figure 1. The HEART UK diet sheet BEST CHOICE Cereals and starchy foods IN MODERATION BEST AVOIDED Potatoes Vegetables and fruit Fish Meat Vegetarian choice Eggs and dairy Oils Spreads Meals Cakes and biscuits Puddings Flavourings. jams and sweets Reproduced with the kind permission of HEART UK 50 nursing standard december 8/vol19/no13/2004 . sauces.
cause arrhythmias. The lipid profile ■ Total cholesterol ■ Low-density lipoprotein cholesterol ■ High-density lipoprotein cholesterol ■ Triglycerides december 8/vol19/no13/2004 nursing standard 51 . ■ Assist smokers to stop. and can contribute to hypertension (Blenkinsopp 2004). stroke and coagulopathies (Lindsay and Gaw 2004). ■ Arrange follow-up. Sacks et al 1996). two to three units for men). Downs et al 1998. high triglycerides and hypertension. Recommended levels to gain cardiovascular protection. Stopping smoking will reduce CHD risk even if a person has smoked for many years. Stress can exacerbate symptoms in people with pre-existing heart disease. Statin therapy can reduce low-density lipoprotein (LDL) cholesterol by up to 60 per cent (McTaggart 2003). Within eight hours nicotine levels will be reduced by half and within 24-48 hours carbon monoxide levels will be comparable to those of a non-smoker. Statins have been proven to be effective at lowering mortality and morbidity for cardiovascular disease (DoH 2000a. tobacco smoking accounts for more than 30. The first statins were produced more than 20 years ago from fungi. Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group 1998. Trials such as this have continued over subsequent years and prove the safety and efficacy of statins and a reduction in cardiovascular events following statin therapy (Athyros et al 2002. both of which help to reduce the risk of developing CHD. consuming too much alcohol places health at risk in a number of ways. Gordon 2000. A more recent study examined people with type 2 diabetes who were therefore at high risk of developing CHD. risk factors for the development of CHD (Lindsay and Gaw 2004). Statins include atorvastatin. Stress A certain amount of stress may be desirable as it keeps people alert and motivated. cerivastatin (now withdrawn). it may lead to the adoption of poor eating habits. cycling and dancing.Health promotion Physical activity Thirty seven per cent of CHD deaths in people under the age of 75 are attributable to physical inactivity (BHF 2003). lovastatin (not available in the UK). Statins These are the most common form of drug therapy for reducing raised cholesterol levels. as stress levels increase and especially if prolonged. statins lower triglycerides (fatty acids attached to glycerol) in proportion to their LDLlowering effect. an enzyme which is involved in cholesterol synthesis in the liver (BNF 2004). if you are physically able. which can easily be fitted into a regular day. alcohol may reduce the risk of CHD by potentially increasing high-density lipoprotein (HDL) cholesterol slightly and reducing thrombotic tendencies (Mukamal et al 2001). When taken in excess. ■ Advise all smokers to stop. This can take the form of walking. Shepherd et al 2002. or a pub measure of wine. but newer versions are man-made. Key features of individual smoking cessation are: ■ Ask about smoking at every opportunity. fluvastatin. Alcohol In moderation (one to two units daily for women. Minhas 2003. The long-term benefits are considerable. It demonstrated Box 2. It is essential that nurses take a proactive role in helping people to stop smoking and provide advice on smoking cessation. rosuvastatin and simvastatin. the Health Survey for England 1998 (DoH 1999b) identified that approximately 70 per cent of people were not taking regular physical activity. However. Smoking Smoking is the single biggest cause of preventable death in the UK. Drug therapy This section examines methods used to control and correct the lipid profile (Box 2). Different statins vary in their effect on HDL cholesterol but they generally cause a small rise and because HDL is cardioprotective this is a beneficial action (Assman et al 1995). alcohol can damage the cardiac muscle. swimming. Men should drink no more than three to four units of alcohol and women no more than two to three units a day. Additionally it may contribute to obesity. However.000 deaths from cardiovascular disease (Callum 1998). sherry or spirits. jogging. lager or cider. Additionally. The Simvastatin Survival Study (also know as the 4S study) in the late 1980s was the first trial to provide this information (Shepherd et al 1995). smoking and increased alcohol consumption and non-concordance with prescribed medication. The nurse can help people to find time for relaxation or teach them simple breathing exercises to help reduce the risk of developing CHD (Blenkinsopp 2004). There are short and long-term benefits. and others are undergoing clinical and scientific study. A unit is defined as a half pint of beer. However. Statins work by inhibiting the action of 3-hydroxy3-methylglutaryl-coenzyme A (HMGCoA) reductase. Wood et al 1998). Each year. other than diet and lifestyle. The cardiovascular benefits of regular physical activity include reduced blood pressure and less likelihood of obesity. pravastatin. are at least 30 minutes of steady activity on five or more days a week (American College of Sports Medicine (ACSM) 2000). Additionally. excess cardiovascular risk from smoking reduces by half within one year and after five years reverts to about the same level as someone who has never smoked (Critchley and Capewell 2003). Hebert et al 1997. they can be counter-productive.
hypothyroidism. This advice was given as a result of several cases of rhabdomyolysis that had occurred at the higher dosage. However. due to excess cases of rhabdomyolysis (muscle breakdown) caused by a previously unknown metabolic pathway. obesity. lowering cholesterol even further provides additional cardiovascular benefit to the patient (Colhoun et al 2004). Screening is offered to all men over 55 years of age. the manufacturers of rosuvastatin advised all prescribers to commence rosuvastatin at the starting dose of 10mg and titrate carefully. regardless of cholesterol level. they should still be offered appropriate lifestyle advice. has been launched to target people at moderate risk of CHD in the UK. Statins are safe and generally well tolerated (DoH 2000a. lower body weight. London) 52 nursing standard december 8/vol19/no13/2004 . a potentially life-threatening event (BNF 2004). This initiative aims to reduce their risk factors. to track how cholesterol levels are responding to the drug. which also outlines variations in the reduction of total cholesterol and LDL cholesterol. liver function test disturbance of unknown long-term significance (rare) and a spectrum of muscle-related side effects ranging from myalgia (common). A number of risk factors for rhabdomyolysis have been identified: older age. Statins do differ from each other in molecular structure and each has a slightly different mode of action. with no other risk factors for heart disease. The most common side effects are usually transient gastrointestinal disturbance. it is not essential to obtain the results of a cholesterol test before commencing the statin. including lowering blood cholesterol levels. If people do not fulfil the pharmacy screening protocol and are not offered the drug. it may be useful to recommend that a cholesterol test is performed when therapy is started and possibly on a yearly basis afterwards. as well as to monitor its effectiveness. following a pharmacy screening protocol. as further investigation and treatment may be required. concomitant therapy and other drugs. They may also have different side effects and cerivastatin was withdrawn. some patients cannot tolerate large doses of statins and this may influence the choice of drug prescribed. However. to men 45-54 years of age and women over 55 years with one or more risk factors. St Mary’s Hospital. Those who fit the criteria are offered lifestyle advice and a statin may be dispensed. Recently. and it is therefore wise Table 1. Profile of statins Drug Dose range Maximum change (%) LDL HDL TG 50 24 34 34 57 41 6 8 9 12 10 12 29 10 16 24 28 18 Lipophilic Metabolic pathway P450 Metabolism 3A4 2C9 3A4 unknown 2C9/2C19 3A4 Atorvastatin Fluvastatin Lovastatin* Pravastatin Rosuvastatin Simvastatin * Not available in the UK 10-80mg 20-80mg 20-80mg 10-40mg 10-40mg 10-80mg Yes Yes Yes No No Yes LDL = Low-density lipoprotein cholesterol. Shepherd et al 2002). It is thought prudent to use the appropriate statin for the patient’s risk profile and in these days of trying to achieve NHS targets (NHS 2004) some statin drugs are viewed as more able to achieve those targets than others. Imperial College. TG = Triglycerides (Reproduced with kind permission of Dr Michael Schachter. The pathway through which the drugs are metabolised is shown in Table 1. Minhas 2003. These risk factors are determined as smoking. A recent initiative. approved by the Medicines and Healthcare products Regulatory Agency (MHRA). Sacks et al 1996. When using the pharmacy protocol. family history of premature death of CHD (before the age of 65 in female relatives and age 55 in male relatives) and people of South Asian origin (MHRA 2004a). to all men and women where the risk of developing heart disease over the next ten years has been estimated as 10 per cent (moderate risk) (MHRA 2004a). Approval has been given for simvastatin 10mg (one of the statin drugs) to be dispensed by a pharmacist.Health promotion that. Department of Clinical Pharmacology. while patients requiring doses of 40mg and above should be supervised in specialist centres (MHRA 2004b). HDL = High-density lipoprotein cholesterol. If on screening. muscle inflammation (myositis) to rhabdomyolysis. someone is identified as ‘high risk’ he or she should be given lifestyle advice and encouraged to consult the GP for advice and management. which may be important to ensure continuation of the therapy.
Department of Health (2000a) National Service Framework for Coronary Heart Disease. 8. Assman G et al (1995) Epidemiological and clinical relevance of triglycerides and high-density cholesterol. Department of Health (1999a) Making a Difference: Strengthening the Nursing. British National Formulary (2004) British National Formulary No 48. 317. Bays H et al (2001) Effectiveness and tolerability of ezetimibe in patients with primary hypercholesterolemia: pooled analysis of two phase II studies. The Stationery Office. Midwifery and Health Visiting Contribution to Health and Health Care. A 10 per cent reduction in cholesterol leads to a 30 per cent reduction in risk of CHD (Law et al 1994). 319. London. Statins are often perceived as first-line therapy after diet and other lifestyle changes. 8. Suppl 12A. resins are often unpalatable – they are in powder form and are mixed with fruit juices or yoghurt – and their unpleasant side effects of flatulence. this has been addressed and newer formulations of nicotinic therapy have included a dose titration pack to minimise the side effects that may be experienced (Capuzzi et al 1998). Blackwell Science. 20. changes in risk factors. Health Education Authority. Pharmacy Magazine. London. However. A position paper developed by the European Consensus Panel on HDL-C.org (Last accessed: November 2 2004. constipation and diarrhoea often mean that patients are not keen to take them. BHF. 8537. 685-696. Their greatest effect. Clinical Therapeutics. 1237-1245. British Medical Association and the Royal Pharmaceutical Society of Great Britain. fibrates. 4. 4. American Journal of Cardiology. British Medical Journal. Lancet. 1615-1622. Department of Health (2000b) The NHS Plan: A Plan for Investment. 8. 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Other cholesterol-lowering products include nicotinic acid. The Stationery Office. 10. Oxford. 20. American College of Sports Medicine (2000) ACSM’s Guidelines for Exercise Testing and Prescriptions. Department of Health (2004) NHS Improvement Plan: Putting People at the Heart of Public Services. John Wiley and Sons. Capuzzi D et al (1998) Efficacy and safety of an extended-release nicotinic acid (Niaspan): A long-term study. Safety of treatment.heartstats. 25-31. Ebrahim S. 5. Gordon D (2000) Cholesterol lowering reduces mortality. Critchley J. resins. Chichester. 23. London. Resins When cholesterol has been made it is stored in the bile ducts and mixed with food to aid digestion. Sixth edition. Cardiovascular Risk Factors. Journal of the American Medical Association. Capewell S (2003) Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. London. 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An overview of randomized trials. 2004-BHS IV. clotting factors.uk/ inforesources/publications/arm18 outcomeqa. 180-188.Health promotion tion and can further enhance cholesterol lowering. Mukamal K et al (2001) Prior alcohol consumption and mortality following acute myocardial infarction. S1-S29. West of Scotland Coronary Prevention Study Group. 19. Journal of Advanced Nursing. Suppl 2. 4. Moher M et al (2001) Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care.htm (Last accessed: November 26 2004). 353. Puffer S. Rashidian A (2004) Practice nurses’ intentions to use clinical guidelines. 316. 311. http://medicines. and long-term incidence of ischaemic heart disease in the Northwick Park Heart Study. New England Journal of Medicine. New England Journal of Medicine. 313-321. British Hypertension Society. Yusuf S et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. 54 nursing standard december 8/vol19/no13/2004 . The American Heart Association scientific statement on diet recommends that patients at risk of cardiovascular disease would benefit from 2-4mg of omega-3 fish oils per day (Kris-Etherton et al 2002). omega-3 fatty acids. 15. many of the risk factors for the development of the disease are modifiable through attention to lifestyle and diet. 21. Kris-Etherton P et al (2002) Fish consumption. 1623-1630. 6925. 4. Conclusion CHD remains a significant cause of death and disability throughout the western world. 9346.uk/ ourwork/monitorsafequalmed/ safetymessages/crestor_9604. It can reduce cholesterol by up to 18 per cent (Bays et al 2001). Second edition.mhra. 139-185. Journal of the American Medical Association. Guidelines to help you are on page 56. British Medical Journal. McTaggart F (2003) Comparative pharmacology of rosuvastatin. New England Journal of Medicine. International Journal of Obesity and Related Metabolic Disorders. Write a short paragraph under each of the learning outcomes to indicate how you have achieved these outcomes. Han T et al (1997) Waist circumference reduction and cardiovascular benefits during weight loss in women. Atherosclerosis Supplements. 59-68. you might like to write a practice profile. Yusuf S et al (2002) The global epidemic of atherosclerotic cardiovascular disease. 285. Monitoring trends and determinants in cardiovascular disease. 10. 9-14. London. 2. The Stationery Office. 342. Law M et al (1994) By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? British Medical Journal. 7380.pdf (Last accessed: November 25 2004. Shepherd J et al (2002) Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Churchill Livingstone. 158-161. 84. British Journal of Cardiology. 1308-1312. 18. Veterans Affairs Density Lipoprotein Cholesterol Intervention Trial Study Group. newer drug therapies and the use of plant stanols and sterols can contribute to reducing blood cholesterol levels and thereby assist in the prevention and management of CHD. 20. 1338-1342. Lancet. Circulation. Tunstall-Pedoe H et al (1999) Contributions of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. 937-952. 5. While much can be done to reduce risk factors for CHD in the community setting. Lindsay G. 367-372. Lean M et al (1995) Waist circumference as a measure for indicating need for weight management. 2337-2340. 7298. National Health Service (2004) General Medical Services Contract Regulations. 127-134. 1213-1220. 410-418. 364. 14.gov. Miettinen T et al (1995) Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group (1998) Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. 9438. It works specifically at the brush border of the intestine. the nurse has an important role to play in raising awareness of the risks of CHD and also in assisting people to make necessary lifestyle changes to minimise these risks TIME OUT 5 Return to the start of the article and look at the learning outcomes. 1. Minhas R (2003) Current progress in lipid therapy. 6. 21. 360.mhra. Rubins H et al (1999) Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Wright F et al (2001) Patients’ and practice nurses’ perceptions of secondary preventive care for established ishaemic heart disease: a qualitative study. In Jairath N (Ed) Coronary Heart Disease and Risk Factor Management: A Nursing Perspective.) Medicines and Healthcare products Regulatory Agency (2004b) New Prescribing Advice for the 40mg Dose of Crestor (rosuvastatin). 20. Journal of Human Hypertension. 1001-1009. Meade T et al (1993) Fibrinolytic activity. Journal of Clinical Nursing. Philadelphia PA. 10. Medical Principles and Practice. Tang J et al (1998) Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects. 7139. New England Journal of Medicine. Murchie P et al (2003) Secondary prevention clinics for coronary heart disease: four-year follow up of a randomised controlled trial in primary care. 322. Lancet. 11. Suppl 2. and cardiovascular disease. 335. British Medical Journal.gov. 333. 1965-1970. Stone N (1996) Fish consumption. 2. 278. 2747-2757. fish oil.
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