Cardiovascular Disease Prevention & Management in Retail Health

Recent statistics reveal that 85.6 million Americans live with cardiovascular disease (CVD) or residual deficits from stroke. In the United States, CVD is the cause of 1 in 3 deaths and an estimated $320 billion in health care costs and lost productivity in 2011.¹The basis of primary prevention includes screening for modification of CVD risk factors (eg, diet, smoking, hypertension, dyslipidemia, physical activity, obesity, and diabetes). Utilizing evidence-based practice in the management of chronic disease is essential to improving outcomes. Retail health clinicians can influence care outcomes at both of these levels.

Knowledge of past medical history, current medication list, and allergies is essential in treating patients with CVD comorbid conditions. A patient presenting to the retail health clinic with lower respiratory infection, treated hypertension, and obesity, who is also a current smoker, will be managed differently than a patient without these comorbid conditions. Every encounter presents a unique opportunity for the clinician to not only treat the acute episodic condition, but to further partner with the patient for consideration of smoking cessation and lifestyle changes to promote weight loss and lower blood pressure.²

Many prescription or OTC medications have serious interactions with common cardiovascular medications or conditions that can cause harm to the patient. Several antibiotics should be avoided when treating a patient who is currently on cardiovascular medications, such as beta blockers, diuretics, or anti-arrhythmic medications. Azithromycin can cause increased hypokalemia or QT prolongation, both of which can increase the possibility of cardiac arrhythmias. OTC cold preparations that contain pseudoephedrine can interact with antihypertensive medications, causing a dangerous increase in blood pressure.³Clear communication between the retail clinician and the patient’s primary care provider enhance care coordination and follow up.

Acute illness can exacerbate previously stable or unknown CVD and cause a life-threatening crisis. Common CVD diagnoses include angina, pulmonary emboli, hypertensive or hypotensive urgency, and cerebrovascular accident. See theTable^5-9for risk factors and warning signs of these acute processes. Activation of the emergency response system is critical to the patient’s survival. With timely provider triage and appropriate use of automated external defibrillators and oxygen, clinicians can apply life-saving interventions while awaiting arrival of emergency medical services.⁴Every encounter offers the opportunity to promote prevention or management of CVD. Encounters for physicals or acute episodic illnesses can identify cardiac issues (abnormal heart sounds, elevated blood pressure), lifestyle habits (eg, smoking, overuse of caffeine or high energy drinks, recreational drugs, alcohol use), or conditions that contribute to CVD (diabetes, obesity, inflammatory conditions).¹⁰The retail health clinician can begin or reinforce disease management with follow- up by the patient’s primary care provider or specialist. Timely use of motivational interviewing can help to solidify smoking quit dates and dietary, activity, or chronic disease management behavior changes.¹¹

Table: Common Cardiovascular Disease Diagnoses

Cardiovascular Disease Diagnosis

Risk Factors

Warning Signs

Acute coronary syndrome, angina^5,6

Age/gender (highest incidence in men under the age of 70 years and postmenopausal women)

Family or personal history of cardiac event before age 55

Hypercholesterolemia

Hypertension

Diabetes

Obesity, inactivity

Tobacco use

Stress, poor diet

Chest pain; may radiate to arm, jaw, back, abdomen

Chest pain with exertion, exposure to cold, or stress

Shortness of breath

Diaphoresis

Syncope or lightheadedness

Nausea or vomiting

Weakness

Women may present with atypical symptoms

Pulmonary emboli⁷

History of blood clots or deep vein thrombosis

Estrogen supplementation

Cancer

Inactivity

Hypercoagulation conditions

Tachycardia

Chest pain

Dyspnea, tachypnea

Anxiety

Presyncope or syncope

Hypotension (systolic BP <90 mm Hg)

Hypertensive crisis^8,9

Family or personal history of elevated blood pressure

Gender (men until 45 years of age, women after 65 years of age)

Lack of exercise/overweight / obesity

Poor diet, excess alcohol

Stress, smoke exposure

Sleep apnea

Hypertension if generally symptomless

Blood pressure >180/110 mm Hg

Severe headache

Shortness of breath

Severe anxiety

Nosebleeds

Cerebrovascular accident⁶

Family or personal history of elevated blood pressure

History of blood clots or deep vein thrombosis

Facial weakness

Arm/leg weakness, tingling, or numbness

Speech impairment

^{Adapted from reference 5-9.}

Collaborative efforts between retail health care clinics and larger health care systems allow for improved communication and coordination of care. Board-certified providers in retail health offer convenient, accessible, and affordable care located close to the patient’s home. Telehealth¹²and partnering with a health system’s emergency care, primary care, specialty, and other service networks are enormous opportunities for growth. Electronic medical record systems with the capability to share data are critical to care coordination. Evidence-based protocols for screening and management of CVD are utilized by retail health clinicians as patients present to their clinics for acute, episodic encounters or management of chronic disease.¹³

Retail health clinicians have a unique opportunity to promote primary prevention, management, or co-management of CVD, and improve patient outcomes.

As clinical educator for Healthcare Clinics at Walgreens, Karen Brautigam, FNP-C, enjoys the opportunity to develop program materials and coach best practices for implementation of new and existing services. Karen’s extensive professional experience includes care of patients across the lifespan in hospitals, home services, long-term care, and primary care. Karen graduated from the nurse practitioner program at St. Louis University (adult) and Maryville University (family). She enjoys the challenge of being a member of the adjunct nurse practitioner faculty at St. Louis University, as well as working in research and leadership roles.Christina Blaesing, FNP-C, worked as an orthopedic and critical care nurse for over 10 years. Upon obtaining her master’s degree as a family nurse practitioner, she helped implement and practice within an orthopedic total joint center working pre-surgical services in collaboration with a multidisciplinary team. She currently works for the Healthcare Clinic at Walgreens as a family nurse practitioner and also mentors new hires as a lead preceptor.

References

1. Research spotlight: cardiovascular disease. Patient-Centered Outcomes Research Institute website. www.pcori.org/sites/default/files/PCORI-Research-Spotlight-Cardiovascular.pdf. Accessed November 8, 2015.
2. Park L. Preventive care in adults: recommendations.UpToDatewebsite. www.uptodate.com/contents/preventive-care-in-adults-recommendations. Updated October 28, 2015. Accessed November 8, 2015.
3. Zithromax. Epocrates [online database]. https://online.epocrates.com/drugs/143703/Zithromax/Contradindications-Cautions. Accessed November 2, 2015.
4. 2015 American Heart Association guidelines for CPR and ECC. American Heart Association website. http://eccguidelines.heart.org. Accessed November 2, 2015.
5. Epocrates [online database]. Overview of acute coronary syndrome. https://online.epocrates.com/. Accessed November 2, 2015.
6. American Heart Association. Warning signs of a heart attack, stroke, and cardiac arrest. American Heart Association website. www.heart.org/HEARTORG/Conditions/911-Warnings-Signs-of-a-Heart-Attack_UCM_305346_SubHomePage.jsp. Accessed November 2, 2015.
7. Epocrates [online database]. Pulmonary embolism risk factors. https://online.epocrates.com/diseases/11632/Pulmonary-embolism/Risk-Factors. Accessed November 2, 2015.
8. American Heart Association. Understand your risk for high blood pressure. American Heart Association website. www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp. Accessed November 2, 2015.
9. American Heart Association. Symptoms, diagnosis, and monitoring of high blood pressure. www.heart.org/HEARTORG/Conditions/HighBloodPressure/SymptomsDiagnosisMonitoringofHighBloodPressure/Symptoms-Diagnosis-Monitoring-of-High-Blood-Pressure_UCM_002053_Article.jsp. Accessed November 2, 2015.
10. Kuo YF, Chen NW, Baillargeon J, Raji MA, Goodwin JS. Potentially preventable hospitalization in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians.Med Care. 2015;53(9):776-783. doi: 10.1097/MLR.00000000000406.
11. Shah BR, Thomas KL, Eliot-Bynum S, et.al. Check it, change it: a community-based intervention to improve blood pressure control.Circ Cardiovasc Qual Outcomes. 2013;6(6):741-748. doi: 10.1161/CIRCOUTCOMES.113.000148.
12. Sami HR. Medical informatics in neurology. Medscape. http://emedicine.medscape.com/article/1136989-overview. Updated November 20, 2014. Accessed November 7, 2015.
13. Bachrach D, Frohlich J, Garcimonde A, Nevitt K. Building a culture of health: the value proposition of retail clinics. Princeton, NJ: Robert Wood Johnson Foundation; April 2015. www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf419415. Accessed November 2, 2015.