An innovative Focus session was held on Tuesday morning to provide practical guidance to clinicians regarding implementing prevention in people at high risk and patients with established cardiovascular disease. The session was chaired by Professor Viviane Conraads and the 3 speakers provided perspectives from general practice, cardiology and nursing. Dr. Martin Scherer provided a case of a 36 year old woman with increased risk factors, including a very heavy smoking habit. This case was especially useful given the data from 4 French Registries (reported Monday by Professor Nicolas Danchin) that showed that the proportion of female STEMI patients under the age of 60 more than doubled, and that in 2010, 73% of these younger women were smokers. Dr. Scherer talked about his approach to the woman in general practice, emphasising the importance of good communication and being there for the patient for the long term. Although a young woman’s absolute risk may be very low despite her risk factors, the SCORE risk assessment system provides a method for determining relative risk and ‘risk age’ in the young. The initial approach was to support lifestyle changes rather than begin with medications, which sparked some debate among the speakers and audience. Professor Joseph Niebauer provided data on the benefits of exercise training as a means of tackling risk in the person for whom primary prevention has not been successful: the patient with established coronary artery disease (CAD). The case presented by Professor Niebauer was a 61 year old man with multiple risk factors including diabetes, and 3-vessel CAD. Professor Niebauer discussed that exercise would improve all of the patient’s risk factors, and described the exercise training strategies that could be used in rehabilitation. He also discussed the current evidence supporting submaximal aerobic exercise and interval training. He provided some examples of interval training undertaken with patients in his facility, including staff-patient football (soccer) matches. Professor Niebauer noted that patients who are older, who have NSTEMI, and multiple comorbidities are less likely to be referred, and ended with an emphatic message of the need to increase referral to cardiac rehabilitation. Professor Christi Deaton completed the session by talking through strategies to support behaviour change. Using a primary prevention case of a 40 year old man with multiple risk factors, and an 83 year old woman post NSTEMI, she advocated a person-centred approach using cognitive behavioural strategies such as helping the patient to determine their own realistic goals, build their confidence in achieving lifestyle changes, problem solve, self-monitor, and engage family and friends in support. These approaches can be effective even in brief encounters and all providers should give feedback and positive recognition for changes. However, spending a longer time to work with patients to develop their goals, plans and strategies to overcome barriers could be the responsibility of nurses and allied professionals. The new prevention guidelines strongly recommend the integration of nurse-coordinated programmes into health care systems to provide patient support, and there is increasing evidence regarding the effectiveness of this approach. Consistent with Dr. Scherer’s presentation, she emphasised that behavioural change takes time and sustained support would be needed. The audience was engaged throughout with provocative questions, and discussion at the end ranged widely from establishment of ‘prehabilitation’ for people at high risk, to the need to promote healthier lifestyles at a societal level beginning with school-age children. Professor Conraads closed the session by re-iterating the importance of all providers taking responsibility for prevention, and urged the audience to educate their colleagues.
Prevention in the multi-risk patient: how to put Guidelines into clinical reality
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