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Cardiovascular disease part 2

Expert Q&A Dr Mahendra Patel answers questions on this month's Update topic with a cardiovascular Q&A on drug selection post-MI, and lifestyle choices to reduce the risk of cardiovascular disease

Dr Mahendra Patel is a pharmacist and senior lecturer at the University of Huddersfield, who has worked on Nice guidelines and is on the editorial board of the British Heart Foundation's Heart Matters. Here, he answers your questions on drug selection post-MI, and lifestyle choices to reduce the risk of cardiovascular disease:


1. What is the latest guidance on using ACE inihibitors after MI? Should they be started immediately or a few days later?

Large-scale trials indicate that, in post-MI patients, between five and 45 lives are saved per 1,000 patient-years of treatment with ACE inhibitors. Greater efficacy is seen if higher risk groups are treated (eg patients with heart failure).


The conclusions are that ACE-inhibitors should be given in the following circumstances:

  • when myocardial infarction is, at any time, complicated by left ventricular failure
  • in the presence of left ventricular dysfunction.

It is probably best to start ACE-inhibition about a week after the myocardial infarction. Earlier administration of within 24 hours of infarction is only advisable is the patient is clinically stable and has a systolic blood pressure greater than 100mmHg.


Evidence concerning the benefits of ACE-inhibition in stable coronary heart disease and no apparent heart failure is provided in trials such as HOPE and EUROPA, showingreduced all-cause mortality, myocardial infarction, and stroke. As a result it was recommended that angiotensin converting enzyme (ACE) inhibitor therapy should be given to all patients with an acute coronary syndrome irrespective of the presence of heart failure or left ventricular dysfunction.


The latest updated guideline published by the Scottish Intercollegiate Guideline Network (Sign) for acute coronary syndrome (February 2013) advises that patients with clinical myocardial infarction should be commenced on long term angiotensin converting enzyme inhibitor therapy within the first 36 hours.



2. Information on salt and cardiovascular risk seems to change regularly. What are the current recommendations and how important is it?

Eating too much salt contributed to 2.3 million deaths from heart attacks, strokes and other heart-related diseases throughout the world in 2010. This represents 15 per cent of all deaths due to these causes, according to research presented at the American Heart Association's Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions.


Last year, a large observational study (PREVEND) was published, involving 5,556 men and women from the general population of Groningen, Netherlands. This highlighted that those having a high-salt diet for several years are more likely to develop high blood pressure.


Reducing salt consumption is an important factor in helping to tackle avoidable premature mortality from coronary heart disease and stroke, and is a priority of the Responsibility Deal Food Network. For example, according to Nice a 3g reduction in mean daily salt intake by adults (to achieve a target of 6g daily) would lead to around 14,000 to 20,000 fewer deaths from CVD annually; this would also save around £350 million in healthcare costs. Fortunately, salt consumption has been declining steadily (down 15 per cent overall) over the past decade, with around a half gram reduction between 2008-11.


Salt levels in many of our staple foods have reduced significantly, by 40 to 50 per cent or more, and since 2007 more than 11,000,000kg of salt have been removed from foods covered by salt reduction targets. However, average salt consumption remains high at around 8.1g /day, so there is a long way to go to meet the population goal of less than 6g (about one level teaspoon) of salt per day for adults.


The food network has just published its new Salt Strategy beyond 2012, which sets out the direction of travel towards making further progress in reducing salt in the nation's diet.


The approach is purposively designed to take a holistic approach to salt reduction. It will enable everyone in the food industry, health organisations and wider to play their full part.


The strategy comprises four key areas:

  • Revising the 2012 salt targets for over 80 categories of food by the end of the year to encourage companies to reformulate recipes
  • Encouraging the out of home sector to do more – by setting new maximum targets for the most popular dishes
  • Asking companies to use their influence in the market – through promotional and other activities – to encourage people to choose lower salt options
  • Getting more companies across the food industry to sign up to salt reduction.

A dietary sodium intake of less than 6g daily or less is recommended as a non-pharmacological intervention in the management of hypertension. If dietary sodium is reduced from 10g per day to 5g per day, then it would be expected that there would be an average reduction in blood pressure of 3-5mmHg.


It is important to bear in mind however that dietary sodium restriction can also increase the efficacy of certain classes of antihypertensive agents - especially ACE inhibitors and probably beta blockers.


Pharmacists should also advise those who have been put onto a low sodium diet to be warned that food will appear to have reduced taste for about four to six weeks – however, after this period their sense of taste will readjust and they will begin to taste food again.

The recommended daily allowance for salt and elemental sodium intake is as follows:

Age

Max. salt per day

Max. sodium per day

1-3 yrs

2g

0.8g

4-6yrs

3g

1.2g

7-10 yrs

5g

2g

11 and older

6g

2.5g

Adults

6g

2.5g


Pharmacists are recognised to have a key public health role and should take the opportunity to provide health information to patients about the dangers of high salt intake, the benefits of reducing consumption and also advise on practical measures on how to do this.


Opportunities may arise when offering healthy living advice, counselling patients when supplying medicines, as part of MURs or the NMS (in England), discharge medicines reviews (in Wales) or chronic medication service (in Scotland).


3. Should cardiovascular disease prevention focus on older patients?

Cardiovascular disease (CVD) still remains the biggest killer in the UK according to the British Heart Foundation. It results in almost 180,000 deaths from CVD each year, with around 80,000 deaths from coronary heart disease (CHD) and 49,000 from strokes.


Furthermore, CVD caused around 46,000 premature deaths in the UK, of which 68 per cent were men. Interestingly around one in three adults in England and Scotland are hypertensive and nearly half of them are not receiving treatment. In terms of blood cholesterol levels around six in 10 adults in England have high cholesterol (5mmol/l or above). In 2009, CVD cost the UK health care system £8.7 billion with a total cost to the UK economy of £19bn - a huge financial burden.


There also continues to be regional and socioeconomic differences in both incidence and case fatality, along with behavioural inequalities and ethnicity. Regular smoking is more prevalent amongst the lower socioeconomic groups, while higher income individuals are more likely to eat fruit and vegetables and take physical activity. The UK also has a high prevalence of heavy drinking among adults compared with the rest of Europe.


Although mortality rates have fallen over the years, the prevalence of some of the medical risk factors for CVD, including type 2 diabetes and obesity, has increased. If left unchecked, these increase the risk of undoing the good work of the preceding decades. There are already signs that some of the improvements in behaviour, such as dietary choice, smoking and physical activity, have stalled and it is only with continued resolve that we will be able to maintain these healthy behaviours.


Everyone is at some risk of developing CVD, and by identifying that risk early and taking steps to reduce it, through wider and effective use of the government's NHS Health Check programme, this could vastly improve the chances of maintaining or improving health with age. This is why the NHS health checks are rightly offered at an early age of 40 years and upwards. The whole intention is to improve life expectancy and reduce health inequalities by engaging with individuals to consider their modifiable risk.


Experts estimate that between 80 to 90 per cent of deaths from CVD in people under the age of 75 years could be prevented by making lifestyle changes such as stopping smoking.


Dr Mahendra Patel answers more question on cardiovascular health in part 1 of the Expert Q&A, focusing on hypertension and statins

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