Heart Health Cardiovascular (CV) disease (which means everything pertaining to and involving the heart and blood vessels) is the leading cause of death in New Zealand, accounting for more than 33% of deaths annually. Every 90 minutes one New Zealander dies as a result of CV disease. Simply getting older increases a person’s risk and males are more likely than females to develop CV disease, although the risk for women increases after menopause. CV disease is more likely to develop in people with a family history of type 2 diabetes or premature coronary heart disease or ischaemic stroke in a firstdegree relative. Personal history factors that also increase risk include: • diabetes or prediabetes (see also Diabetes) • high blood pressure (BP) • high cholesterol and high density lipoprotein (HDL) ratio of 7 • kidney disease (eGFR less than 60 ml/min/1.73m 2 ) • obesity: a BMI of 30 or more or truncal obesity (see also Weight Loss) • smoking or a history of smoking within the last 12 months • women with a history of gestational diabetes or polycystic ovary syndrome. Several non-traditional risk factors have also been identified including high blood levels of C-reactive protein (CRP), lipoprotein A, fibrinogen or homocysteine. Cardiovascular Disease Risk Assessment (CVDRA) All men should have a CVDRA from at least the age of 45 and women by the age of 55. If risk factors are present, or the person is Maori, or from the Pacific Islands or Indian subcontinent, a CVDRA should be carried out at 35 (men) or 45 (women). These assessments may be free for certain people. Annual assessments are recommended for people with diabetes, those on lipid or blood pressure medication, and in people with risk factors of clinical concern. Refer customers who fit these criteria to their doctor. During this check-up, the doctor will determine their five-year risk of having a heart attack or stroke. Risk ranges from mild (less than 10%) to very high (20% or over). Anybody who has had a previous CV event, such as a heart attack, stroke, transient ischaemic attack (mini stroke), angina or narrowing in the arteries of the legs is at clinically high risk. Your Heart Age Forecast (available through www.knowyournumbers.co.nz) can help a person forecast their risk of having a heart attack or stroke as they get older. Successful interventions can dramatically reduce CV risk. Signs of a heart attack Heart attack symptoms are not always described as painful, and may be described as a heaviness, tightness, pressure or discomfort in the upper half of the torso, neck, or arms. Call an ambulance for anybody with symptoms that are not relieved with rest or appear to be getting worse. Cholesterol Cholesterol is a white, waxy substance manufactured naturally mainly by the liver. It has a crucial role in the production of steroid hormones (eg, testosterone, oestrogen) and absorption of fat soluble vitamins. Its largest use is as a vital building block of the body’s cells. People with too much cholesterol generally do not have any symptoms until a major event occurs (eg, heart attack or stroke). This highlights the importance of regular screening tests for cholesterol, TREATMENT OPTIONS Category Examples Comments Cholesterol and triglyceride treatments Blood pressure treatments Antiplatelet agents Natural / herbal products / supplements [PRESCRIPTION MEDICINE] eg, acipimox, atorvastatin, bezafibrate, colestipol, ezetimibe, gemfibrozil, nicotinic acid, pravastatin, simvastatin [PRESCRIPTION MEDICINE] Includes beta-blockers, diuretics, ACE inhibitors, angiotensin II antagonists, calcium channel blockers, alphablockers and nitrates [GENERAL SALE] eg, Aspirin (Aspec 75mg*, Cartia*, Ethics Aspirin) [PRESCRIPTION MEDICINE] eg, clopidogrel, dipyridamole, prasugrel, ticagrelor Co-enzyme Q10, English walnut, fish oil, Ginkgo Biloba, quercetin, red krill oil, resveratrol Statins (eg, atorvastatin, pravastatin, simvastatin) reduce LDL cholesterol, total cholesterol and triglycerides (moderately) and increase HDL (very moderately). Report any muscle pain promptly to a doctor. Fibrates (eg, bezafibrate) decrease triglycerides effectively, increase HDL cholesterol and improve cholesterol moderately. Colestipol binds cholesterol preventing its absorption into the blood. Mainly lowers LDL but can increase HDL slightly. Most people will need more than one medicine to reduce their blood pressure sufficiently. As this condition generally has no symptoms, compliance can be a problem. Despite the fact aspirin can be bought on general sale, it is important people discuss taking it with their doctor. Usual daily dosage is 75–150mg to help prevent heart attacks and stroke. Aspirin is contraindicated in those who are sensitive to aspirin or NSAIDs, have a peptic ulcer, have bleeding risks or have uncontrolled high blood pressure (See also Reference Section, OTC Medicines – Precautions). Walnuts and other nuts may reduce risk of coronary heart disease. Fish oil may reduce mortality in some people with congestive heart failure. A higher dietary intake of quercetin has been associated with a reduced risk of death from coronary heart disease. Red krill oil is a source of phospholipids, omega-3 fatty acids and antioxidants. Products with an asterisk have a detailed listing in the Heart Health section of OTC Products, on page 245. Significant learning opportunity: Wound care Your new Group 3 CPD project Page 92 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION especially for people at high risk. There is only one type of cholesterol; however, a standard cholesterol test measures the different carriers that transport cholesterol around the body. There are two types of carriers: LDL (low density lipoprotein) transports cholesterol around the body and through blood vessels and HDL (high density lipoprotein) transports cholesterol back to the liver where it is broken down. Traditionally, LDL cholesterol has been termed “bad cholesterol” and HDL cholesterol has been described as "good cholesterol". Recently, experts have recognised the need for a better lipid target than LDL cholesterol that more accurately reflects the amount of cholesterol within all lipid-containing particles. Some countries now report non-HDL cholesterol, in addition to HDL cholesterol and total cholesterol. Most of the cholesterol contained in our bloodstream is manufactured within our body, with only a limited amount coming from diet. Experts no longer suggest an upper limit for daily dietary cholesterol consumption because available evidence does not show a relationship between dietary intake of cholesterol and serum cholesterol. Alcohol excesses, high sugar or fructose-containing diets, hypothyroidism, diabetes, liver disease, nephrotic syndrome and steroid treatment can also influence lipid levels. Any identifiable cause of a raised cholesterol should be treated and a diet high in vegetables should be encouraged for everyone, not only those people with high cholesterol. A rise in cholesterol is normal in pregnancy and a cholesterol level should not be measured at this time. What is blood pressure? BP is usually measured from the arm with a device called a sphygmomanometer which may be manual or electronic. An inflatable cuff creates pressure on the arm causing the blood flow to stop briefly in the arm. As the air is released from the cuff, blood starts to flow again through the artery. The first recording is called the systolic pressure and it measures the force the heart has to pump against (resistance) to get the blood to flow around the body (indicated by the pressure around the arm, which stops the blood flow). The second sound recorded is the diastolic pressure. This measures the resting pressure when the heart relaxes. High BP (hypertension) affects nearly one in five New Zealanders, and is more common in older age groups. Most people have no symptoms, even if their BP is quite high, although some people may develop a headache or feel unwell. BP should be checked regularly, as part of a cardiovascular risk assessment. Persistent high BP can cause the heart to enlarge and weaken. It also contributes to blood vessel damage, especially in people with diabetes, high cholesterol or who smoke. If blood vessels become narrowed or blocked, a heart attack or stroke may occur. High BP is also linked to kidney and eye damage, and poor circulation in the arteries of the legs. A “normal BP” is generally stated as 120/80mmHg. Ideally, a person’s BP should be below 130/80mmHg, although actual recommendations vary depending on individual risk factors. Lifestyle changes (eg, improving diet, limiting alcohol, exercising, losing Refer to DOCTOR • Refer all customers with CV risk factors to their doctor for ongoing monitoring and treatment. • Get urgent medical attention for any customer with chest pain. weight, smoking cessation) should be made alongside BP medication (if needed). Sleep apnoea (see Sleep Problems and Snoring), use of certain medicines (eg, oestrogen, anti-inflammatory agents), and other disorders can also impact on BP and should be corrected if possible. Initial assessment If a customer complains of chest pain or discomfort, provide them with a chair to sit on and ask if they take pills or a spray for angina. Call both an ambulance and a pharmacist if rest or their own medication does not relieve their discomfort. Refer any other customers requiring information about CV disease to a pharmacist. Advice to customers • Know your risk of having a heart attack or stroke. Be aware of how healthy your heart is and the effect your lifestyle is having on your body. • Follow the Ministry of Health's Eating and Activity Guidelines. Eat plenty of vegetables and fruit; grain foods (mostly wholegrain and those naturally high in fibre); some milk and milk products (mostly low or reduced fat); some legumes, nuts, seeds, fish, poultry and lean meat. »» Cut back on foods high in sugar, salt, and trans fats. »» Make water your preferred drink. • Partake in at least 150 minutes of moderate or 75 minutes of vigorous intensity physical activity throughout the week. Do muscle strengthening exercises on at least two days per week. Break up long periods of sitting with activity. • Stop smoking, lose weight, keep alcohol intake low, and maintain good blood glucose control if you have diabetes. Visit ELearning to start your project www.pharmacytoday.co.nz Facilitated by Dr Alesha Smith Page 93
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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