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Published on 2 March 2009

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Developing a pharmacist-managed cardiovascular risk reduction clinic

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An innovative risk reduction clinic in Hospital du Sacr-Coeur de Montral, Canada, asked the hospital’s pharmacists to take the lead in improving outcomes for cardiology patients

Chantal Pharand [1],[3],[4]
PharmD

Jean G Diodati [2],[3],[5]
MD

1. Pharmacy Department
2. Cardiology Division
3. Research Centre Hopital du Sacr-Coeur de Montral
4. Faculty of Pharmacy
5. Faculty of Medicine Universit de Montral
Montreal
Quebec
Canada

Cardiovascular disease is one of the major causes of death in the industrialised world.[1] In North America, the prevalence of modifiable risk factors for cardiovascular disease, such as smoking, hypertension, diabetes mellitus, obesity and dyslipidaemia, remains high. In Canada, as many as eight in 10 patients present with at least one of these risk factors, while one in 10 presents at least three.[2]

Optimisation of therapy is achieved through attaining therapeutic targets, as defined in consensus guideline reports published by international societies. However, these target values are rarely achieved in patients with coronary artery disease, as demonstrated in several large trials such as EUROASPIRE I and II (published in 1997 and 2001 respectively).[3-5] Moreover, despite the publication of the Joint European Societies Report on Coronary Prevention in 1998, no noticeable improvement has been observed with regard to risk factor control between these two cohorts;[5] for example, higher rates of smoking and obesity were observed in EUROASPIRE II.[4] Hence, these results and others suggest  that current clinical practice does not allow adequate management of risk factors in secondary prevention of cardiovascular disease.

In Canada, the healthcare system suffers from a shortage of physicians, exacerbated by the ongoing ageing of the population.[6-8] In the province of Quebec various approaches were adopted in a bid to palliate the relative lack of medical resources. Such measures included Bill 90, which gives various health professionals a wider allowable range of actions within their respective fields.[9] For the pharmacist, such measures
translate into the right to initiate or adjust a patient’s pharmacotherapy according to a prescription (called a “collective order”), and if necessary to utilise laboratory analyses.[10] Hence, pharmacists are now able to follow some of their patients pharmacotherapy more closely and adjust it if necessary.

The risk reduction clinic at Sacra-Coeur
At Hospital du Sacra-Coeur de Montral (HSCM) in 2001, some 80% of all patients evaluated in cardiology presented with two to four risk factors for cardiovascular disease and 50-60% did not reach target values in terms of lipid profile. In order to
improve this situation, in 2006 we developed a multidisciplinary risk reduction clinic. Although several similar programmes are currently running in North America and elsewhere, HSCM’s risk reduction clinic is unusual in that from the start it had been decided that it would be run by a pharmacist, in view of the shortage of physicians and specifically of cardiologists in the hospital.

This clinic’s main objective is to follow all patients discharged from the hospital after an acute coronary syndrome in order to improve attainment of target values for six major risk factors: dyslipidaemia, hypertension, diabetes mellitus, smoking, obesity and physical inactivity. In addition to the pharmacist, the clinic
includes a cardiologist and a nurse. However, several other health professionals are involved on a referral basis: an endocrinologist, a nutritionist, an exercise specialist and a smoking cessation specialist.

All patients admitted to the hospital with an acute coronary syndrome are referred to the clinic. About six weeks after  hospital discharge patients are scheduled to return to the hospital to give blood samples, and are then expected see their cardiologist about two weeks after that. The first risk reduction clinic appointment is scheduled for three months after discharge. At their first visit to the clinic patients meet the cardiologist and pharmacist together. A therapeutic plan is decided upon jointly and therapeutic adjustments are prescribed
if necessary. If target values for some of the risk factors are not achieved at the first visit or changes are ordered to medication, a follow-up visit is scheduled with the pharmacist alone. Additional changes to the therapy may be ordered by the pharmacist at that time, based on a collective order, or reference to one of the consultant specialists may be requested if needed. The pharmacist will follow patients periodically until target values have been achieved for all six risk factors. Patients will then be seen jointly by both the pharmacist and cardiologist every year thereafter, or if any issues present that requires the expertise of the cardiologist.

[[HPE41.61]]

Figure 1. Example of a drug adjustment protocol for managing dyslipidaemia

In order to allow pharmacists to implement the required therapeutic changes in the absence of a physician, drug adjustment protocols (Figure 1) and collective orders (Figure 2) were written for lipid, hypertension, and smoking cessation management and approved by the hospital administration.

[[HPE41.62]]

Figure 2. Example of a collective order for dyslipidaemia management

In addition to the cardiologist and pharmacist, a nurse is actively involved in the clinic. She is responsible for organising the clinic (including appointments, blood withdrawals and requests for follow-up with consulting specialists), in addition to answering phone calls from and participating in individual teaching programmes provided to patients.

In conclusion, optimal cardiovascular risk-factor management is essential to decrease the morbidity and mortality associated with the recurrence of coronary events. Several models can be put in place to allow optimisation of therapy. With their professional training, pharmacists are well suited to undertake the role of the pivotal agent in this setting.

References
1.
Heart and Stroke Foundation of Canada. The changing face of heart disease and stroke in Canada 2000. Ottawa: HSFC; 1999. Available online at: www.phac-aspc.gc.ca/ ccdpc-cpcmc/cvd-mcv/publications/pdf/card2ke.pdf
2.
Heart and Stroke Foundation of Canada. The growing burden of heart disease and stroke in Canada 2003. Ottawa: HSFC; 2003. Available online at: www. cvdinfobase.ca/cvdbook/CVD_En03.pdf
3.
EUROASPIRE Study Group. A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results. Eur Heart J 1997;18:1569-82.
4.
EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries: principal results from EUROASPIRE II Euro Heart Survey Programme.Eur Heart J 2001;22:554-72.
5. EUROASPIRE I and II Group. Clinical reality of coronary
prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001;357:995-1001.
6. Stafford L. 4,5 millions de Canadiens nont pas de madecin de famille. Communiqu du coll¨ge des madecins de famille du Canada 20 May 2003. Available online at: www.cfpc.ca/French/cfpc/communications/new
s%20releases/2002%2011%2007/default.asp?s=1
7. Para I. Ã’ude du colla¨ge des madecins: de moins en moins de mdecins à temps plein. Le Devoir 23 May 2002. Available online at: www.ledevoir.com/2002/05/23/1692.html
8. Fournier M-A, Contandriopoulos A-P. Caractristiques des mdecins du Qubec et de leur pratique selon le temps consacr à leurs activits professionnelles. GRIS: Groupe de Recherche Interdisciplinaire en Sant February 2005. Available online at: www.gris. umontreal. ca/rapportpdf/R05-01.pdf
9. Lorquet E. Projet de loi n° 90: un nouveau cadre juridique pour le partage des activités professionnelles. Le Collège 2003;43;3:6-12. Available online at: www.cmq.org/DocumentLibrary/UploadedContents/loi90.pdf
10. Assemble Nationale. Projet de loi n° 90 : Loi modifiant le Code des professions et dautres dispositions lgislatives dans le domaine de la sant. 2002. Éditeur officiel du Qubec. [cited 2007 Oct 15]. Available from: http://www2.publicationsduquebec.gouv.qc.ca/
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