Missed opportunities in prevention of cardiovascular disease in primary care: a cross-sectional study

This study highlights very well the missed opportunities for intervening in primary care and focuses on pharmacotherapy, as current data recording allows this to be measured more easily than monitoring advice and impact of advice given on lifestyle interventions. In general practice, there is a risk that we become "pharmaceutical physicians" and are measured on our prescription data and BP recordings. There is a range of data which support the notion that increasing physical activity and weight reduction if overweight has a powerful effect in cardiovascular risk reduction which can be equivalent to the benefit gained from prescribing statins and further BP lowering agents. Indeed increasing physical exercise was shown to have both an equivalent and an additive effect to statins.(1)

We need a way to move away from relying on drugs and work with public health colleagues (now within local authorities) in facilitating changes in behavior. Clearly this is not a simple task but it does start with general practice being aware of the benefits of lifestyle change and then being supported in this task as clearly there is not sufficient resource for this type of intervention. It is much simpler to prescribe a drug which is then automatically funded within the prescribing budget.

Another area we are not measuring within practices is the uptake of cardiac rehabilitation which has been shown to be more cost effective than many interventions such primary PCI, stenting, and coronary artery bypass. We have clear evidence that cardiac rehab is effective in reducing total and cardiovascular mortality and hospital admissions in people with coronary heart disease(2) and also reduces all-cause and cardiovascular mortality rates in patients after MI when compared with usual care, provided it includes an exercise component.(3)

There is also research data that cardiac rehab significantly reduces hospitalisation for chronic heart failure and significantly improves quality of life and exercise tolerance for people with heart failure.(4)

The key to cardiac rehab would seem to me that there is structured resource to ensure the adherence to guidelines both for pharmacotherapy and for lifestyle modification.

References

(1) Huseyin and Ioannidis. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5577

(2) Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; 7: CD001800

(3) National Clinical Guideline Centre. Post myocardial infarction: secondary prevention in primary and secondary care for patients following a myocardial infarction (full guideline). 2013.

(4) National Clinical Guideline Centre. Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care. 2010.

Conflict of Interest:

None declared