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Hearts in need of some TLC - Medical Observer

Medical & health articles | Medical Observer 7 Nov 2017
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In the latest 'Talking Women' article for Medical Observer, Associate Professor Lynne Pressley discusses how many women are unaware of the risk of cardiovascular disease and how to beat it.

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Jean Hailes is proud to provide a monthly column in the medical newspaper, Medical Observer. Designed to give GPs and health professionals a short informative summary of important women's health topics and conditions, these articles provide practical information to inform and enhance clinical practice.

By Assoc. Prof. Lynne Pressley
MBBS (HONS) BMEDSCI (HONS), DPHIL (OXON), FRACP FCANZ
Interventional cardiologist

Cardiovascular disease is a leading cause of death among Australian women, yet many patients mistakenly view it as a man's disease. Although more men than women die from cardiovascular disease (CVD), one woman dies from it every hour and more than 48,000 women are hospitalised annually, according to the Heart Foundation. Lack of awareness is a major problem; most women simply don't realise they are at risk of CVD and don't know how they can reduce their risk. GPs are on the frontline of detection, prevention and management of CVD but patient awareness and involvement is key.

Risk factors

Patients need to know all the ways in which they can improve their heart health, including, if required, modifying risk factors such as hypercholesterolaemia, hypertension and lack of physical activity. GPs are in the perfect place to advise them. The sooner discussions start with young patients the better, because cholesterol can begin to build up in arteries in childhood and hypertension has been shown to develop as early as age 10. It's important to discuss heart disease with women at times of peak risk, such as pregnancy and postmenopause, and when they have a family history of CVD because these individuals are at significantly greater-than-average risk. We know from health surveys that one in three Australian women has high cholesterol, but only one in 10 is aware of their condition.

Similarly, one in four women in Australia has hypertension, but only two out of three who have it know that they have it. Lifestyle modifications that need to be emphasised include reducing dietary salt and alcohol, increasing physical activity and maintaining a healthy body weight. If this isn't working for a patient, it's usually possible to find a suitable drug that does not give her side effects. Another important risk factor is smoking: one in six women aged 25-34 years smokes, the highest incidence of any age group. If they quit smoking, within two years their risk of CVD is the same as a nonsmoker (although sadly, this doesn't apply to their risk of lung cancer).

Interventions

During pregnancy, when the work of the woman's heart increases significantly, vigilance is required in those with a family history of heart disease, gestational diabetes or hypertension. The development in pregnancy of hypertension, pre-eclampsia, diabetes or small-for-dates babies indicates a much greater risk of a subsequent coronary event. Such women should be followed up postpartum and given all the usual checks such as blood pressure, lipid profile, level of exercise and weight. Absolute cardiovascular disease risk assessment is essential. Encouraging all women to learn about CVD and explaining how lifestyle can play a large role in their future outlook is important, regardless of age. It's helpful to provide the patient with printed resources to take home because they may often forget the details discussed during a consultation.

Having access to a multidisciplinary team (including dietitians) is of great value for patient motivation and support. Losing weight can be difficult, especially as people get older. A number of my patients have had great results from buying pre-packaged, low-calorie meals; others from doing the 5:2 diet. In the first instance, I send them to a dietitian for help and guidance because it can take time to change lifelong eating habits. Likewise, referral to an exercise group or exercise physiologist is of real benefit in helping patients learn new exercise habits and helping them stick to new routines.

Behaviour change

Behaviour change is challenging, takes time and can be difficult. Try to tailor messages to each patient's level of health literacy and lifestyle, both of which may be influenced by their ethno-cultural background. Encouragement and access to a support network can make a real difference. When people make a commitment to do something with someone else — such as walk the dog with a neighbour — then they are more likely to do it. Socially isolated people can benefit by using digital technology such as pedometers or activity trackers to encourage them to be more physically active.

Practice points

  • Healthy weight: BMI for women 18.5-25 kg/m2
  • Smoking: repeated, brief and non-judgemental advice about quitting is effective
  • Nutrition: limit salt intake to 4g/day (1550mg sodium). Encourage plant-based diet with moderate amounts of reduced-fat, low-fat or no-fat dairy products. Moderate amounts of lean, unprocessed meat, poultry and fish. Moderate amounts of polyunsaturated/monounsaturated fats (olive and canola oils)
  • Physical activity: 150 mins weekly, 30 mins daily minimum. Assess comorbidities. Patients with unstable angina, uncontrolled or severe hypertension, severe aortic stenosis, complicated acute MI, uncontrolled diabetes, uncontrolled heart failure, symptomatic hypotension, arrhythmias or resting tachycardia will need clinical assessment prior to physical activity
  • Blood pressure: BP<140/90mmHg, except for those with high cardiovascular risk where SBP<120 mmHg is recommended
  • Lipids: Low-density lipoprotein cholesterol (LDL-C) <2.0 mmol/L, High-density lipoprotein cholesterol (HDL-C) >1.0 mmol/L, Triglyceride (TG) <2.0 mmol/L
  • Alcohol: limit alcohol intake <2 standard drinks daily with 2 alcohol-free days per week.

Conclusion

If women are educated about the risk of CVD and how to reduce that risk, we can not only improve their quality of life but also reduce the economic burden of the disease.

Patient resources

About the author

This article was written by Associate Professor Lynne Pressley (MBBS (HONS) BMEDSCI (HONS), DPHIL (OXON), FRACP FCANZ). Dr Pressley's areas of interest include the management of pregnancy in patients with heart disease, adolescents and adults with congenital heart disease and valvular heart disease. She is Clinical Associate Professor of Medicine at the University of Sydney.

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