Apr 04, 2014
Preventing cardiovascular disease in women
The Women’s Healthy Heart Initiative Clinic, three years on
The Women’s Healthy Heart Initiative clinic was launched in 2009 at the McGill University Health Centre to provide women with comprehensive primary prevention care. The mission of this nurse-led clinic is to increase awareness among women of their risk of heart disease and to empower them to be proactive in achieving heart health. In this article, the author discusses the findings from an analysis of clinical measures in the clinic’s first three years of operation. The clinic has helped patients reduce their blood pressure, cholesterol levels and weight. The clinic’s nurses have gained insights into the importance of self-referral and family history in preventive care. The results demonstrate the effectiveness of this collaborative care model in heart disease prevention.
Cardiovascular disease is responsible for 30 per cent of deaths in women in Canada (Statistics Canada, 2011), but many women continue to be unaware how great a threat it poses to their health and lives and that it is a largely preventable disease (Heart and Stroke Foundation, 1997). Many women ignore the symptoms of heart disease and fail to make changes to lower their risk. Given how much we know about how to identify those at high risk and that so many treatments have been shown to reduce risk, this ignorance is tragic. As health-care providers, we have a responsibility to find creative ways to address this problem.
As a nurse clinician working in cardiology outpatient clinics, I knew first-hand that not enough cardiovascular disease prevention services were available in my hospital, particularly for women. Women often told me that their physicians were not addressing cardiac health concerns with them or that they were not getting the disease and lifestyle information they wanted. Also, many of the female patients for whom I provided care were unaware of the cardiovascular risks they faced. Clearly, the conventional cardiovascular prevention models were not working at our hospital. The challenge was to design a better one.
The Women’s Healthy Heart Initiative (WHHI) clinic was launched in 2009 at the Royal Victoria Hospital, a tertiary care institution within the McGill University Health Centre (Wray, 2010). We had developed a nurse-led preventive care approach that empowered women age 45-65 to improve their cardiovascular health within an atmosphere in which their individual needs would be respected. We wanted to blend the skills and objectives of the nurse with those of the cardiologist, to be holistic and health oriented as well as disease oriented, by having nurses and physicians work together collaboratively. How has our approach worked? Very well, it turns out. We have taken a look back over our first three years in operation, and in this article I share our findings.
The WHHI clinic
Nurses conceived and organized the clinic, which focuses on disease prevention and lifestyle management, and continue to direct it. Two cardiologists work together with two cardiac nurses in the clinic. Each nurse has at least 15 years of cardiology experience and receives several months of ongoing intensive preceptorship and advanced cardiac training with the cardiologists when first joining the clinic, gradually assuming more responsibility for patient care. We provide participants with ongoing coaching and counselling to encourage them to engage in regular physical activity, lose weight, moderate their alcohol consumption, improve their nutrition, decrease their sodium intake and stop smoking. We use motivational interviewing to enhance behavioural change (VanBuskirk & Wetherell, 2013). This approach tailors the lifestyle interventions to the individual, placing the control with the participant while we help her to identify and deal with barriers to change. Our goal was to enrol 200 women in the clinic in the first three years.
Three years after we launched the clinic, we took stock of how we were doing. Our institution’s ethics committee did not require that we obtain patient consent for our review because it represented a routine assessment of aggregate clinical outcomes. We included those patients whose electronic medical records contained all of the data of interest, including presence of a family history of cardiovascular disease, presence of diabetes, and weight, body mass index, blood pressure and lipid levels at the time of the patient’s first visit and most recent visit. In addition, we reviewed the results of a patient satisfaction survey we conducted in 2011. The questionnaire, consisting of four open-ended questions, was completed anonymously. We received 67 responses.
For patients with hypertension (defined as blood pressure >140/90 mmHg; Hypertension Canada, 2013), we calculated the difference between initial and most recent blood pressure measurements. In addition, we determined how many patients with hypertension were able to lower their blood pressure to this threshold or below. Diagnosis of hyperlipidemia and target levels of low density lipoprotein cholesterol (LDL-C) and apolipoprotein B (ApoB) were based on the most recent guidelines of the Canadian Cardiovascular Society (Anderson et al., 2013). We analyzed differences between initial and most recent lipid measurements in patients with hyperlipidemia and determined how many of them reached target levels. The statistical significance of differences was determined by paired t-test.
During the clinic’s first three years of operation, we enrolled 338 women. We examined the records of the 317 patients for whom all data of interest were available. The study period was between May 2009 (the month the clinic opened) and December 2012. The average age was 57 (range 31-83). Most of the women (76.3 per cent) had a family history of cardiovascular disease, and this was by far the most common reason for enrolment. The next most common reasons were concerns about chest pain, shortness of breath and palpitations.
Sixty of the 317 patients lost weight, achieving a combined loss of 582 lbs. The average body mass index decreased from 28.1 to 27.4.
Ninety-one (28.7%) of the patients had hypertension. Systolic and diastolic blood pressure decreased substantially for those with both previously diagnosed hypertension (i.e., diagnosed before they first came to our clinic) and newly diagnosed hypertension during the study period (Table 1). With pharmacological and lifestyle therapy, 15 of the 18 patients with newly diagnosed hypertension were able to reduce their blood pressure to 140/90 mmHg or lower, and 12 of them achieved a blood pressure of 135/80 mmHg or lower. Thirty of the 73 with previously diagnosed hypertension had initial readings below 140/90 mmHg; with further care through our clinic, an additional 33 patients achieved readings below this threshold. Sixteen of the 73 had their hypertension under even better control (below 135/80 mmHg) at the time they enrolled in the clinic. By the end of the study period, 51 patients in total had achieved this target.
Both mean LDL-C and mean ApoB decreased significantly in the 67 patients with hyperlipidemia (Table 2). Although we had discussed healthy lifestyle choices with them, those whose LDL-C and ApoB values dropped also had their pharmacological therapy changed over the study period.
Twenty-six of the patients had diabetes (HbA1c ≥ 6.5%); our team diagnosed the condition for seven of these women, all of whom were referred to a diabetes clinic for treatment.
Comments on the 67 completed patient satisfaction surveys indicated that patients were pleased they could access care without a medical referral. They appreciated that their concerns about their heart health were addressed and that individualized tools and support were provided.
The clinic appears to be a considerable success from several perspectives. First, more women chose to participate than we anticipated. Second, our team diagnosed and successfully treated a substantial number of patients with hypertension, hyperlipidemia or hyperglycemia. Third, the weight loss of 60 of the women pointed to important improvements in personal health behaviours. Fourth, the positive feedback from the survey indicated that patients feel acknowledged and valued as individuals.
Study limitations are that the length of the patients’ participation time in the clinic varied and that because we lacked more specific quantitative measures for exercise and nutritional status, we were unable to determine improvements in these areas.
All but five patients were self-referred. The single most important driver for enrolment was a positive family history for cardiovascular disease. Many patients did not have a family physician, and we believe that ensuring access to preventive care that is not dependent on medical referral has been an important ingredient in our success.
The average age of this group was 57. Given that cardiovascular clinical events do not become common in women until they are in their 60s (Go et al., 2013), we are pleased that these patients presented in time to receive effective preventive care. Many told us they heard about the clinic from relatives, friends or work colleagues, demonstrating the importance of women networking with women.
Cardiovascular disease is a major risk factor for premature (i.e., before the age of 65) cardiac events. Chest discomfort, shortness of breath and palpitations were the most common symptoms in this group, and we learned that dealing with patients’ concerns about these symptoms had to take priority. For example, we might be concerned about a patient’s high blood pressure reading, while her focus might be on her atypical chest pain. Only once their symptoms were addressed were patients satisfied and able to move on to deal with identified risk factors.
Patients with hyperlipidemia or hypertension improved their lipid levels or blood pressure through our individually tailored interventions incorporating lifestyle changes and medical management. We believe the frequent one-on-one contacts between nurse and patient were key to the improvements in outcomes.
Some patients told us they felt more motivated to make changes because they knew we were following and documenting their progress. With our electronic database, we can show each one her progress over time; this is especially helpful if someone becomes discouraged or stalled in the process. If a patient knows that change will take time and if she expects to have some setbacks, she will be more realistic in her expectations and will be better able to cope with failures.
We believe that the collaborative role provides us with greater autonomy and a new opportunity to engage in disease prevention. The holistic nature of nursing means that we are ideally suited to provide the ongoing support and counselling necessary for patients to meet the challenge of making successful lifestyle changes. In informal discussions, the cardiologists have told us that our collaborative care model both improves our hospital’s prevention efforts and frees up more of their time so they can focus on ill patients who require their medical expertise.
We hope that by documenting our outcomes and sharing our success in these pages, we can generate enthusiasm within the Canadian nursing community for this model of care and encourage other centres to establish similar clinics. We hope to establish a registry that others could use for research on prevention of cardiovascular disease in women. Although we are facing the difficult challenge of establishing sustainable funding, we believe the effort is worthwhile: we have shown that nurses can play a central role in the prevention of cardiovascular disease, and we know that our clinic is making a difference in women’s health.
The process of care
- Patients can access the services of the clinic without a referral, but some are referred by a physician or a nurse.
- The patient’s 60-minute first appointment is with a nurse, who takes complete medical, cardiac, family and lifestyle histories, conducts a cardiac physical examination and orders a comprehensive panel of blood tests for cardiac screening.
- The nurse evaluates the patient’s cardiovascular disease risk and formulates a plan to improve her overall cardiovascular health, including any medical measures that may help to reduce her risk.
- The patient is seen by a cardiologist, who reviews the findings and assessment of the nurse.
- The nurse and cardiologist together review the case and individualized care plan.
- Consultations are booked with the exercise trainer and dietitian affiliated with the clinic, as well as with any other services the patient requires, such as those offered by the hospital’s endocrinology and gynecology clinics.
- The nurse follows the patient’s progress with regularly scheduled 30-minute appointments and keeps the cardiologist informed. The patient sees the cardiologist again only when necessary. The frequency of appointments is adjusted as needed to accommodate the individual needs of the patient, to reflect her current health status and to encourage her to continue to participate in the clinic.
- An electronic medical record is created for each patient and is accessible to the clinic’s cardiologists and nurses.
Anderson, T. J., Grégoire, J., Hegele, R. A., Couture, P., Mancini, J., McPherson, R.,… Ur, E. (2013). 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Canadian Journal of Cardiology, 29(2), 151-167.
Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Borden, W. B., … Turner, M. B.; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2013). Heart disease and stroke statistics — 2013 update: A report from the American Heart Association. Circulation, 127(1), e6-e245.
Heart and Stroke Foundation of Canada. (1997). Women, heart disease and stroke in Canada: Issues and options. Ottawa: Heart and Stroke Foundation of Canada.
Hypertension Canada. (2013). The 2013 Canadian hypertension education program recommendations.
Statistics Canada. (2011). Mortality, summary list of causes 2008. Cat. no. 84F0209X.
VanBuskirk, K. A., & Wetherell, J. L. (2013). Motivational interviewing with primary care populations: A systematic review and meta-analysis. Journal of Behavioral Medicine. Epub ahead of print.
Wray, W. (2010). The Women’s Healthy Heart Clinic. Canadian Nurse, 106(1), 14,16.