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Australian Journal of Pharmacy : March 2005
pharmacy practice foundation research The future burden of cardiovascular disease: what can pharmacists do? Alexandra (Sasha) Bennett, Associate Professor Ines Krass, Professor Jo-anne Brien, Faculty of Pharmacy, University of Sydney With an ageing population, the growing burden of cardiovascular disease on society is expected to increase; it already accounts for almost four in ten Australian deaths.The following article discusses this burden, identifies barriers to treatment and examines how pharmacists can play a more effective role in reducing the prevalence of cardiovascular disease T HE health and economic burden of cardiovascular disease (CVD), (heart, stroke and blood vessel disease) in Australia exceeds that of any other dis- ease.1 CVD was the leading cause of death in 2000, ahead of all cancers and other groups of causes of death, accounting for 39 per cent of all deaths.1 Five per cent of the population has a his- tory of coronary heart disease: angina or myocardial infarction2 heart disease are the leading causes of death followed by stroke.1 and coronary Each year, approximately 40,000 suffer a stroke, with 70 per cent of these being first-ever strokes.1 Death rates from CVD have been declining since 1966 due to: • reduction in the prevalence of risk fac- tors, notably tobacco smoking, hyper- tension and saturated fat intake; and • improvements in disease management including drug use, emergency care, medical and surgical treatment, coun- selling and follow-up care. Nevertheless, cardiovascular risk fac- tors such as tobacco smoking, physical inactivity, hypertension and obesity per- sist in the population. Evidence also suggests that improved preventive and treatment strategies for coronary heart disease have altered the natural history of the disease leading to more chronically affected individuals. It is estimated that more than 500,000 Aus- tralians aged >35 years were affected by angina pectoris (AP) in 2000 resulting in 600,000 angina-related visits to GPs.7 Barriers to optimum diagnosis, management and care It is also estimated that atrial fibrillation (AF) affects more than 2 per cent of the popu- lation aged >45 years and contributes to 600,000 hospital days.8 As the population ages, the prevalence of AP and AF can be expected to rise. Despite reduction in mortality rates from acute coronary events, the incidence and prevalence of heart failure (HF) is also increasing due to the long-term effects of residual damage caused by these coro- nary events and the progressive ageing of the population. In 2000, approximately 325,000 Australians had typical symp- toms of breathlessness and fatigue due to underlying HF.9 A further 214,000 had underlying HF without overt symptoms and were at risk of developing sympto- matic HF and/or dying prematurely with- out appropriate detection and treatment.9 At least 25 per cent of these individuals live in rural and remote regions without adequate specialist services.9 Based on the figures above there are between 25 and 30 HF patients per GP and at least 100 HF patients per commu- nity pharmacy, and these will increase in the future. In view of the likely future bur- den of HF and the importance of pre- ventive strategies to reduce risk factors leading to HF, funding support for com- munity-based programs is imperative. 166 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 MARCH 2005 Despite the recent advances and formu- lation of many consensus guidelines10–16 for optimal treatment of at-risk popula- tions, there is a large body of evidence to show poor transferability of evidence to real-life practice.17–21 Barriers in primary care The complex and chronic nature of CVD is such that patients often require inten- sive education, ongoing supervision and monitoring. However, medical attention is frequently directed at treating the conse- quences of CVDand diabetes, rather than preventive measures such as assessing and modifying risk factors for these condi- tions.6 A metropolitan and rural study deter- mined that while preventive activities for CVD and diabetes are being undertaken in general practice, performance of these activities is less than ideal.22 Doctors iden- tified only 66 per cent of self-reported smokers, 40 per cent of heavy drinkers and 59 per cent of overweight patients. Screening and/or counselling of patients in the consultation were highest for blood pressure (47 per cent) and smoking (34 per cent), and considerably lower for over- weight (22 per cent), alcohol (19 per cent), and cholesterol (6 per cent). Other impor- tant factors contributing to sub-optimal identification and treatment are poor con-