One American dies every 35 seconds due to heart disease.1 This statistic is very sobering. Coronary heart disease (CHD) is the leading cause of death among American men and women and accounts for nearly 40% of all deaths annually. CHD is also the leading cause of premature disability, impacting productivity and quality of life. These figures are particularly troubling because CHD is often preventable.1 Therefore, it is very important that all health care providers communicate effectively with patients who are at risk of developing cardiovascular disease. Some patients might be sensitive about these topics, especially when the pharmacist points out lifestyle modifications that are important in decreasing cardiovascular risk. Also, some patients might be resistant to taking chronic medications for an asymptomatic condition such as hypertension or dyslipidemia. This article provides guidance for pharmacists who find it difficult to counsel patients who are resistant to change. After reviewing this information, pharmacists may feel more comfortable engaging patients in a dialogue concerning their heart health.
Coronary Heart Disease
CHD is a disease where blood flow to the heart tissue is decreased and the
tissue perfusion can be compromised. This condition is often caused by
atherosclerosis, which is characterized by fatty deposits and fibrosis of the
inner lining of the arteries. When this occurs in the coronary arteries, it
can lead to coronary symptoms such as chest pain, heart attack, and heart
damage. When atherosclerosis occurs in the carotid arteries, it can result in
stroke. Since CHD is associated with such significant morbidity and mortality,
it is important for health care providers to engage patients in a dialogue to
explore the patient's knowledge and understanding of this condition.
1
Some CHD risk factors such as age, gender, and family history cannot be changed. However, there are several established risk factors that can be modified in order to improve a patient's cardiovascular outlook. For instance, a patient's lifestyle can significantly impact their overall cardiovascular health. When a person is at risk for heart disease, it is important that they maintain a healthy weight, eat a heart-healthy diet, engage in regular exercise, limit dietary sodium, avoid using tobacco, and avoid excessive alcohol intake. It is important that patients maintain medication adherence to optimize control of diabetes, hypertension, and dyslipidemia, thereby decreasing their CHD risk.1 Pharmacists can interview patients to identify areas they should focus on in order to improve their heart health, and then provide advice concerning beneficial interventions to improve outcomes. The following are a few important counseling points.
Counseling Points
Overview of CHD: It is important to provide a thorough overview of
cardiovascular disease for the patient. Many patients do not understand the
health consequences associated with uncontrolled hypertension, high
cholesterol levels, or diabetes mellitus, especially when they feel healthy.
It is not uncommon for patients to resist taking a daily medication for an
asymptomatic condition. They might complain that the medication makes them
feel worse than they have ever felt before and express concerns about the
efficacy and safety of long-term therapy. In these situations, it is important
to acknowledge, respect, and address the patient's concerns. Do not dismiss or
minimize their feelings.
First, review the benefits of treatment. It is helpful to keep an assortment of booklets, fliers, videos, or computer tutorials on these topics in the counseling area in order to guide discussions. The pharmacist might want to consider purchasing wall posters or desk models that depict various stages of atherosclerosis so the patient can visualize how risk factors, such as dyslipidemia, can impact cardiovascular health. There are also computer programs that can be used to calculate cardiovascular risk. Many of these programs allow the pharmacist to graph the patient's CHD risk and compare that risk to expected values for their age and gender. These tools can help the patient grasp abstract concepts and understand the risks he or she is facing. It is important to review not only the risk of death due to CHD but also the risk of disability following a heart attack or stroke, so the patient has a full picture of the potential benefit of taking their medicines.
Next, the pharmacist should review the possible adverse effects of therapy. The patient should understand how to monitor for these effects and when to report to a health care professional if he or she experiences a problem. It is important that the patient appreciates the importance of routine follow-ups with his or her physician. Patients should be instructed to avoid discontinuing therapy themselves due to fear of adverse effects. They should realize that other treatment options are often available and that if they experience adverse effects, they should inform their physician, who will decide whether to adjust the dose, change products, or discontinue therapy.
Weight Management: Patients at risk of CHD (or who have established CHD) should also be encouraged to maintain a healthy weight. The pharmacist can have a significant role in providing education on the importance of weight management. In order to assess a patient's weight-related health risks, pharmacists can collect data on the patient's height and weight, waist and hip circumference, body fat percentage, blood pressure, and fasting blood glucose and lipid values. The patient should be encouraged to lose weight if his or her body mass index (BMI) is >=25.0 or if the patient has a high-risk waist circumference (WC), defined as >35 inches for women or >40 inches for men, with two additional risk factors. It is important for a patient to understand that even if he or she is just mildly overweight, a large WC significantly increases the risk of type 2 diabetes, dyslipidemia, hypertension, and CHD.2
Some patients can be very sensitive about this topic. When a health care professional recommends weight loss for health improvement, some patients do not hear the message clearly. They might overlook the reference to health and become self-conscious about their body image. Because the patient might be embarrassed, this topic should be broached with the utmost sensitivity. The patient should be moved to a private counseling area where he or she will feel safe engaging in a discussion without fear of being overheard. The pharmacist might initiate the discussion by reviewing the patient's vital signs and laboratory data and summarizing how the results translate into CHD risk. Then, the pharmacist can discuss appropriate interventions that would decrease these risks. When this message is shared with the patient with evident empathy and concern, the counseling is often better received and more successful.
It is important that the patient understand that he or she is not being asked to reach an ideal weight or clothing size but just to make some modest changes in lifestyle in order to achieve better health. Many people do not know that even a slow, steady, and modest weight loss of 10% of baseline weight over a six-month period can have a significant impact on a person's cardiovascular health risks. This can be achieved by reducing daily calorie intake by 500 to 1,000 kcal/day below the patient's daily needs (for a 1- to 2-lb weight loss per week).2 There are a number of educational tools available that can help a patient understand how to achieve this. The pharmacist should select the resources that best fit his or her counseling style. For instance, there are a variety of videos, computer tutorials, food models, food scales, books, pamphlets, food diaries, and PDA software that patients can use to learn more about this topic.
Heart-Healthy Lifestyle: Every patient with CHD risk, regardless of baseline weight status, should be encouraged to engage in a healthy lifestyle. Many patients have questions concerning how to eat healthy to take care of their heart. Patients should be advised to:3
• Limit dietary sodium intake to 2,300 mg of
sodium (1 teaspoon) or less per day.
• Limit dietary cholesterol to
<300 mg/day (<200 mg/day if a patient has heart disease).
• Limit foods high in total fat,
trans fat, and cholesterol. Daily fat intake should not exceed 30% of total
daily calories. (Saturated fat should be 7% or less and trans fat should be 1%
or less.)
• Eat fish at least twice per
week, especially fish high in healthy omega fatty acids (e.g., salmon,
mackerel, albacore tuna, lake trout, herring).
• Choose complex carbohydrates
that are high in fiber, such as fruits, vegetables, and whole grain starches
(e.g., breads, cereals). Target ingesting at least 25 to 30 g of dietary fiber
per day.
• Drink alcohol in moderation (no
more than one to two servings of alcohol per day). One serving of alcohol is
12 ounces of beer, 4 ounces of wine, 1.5 ounces of 80 proof spirits, or 1
ounce of 100 proof spirits.
• Eat two to three servings of
low-fat or fat-free dairy products (e.g., milk, yogurt, cheese) per day.
In addition to following a heart-healthy diet, it is important that individuals be physically active. Everyone should strive to engage in at least 30 minutes of moderate physical activity every day.3 One way this can be achieved is by increasing activities of daily living with small changes in daily routine. For instance, if a patient's health and mobility allows, they should take the stairs, park farther away from their destination, or walk to a meeting. Patients might benefit from wearing a pedometer to monitor their level of daily activity, to achieve an ultimate goal of walking 10,000 steps or more per day. A pedometer can provide objective data that can be very enlightening and motivating for patients.
Pharmacists should also encourage patients to stop smoking and avoid exposure to tobacco smoke; to drink alcohol in moderation; to check their blood pressure frequently; and to get their cholesterol and blood sugar checked periodically (at least every five years if within normal limits and more frequently if higher than target). Also, it is important for patients to know the warning signs and symptoms of a heart attack or stroke and to understand when to call for help if they experience discomfort.3
Communication Considerations
Any recommendations the pharmacist makes must be effectively communicated to
patients. This can be particularly challenging when the patient is resistant
to changing their lifestyle, modifying their diet, or taking medications. A
fundamental concept that is important when assisting patients with making
these behavior changes is called "decisional balance."4
Patients develop an internal set of pros and cons with regard to the benefits
of and barriers to taking their medicine, changing their eating habits, and
exercising. In order to "tip" the balance in favor of making the desired
behavioral change, the pharmacist must explore these pros and cons with the
patient. Because many of these conditions are asymptomatic, patients often
have doubts about whether they really need to take medications or make
lifestyle changes. They also sometimes have doubts about whether the medicine
is really working because they don't feel any different. When patients are
ambivalent about any of these behaviors, it simply means that in terms of
their decisional balance, the pros equal the cons of taking the medicine. When
patients are resistant, the cons outweigh the pros. The role of the health
care provider is to explore this ambivalence or resistance, not to
squash it or explain it away. Trying to persuade patients who are not ready to
make a change forces them to defend the behavior you are trying to change.
Therefore, explore, don't explain.
The concept of decisional balance requires that patients perceive the benefits of taking their medicine to be greater than the barriers. The pharmacist can have an important role in assisting patients to understand the benefits and overcome the barriers. Keep in mind that when patients are ambivalent or unsure about whether they really need to take medicine or lose weight, or whether the medicine is working, the benefits equal the barriers for them. Telling the patient the benefits forces the patient to tell you the barriers. A better approach is to ask patients what they perceive to be the benefits of taking the medicine, changing their diet, and exercising. Here's a sample dialogue to illustrate how to "tip" the decisional balance for patients who are ambivalent or resistant to making a change:
Patient: I just don't know about taking this medicine for my high blood pressure. I feel just fine.
Health care provider (HCP):
So, because you feel OK, you are having some doubts about whether you really
need the medication. (HCP responds with empathy and
understanding.)
Patient: Right.
HCP: It is quite common that people with high blood pressure feel OK even though their blood pressure is elevated. What do you see as the possible benefits of taking the medicine?
Patient: Well, I guess it's supposed to lower my blood pressure to reduce my risk of a stroke or a heart attack.
HCP: That's exactly right. May I suggest some additional benefits? (Response respects the patient's autonomy by asking permission to provide additional information.)
Patient: OK.
HCP: By lowering your blood pressure, you can lead a more normal life. For example, I know that you like to jog. It is important to get your blood pressure down before you exercise vigorously, since exercise can raise your blood pressure. We want you to continue exercising, but we want it to be safe for you.
Patient: I see. I hadn't thought of that.
HCP: What do you see as the barriers to you taking the medicine?
Patient: Well, as I said, I felt OK, but you said you can feel OK if your blood pressure is up.
HCP: Right. Would it help if we took your blood pressure here to see where it is?
Patient: Sure.
HCP: OK, we can do that. What other barriers might keep you from taking the medicine?
Patient: I heard that it can make you feel sluggish or dizzy.
HCP: Those are legitimate concerns. Some patients feel a little sluggish until their bodies get used to the medicine. Also, when you first start taking it, you might feel a little lightheaded when you first sit up in the morning. These problems usually go away after about a week on the medicine. It is best to see how the medicine will affect you. Getting up and out of bed slowly in the morning will help.
Patient: OK. I also heard that some men have "male problems" with some of these medicines. Is that true?
HCP: Having trouble getting an erection occurs in very few males … and usually the problem subsides in about a week. If the problem persists, just call and let me know and we can call your doctor and either adjust your dose or choose another medicine. The problem is completely reversible when the medication is stopped.
Patient: Why would he give me something that could do that?
HCP: As I said, this side effect does not occur very often, and the medicine is very effective in lowering blood pressure.
Discussion
In this dialog, the
pharmacist respectfully addresses the patient's concerns, provides additional
benefits by asking permission, and addresses barriers to taking the medicine.
The same approach may be taken with exercise and diet. First, the
benefits are explored and then barriers are addressed. Keep in mind that when
discussing exercise, many patients think of exercise as being something very
rigorous. Suggest walking, parking farther from the building where they work,
and taking the stairs instead of an elevator--these are also forms of exercise
that the patient may not have considered. When asking patients about barriers,
it is best to ask what the patient's thoughts are about how he or she might
overcome the barriers. Any solutions a patient comes up with are likely to be
far more effective than other suggestions that might not fit their lifestyle.
If they get stuck, it is appropriate to say, "May I suggest how other patients
have dealt with this barrier?" Next, describe the solutions, and then ask,
"What do you think?" or "Which of these solutions would work for you?" This
helps the patient make a commitment to change.
The approaches described should help assist patients make the changes necessary to treat their CHD. The concept of decisional balance helps put "bad patients" or stubborn behavior into perspective. If the patient is ready to engage in a behavior, it simply means that the benefits outweigh the barriers. If he or she is not ready, the barriers outweigh the benefits and these things need to be respectfully explored.
Conclusion
CHD is a common condition that is associated with significant morbidity and
mortality. Therefore, it is important that pharmacists help identify patients
who are at risk for CHD and provide education concerning how to improve health
outcomes. If a patient is resistant to the recommended behavioral changes, the
pharmacists can help the patient explore the perceived pros and cons of the
intervention in an attempt to "tip" the patient's decisional balance towards
the recommended behaviors to decrease CHD risk. Using this communication
strategy, in conjunction with appropriate sensitivity, empathy, and listening
skills, maximizes the opportunity for a successful intervention.
References
1. Gerberding JL. Division for Heart Disease and Stroke Prevention:
Addressing the Nation's Leading Killers. Strategies for a Heart-Healthy and
Stroke-Free America. Atlanta, GA: U.S Dept. of Human Services, Centers for
Disease Control and Prevention; 2006. Available at:
www.cdc.gov/nccdphp/publications/aag/pdf/aag_cvh2006.pdf. Accessed December
12, 2006.
2. The Practical Guide for the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults.
3. American Heart Association, Learn and Live.
4. Miller WR, Rollnick S. Motivational interviewing: Preparing people for
change. 2nd ed.
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