32 | Nursing in Practice | Winter 2023
IN FOCUS : INTERVIEW
Tackling CVD together
Delyth Rucarean , chair of the British Society for Heart Failure ( BSH ) Nurse Forum and an advanced heart failure nurse practitioner in Wales , gives Nursing in Practice editor Carolyn Scott her perspective on current priorities in cardiovascular disease prevention and management
Where are we now regarding cardiovascular disease , from your point of view ? We know cardiovascular disease ( CVD ) is very common , with really high mortality rates , and that it is the largest cause of premature death in areas of deprivation across the UK . The rate of death from acute events such as heart attacks has fallen in recent decades , but the number of people living with heart conditions and associated risk factors has risen , possibly linked to the 1950s baby boom translating into a peak of people in their 70s with CVD .
Looking at heart failure , for example , we know prevalence is set to double by 2040 . 1 Currently , we have a million people in the UK with heart failure and 200,000 people receiving a new diagnosis each year . We also estimate there are some 385,000 people living with undiagnosed heart failure 1 who are consequently are missing out on life-preserving treatments . But we can make a big impact in the NHS in the next 10 to 25 years .
The BSH ’ s ‘# 25in25 ’ quality-improvement programme aims to help reduce heart failure deaths by 25 % in the next 25 years . 1 This could translate to 10,000 lives saved each year . There will be a pilot phase in 2024 and the initiative will roll out nationally in 2025 . It aims to improve population health by identifying undetected heart failure , based on four domains : risk analysis ; accurate and timely diagnosis ; guideline-directed medical therapy ; and patient quality of life measures such as mental health and wellbeing .
There will be a focus on health inequalities by tackling access , patient experience and improving outcomes in under-served communities .
While 80 % of people are diagnosed in hospital , 40 % of them have symptoms that might have triggered concern earlier through assessment in primary care . 2 I often see patients in hospital who have had leg oedema or breathlessness for several months that they have put down to other things such as ‘ getting older ’. They may not recognise their symptoms as potentially indicating heart failure .
This is highlighted by the BSH ’ s ‘ The F Word ’ campaign , which encourages people to recognise the common heart failure symptoms of Fighting for breath , Fatigue and Fluid build-up . 3 This provides an earlywarning system for symptoms leading to heart failure , and encourages prompt diagnosis and referral .
What ’ s being done across the UK in cardiovascular disease ? A range of things is being done to help with this sizable challenge , such as the national cardiovascular disease programme alongside the NHS Long Term Plan , which looks to promote early detection and treatment optimisation , and identify undetected and high-risk conditions , such as high blood pressure , raised cholesterol and atrial fibrillation ( AF ). 4
Nationally , we are looking at improving data flow and referral across pathways between primary secondary care . In Wales , for example , we have the Welsh clinical portal , which enables us to share information between hospital and community settings . 5 From the hospital side , we can ’ t necessarily see all the GP consultations but we can see the medications issued , blood test results and so on . Within our area , nurses in general practice can see hospital discharge letters and clinic letters , and the results of tests done in hospital , such as bloods , chest X-rays and echocardiography .
A more collaborative approach is needed between primary and secondary care , local authorities and voluntary sector partners and others such as community pharmacies . We ’ ve been working in silos for too long , and we need to change the way we deliver healthcare . More community pharmacists are offering hypertension checks and health-check services , for example .
I think it ’ s useful to be aware of the new national cardiovascular disease prevention audit for primary care – the CVDPREVENT audit . 6 This will pull out routinely recorded but anonymised GP data , to enable GP practices to identify individuals whose treatment can be improved or risks reduced . This will help to address inequalities and improve outcomes for individuals and populations .
It will focus on six high-risk conditions that cause stroke , heart attack and dementia : AF ; high blood pressure ; high cholesterol ; diabetes ; non-diabetic hyperglycaemia ; and chronic kidney disease . It also has a range of online resources for patients .
Testing and evidence There is much work to be done . Better identification and management of AF is a priority to reduce stroke risk – there are a lot of people with undetected AF , putting them at high risk of stroke . Then there ’ s a need to expand access to genetic testing for familial hypercholesterolaemia , and – coming back to heart failure and heart valve disease – increase access to diagnostic tests .
We need greater access to echocardiography within primary care settings , not just in secondary care . The gold standard for diagnosing heart failure is an echocardiogram , but I think we also need to ensure access to the B-type natriuretic peptide ( BNP ) blood test , which is recommended by NICE for the assessment of suspected heart failure . 7 It ’ s a simple , cheap test – it ’ s not diagnostic but it will help rule out heart failure in a patient presenting feeling breathless .
It ’ s important that we all ensure that we are aware of what ’ s in the NICE guidance , and that we are all working to that evidence-based approach .
It ’ s also great that we have a national network of trained community first responders and defibrillators , known as GoodSAM . 8 This is a large system that integrates with ambulance services and computer-aided
A more collaborative approach is needed – we ’ ve been working in silos for too long , and we need to change how we deliver healthcare