APLIE HEALTH pharmacist undertakes Medicine Use Reviews (MUR) to help patients understand how their medicines work and why they have to take them, which can help with adherence to treatment. We also advise patients about the adverse effects of their medicines and look for potential interactions with other medicines/treatments they may be taking, to ensure that their different treatments are compatible. Our pharmacists also offer specialist health checks, such as blood pressure monitoring and diabetes screening, as well as running smoking cessation clinics and weight reduction programmes, all of which may help in the primary and secondary prevention of cardiovascular issues.
APLIE HEALTH pharmacist undertakes Medicine Use Reviews (MUR) to help patients understand how their medicines work and why they have to take them, which can help with adherence to treatment. We also advise patients about the adverse effects of their medicines and look for potential interactions with other medicines/treatments they may be taking, to ensure that their different treatments are compatible.
Our pharmacists also offer specialist health checks, such as blood pressure monitoring and diabetes screening, as well as running smoking cessation clinics and weight reduction programmes, all of which may help in the primary and secondary prevention of cardiovascular issues.
Upon discharge from hospital, many patients with cardiac diseases i.e. Acute Coronary Syndrome (ACS) are likely to be taking several medications, at least some of which will be unfamiliar to them. Added to this medication burden will be the ongoing need for drugs that patients were already receiving for related or co-morbid conditions prior to their event – for example, oral ant diabetics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants and anti-asthmatics.
Once discharged from hospital, patients with ACS return to the care of their primary healthcare team – headed by their general practitioner (GP), cardiac rehabilitation nurse and community pharmacist.
By the time they reach this point in their journey, patients with ACS will have had vastly different care experiences. Some will have been discharged home after receiving medical therapy only with overnight observation; at the opposite end of the spectrum, others will have had bypass surgery or rescue PCI and spent several days in hospital.
The primary care team must respond to these differences in experience, by providing care that is tailored to individual patients’ needs, and recognises that ACS represents a spectrum of clinical disease rather than a single disease entity.
Goals and objectives
People with Acute Coronary Syndrome (ACS) remain at significant risk of death and cardiovascular events (myocardial infarction or stroke) after discharge from hospital, as well as complications such as heart failure and arrhythmias.
The goals of management in the primary sector are therefore:
to rehabilitate ACS patients following their return home, to facilitate a return to normal activities or work in the shortest possible time
to monitor patients for complications, and institute appropriate and effective management strategies to limit their impact
to prevent death and future cardiovascular events by initiating de novo secondary prevention strategies, continuing those implemented before discharge, and monitoring the effectiveness and safety of both
An important role for primary care healthcare professionals is to ensure that all medication being taken by a patient with ACS is appropriate, effective, safe and manageable, taking into account any co-morbidities, concomitant medications and other factors (e.g. cognitive function). For example, a pre-existing repeat prescription for an NSAID, prescribed for the treatment of osteoarthritis, may need to be reviewed or monitored in a patient with new-onset left ventricular dysfunction, to reduce the risk of fluid overload, heart failure and recurrent myocardial infarction. Similarly, an ACE inhibitor prescribed for secondary prevention post-ACS may need to be changed to an angiotensin II receptor blocker (ARB) in patients who develop ACE inhibitor-related cough. Many patients, particularly older patients and those without social support, may be unable to manage complex regimens that can contain 10 or more medications; confusion over dosage and frequency could negate the intended benefit of treatment and, at worst, have serious adverse consequences.
In the primary care setting, medication reviews are usually conducted by a GP, community pharmacist or nurse prescriber. They are generally indicated for patients receiving multiple (4 or more) medications, and can be conducted because of concerns about drug-drug or drug-disease interactions or tolerability; they may also be undertaken to simplify treatment and improve compliance. The aim is to improve or optimise the impact of treatment for an individual patient.
A medication review checklist might include the following questions:
Is there a documented indication for each prescribed medication?
Does each medication carry specific, appropriate dosage instructions?
Are there any contraindications?
Has the potential for drug-drug or drug-disease interactions been considered, and action taken as appropriate?
Has the potential for adverse drug reactions been considered and discussed with the patient?
Have appropriate monitoring parameters been identified and addressed?
If so, are test results available, and has any appropriate action been taken?
Is the patient managing to comply with their medication?
Has any potential over- or under-prescribing been identified and rectified?
During the review, patients should be given the opportunity to raise questions and highlight problems with their medicines.
It is important to note that medication review is an ongoing process and should, ideally, be repeated at regular intervals, to ensure that all medication remains appropriate and that efficacy and safety are optimised.
Primary care providers play a critical role in assessing ACS patients’ risk of a future cardiovascular event, and ensuring that all appropriate preventive measures are in place. Interventions that prevent death or recurrent cardiovascular events in patients with a past history of ACS are described as secondary prevention initiatives.
Factors that increase the risk of coronary artery disease (CAD) also increase the risk of ACS and be classed as non-modifiable or modifiable.
Non-modifiable risk factors include:
positive family history
Modifiable risk factors include:
Smoking is thought to be responsible for approximately 17% and 20% of CAD-related deaths in women and men, respectively.1 Risk is proportional to the number of cigarettes smoked, and declines to almost normal after 10 years’ abstention.
Diet, exercise and bodyweight Poor diet (high in fat, low in antioxidants), lack of physical exercise and obesity are all associated with an increased risk of CAD. Conversely, weight loss, through dietary modification and increased exercise, has been shown to reduce the incidence of cardiovascular disease and diabetes/insulin resistance.1
Blood pressure Systolic and diastolic hypertension are both associated with an increased risk of CAD.1 In patients with diabetes or existing cardiovascular disease, a target BP of 130/80 mmHg is recommended.2
Cholesterol In patients with ACS, target levels of total and LDL-cholesterol are <4.5 mmol/L and <2.5 mmol/L, respectively. Low levels of HDL-cholesterol (<1.0 mmol/L in men and <1.2 mmol/L in women) and elevated fasting levels of triglycerides (>1.7 mmol/L) are associated with increased cardiovascular risk, but no specific treatment goals have as yet been defined for these lipids.2
Glycaemic control Diabetes is strongly associated with cardiovascular disease. In patients with type 2 diabetes, each 1% reduction in glycated haemoglobin (HbA1c) is associated with a 14% reduction in the rate of myocardial infarction, and lower all-cause mortality.3 Guidelines from the International Diabetes Federation-Europe currently recommend an HbA1c target of <6.5%, with fasting and post-prandial glucose levels not exceeding 6.0 and 7.5 mmol/L, respectively.3
A key part of the care for patients with ACS in the community is therefore to monitor modifiable risk factors – including bodyweight, blood pressure, lipid levels, smoking status and glycaemic control – and initiate or modify interventions to lower overall risk.
Diet and lifestyle advice
Five key aspects of lifestyle modification have been shown to be clinically beneficial, in terms of reduced mortality or the prevention of recurrent cardiovascular events, in patients who have experienced ischaemic cardiac events.4 These are:
Diet Adoption of a ‘Mediterranean’ diet (increased consumption of bread, fruit, vegetables and fish; reduced intake of meat; and substitution of butter and cheese with plant-based products) has been shown to reduce mortality in patients with prior myocardial infarction. There is also good evidence to support the increased intake of oily fish and, in some circumstances, dietary supplementation with omega-3-acid ethyl esters. However, there is little or no evidence to support the routine use of supplementation with vitamin C, vitamin E or folic acid.
Exercise In the secondary prevention setting, patients who exercise regularly have been shown to have improved survival rates and a reduced incidence of non-fatal myocardial infarction. Current advice is that patients with prior myocardial infarction should exercise to the point of slight breathlessness for 20 to 30 minutes per day.
Alcohol consumption Although there is some evidence that low-to-moderate alcohol intake has cardiovascular benefits in men, patients who drink alcohol are advised to keep their intake to within recommended limits (21 units per week for men, and 14 for women) and to avoid binge drinking.
Smoking Patients who continue to smoke following myocardial infarction should be advised to quit, and offered assistance from a smoking cessation service.
Weight reduction Following myocardial infarction, all patients who are overweight or obese should be offered advice and support to achieve and maintain a healthy weight.
Advice on lifestyle modification is a cornerstone of cardiac rehabilitation, and can have a profound impact on outcomes..
Following discharge, patients with ACS are likely to be receiving:
an ACE inhibitor
a statin and
These four categories of medication are recommended for secondary prevention by the National Institute for Health and Clinical Excellence (NICE) because of their proven ability to improve clinical outcomes in patients following myocardial infarction.4
Additional drugs that may be appropriate for certain groups of patients include:
angiotensin II receptor antagonists (e.g. valsartan), for patients who cannot tolerate ACE inhibitors the aldosterone receptor antagonist eplerenone, for patients with left ventricular dysfunction and evidence of heart failure following myocardial infarction oral anticoagulants, for patients with a specific indication (e.g. atrial fibrillation)
Cardiac rehabilitation programmes
All patients, regardless of their age, should be given advice about and offered a cardiac rehabilitation programme that includes an exercise component.
The World Health Organization (WHO) defines cardiac rehabilitation as:5
“the sum of activity and interventions required to ensure the best physical, mental and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life” (www.who.int)
Cardiac rehabilitation programmes are co-ordinated by specialist nurses, and often include exercise, educational and stress management components. Programmes that include an exercise component have been shown to reduce all-cause and cardiovascular mortality following myocardial infarction.4
Educational and stress management components reduce cardiac mortality and recurrent myocardial infarction, may reduce anxiety, and can help patients return to work. National standards for cardiac rehabilitation programmes have been published,6 and the Heart Manual – a series of evidence-based cardiac rehabilitation programmes designed for self-management – has been developed by NHS Lothian as a one-step approach to meeting these standards.7
Cardiac rehabilitation programmes need to be inclusive, in that they must seek to maximise uptake among all ACS patients regardless of barriers presented by age, disability, educational level, socioeconomic status, culture and language. Uptake can be improved by motivational communications, in the form of letters and other written materials, and conversations with healthcare professionals.
Kumar P, Clark M. Clinical medicine. 7th ed. Edinburgh: Saunders Elsevier, 2009.
Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur J Cardiovasc Prevent Rehab 2007;14 Suppl. 2:E1-40.
Rydén L, Standl E, Bartnik M, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text.
Eur Heart J 2007;28:88-136.
National Institute for Health and Clinical Excellence (NICE). MI: secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction. May 2007. Clinical guideline 48. Available at: guidance.nice.org.uk/CG048 Accessed: December 2010.
World Health Organization Regional Office for Europe. (1992). Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CVD: Report on two WHO consultations. Geneva: World Health Organization.
Department of Health. National Service Framework for coronary heart disease. March 2000. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_4094275 Accessed: December 2010.
Welcome to the APLIE health Hospital services. Here you can find information about the medical services that we provide at this hospital, including details of our specialist consultants.
Getting the information you need You can find a list of our services on the left, arranged in alphabetical order. Select a link to find out more detailed information. These links also take you to information about the specialist consultants who provide the service.