Evaluation of risk factor modification management in patients with coronary heart disease and patients´ experiences of secondary prevention

Abstract: Aim: To evaluate management of risk factor modification among patients suffering from coronary heart disease and to explore patients experiences of secondary prevention. Methods: After establishing a secondary prevention programme, patients were offered follow-up visits to a nurse, one year after the coronary event for evaluation of various risk factors associated with recurrence (I, II). Self-report of smoking cessation was validated against biochemical markers for smoking, cotinine in plasma and carbon monoxide in expired air (III). Factors that can predict who will resume smoking after an acute coronary syndrome were identified (IV). An in-depth interview with a narrative approach and hermeneutical analysis was conducted in patients after a myocardial infarction (V).Results: The evaluation showed that 70% of all patients had one or more of the following risk indicators; s-cholesterol >6.5 mmol/l (30%), s-triglycerides >3.0 mmol/l (19%), fasting blood glucose > 6.7 mmol/l (29%), systolic blood pressure >160 mmHg (9%), diastolic blood pressure >90 mmHg (8%) or smoking (36%), compared with 67% at follow up (I). No change in mean body weight was observed (I, II). Over time a substantial lowering of serum lipids was observed parallel to a three-fold increase in the use of lipid-lowering drugs. Out of 1320 patients, with acute coronary syndromes (IV), 434 (33%) were current smokers. Three months after discharge 51% of those were still smoking. Six factors were independently associated with smoking at follow-up: non-participation in the cardiac rehabilitation programme, treatment with sedatives or antidepressants at time of admission, a previously known cardiac event or cerebral vascular disease, smoking related pulmonary disease and high average cigarette consumption. Of 260 former smokers, 17 (6.5%) had biochemical markers that contradicted their self-report. The experiences of patients following a first myocardial infarction were described as impact of medication and impact of health professionals (V). Patients interpreted bodily symptoms as a consequence of being medicated rather than as a result of their heart attack. The medication led to feelings of being intruded upon but also to feelings of security. The communication with different physicians and other health professionals led to some perplexity about the illness and its treatment. Patients expressed a need of being reassured by the physician regarding their physical health status. Conclusions: The findings indicate difficulties in the management of risk factor modification in secondary prevention. Although there has been a marked improvement in serum lipids levels by increased use of lipid lowering drugs, there are still problems with modification of life style related risk factors, such as overweight and smoking. With even lower treatment targets for hypertension there is a potential for improvement of this risk factor as well. Self-reported smoking cessation and biochemical markers corresponded in the majority of cases. Following a first myocardial infarction, care of patients has to be considerated regarding the impact of the pharmacological treatment on patients life. The point initiation in secondary preventive work must be patients beliefs about their condition and the treatment they receive.