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`What are we trying to prevent? 2NHS Health Check: Best Practice Guidance Figure 2. Overview of the vascular risk assessment and management programme 3456General Practice Physical Activity Questionnaire Date……………………… Name…………………….. 1. Please tell us the type and amount of physical activity involved in your work. Please mark one box only I am not in employment (e.g. retired, retired for health reasons, unemployed, a full-time carer etc.) b I spend most of my time at work sitting (such as in an office) I spend most of my time at work standing or walking. However, my work does c not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.) My work involves definite physical effort including handling of heavy objects d and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.) e My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.) 2. During the last week, how many hours did you spend on each of the following activities? Please answer whether you are in employment or not Please mark one box only on each row None Some but 1 hour but 3 hours or less than less than more 1 hour 3 hours Physical exercise such as swimming, a jogging, aerobics, football, tennis, gym workout etc. b Cycling, including cycling to work and during leisure time Walking, including walking to work, c shopping, for pleasure etc. d Housework/Childcare e Gardening/DIY 3. How would you describe your usual walking pace? Please mark one boxonly. Slow pace Steady (i.e. less than 3mph) average pace Brisk pace Fast pace (i.e. over 4mph) Hit return to calculate PAI 7 THE NHS HEALTH CHECK AND FAMILIAL HYPERCHOLESTEROLAEMIA Why is a diagnosis of Familial Hypercholesterolaemia (FH) important? Since monogenic FH is a single gene disorder and ‘runs in families’, 50% of the brothers and sisters and 50% of the children of your FH patient are at risk of also having FH. If the diagnosis of FH is confirmed, they can easily be offered diagnostic tests and affected individuals effectively treated with statins to reduce their subsequent risk of early onset heartdisease. What should a GP do when an individual has been identified through the NHS Health Check programme with a total cholesterol of > 7.5 mmol/L? The following steps should be carried out: • Repeat the measurement on a fasting blood sample. The laboratory can then calculate the LDL cholesterol concentration. The diagnostic cut-off for a possible diagnosis of FH in an adult is a total cholesterol of > 7.5 mmol/L but more specifically an LDL cholesterol of > 4.9mmol/L. • If on the retest the LDL is >4.9 mmol/L, exclude secondary causes of hypercholesterolaemia. These are: (a) Hypothyroidism (measure TSH levels) (b) Renal impairment (measure creatinine) (c) Obstructive liver disease (measure liver function tests) (d) Diabetes (using a fasting blood glucose measure) – usually associated with hypertriglyceridaemia • If secondary causes of hypercholesterolaemia have been excluded, or the patient continues to have a high cholesterol despite management of the secondary cause, then the patient should be referred to a local lipid clinic. The clinic will carry out further tests and take a detailed family history for the confirmation of the diagnosis. If not confirmed, the patient will be referred back to the GP. If confirmed the clinic will, initiate intensive statin therapy and cascade testing of affected relatives. Usually once the NICE recommend lipid lowering for FH patients is achieved (target of 50% lowering of pre-treatment LDL cholesterol) the patient will be discharged back to the GP for a shared care arrangement and agreed annual review schedule as recommended by the NICE guidelines. Click here to use the Heart UK lipid clinic finder Find your nearest cholesterol specialist | HEART UK 8To Note: 1 The probability of an individual having FH is increased by the degree of elevation of LDL cholesterol. While an LDL of 4.9-5.5 can be diagnostic of FH, it can also be due to “polygenic” causes. Conversely, in an individual with LDL levels over 6.0 mmol/L polygenic causes are much less likely, and a diagnosis of FH is very much morelikely. 2 Individuals who report having relatives with either elevated cholesterol levels and or early heart disease are very likely to have monogenic FH and should definitely be referred. The NICE guideline suggests using the criteria for early CHD as under 55 years in a first-degree male relative and under 65 in a first-degree female relative. For other sites with information about FH Visit the BHF http://www.bhf.org.uk/ or for their fact file on FH see Familial hypercholesterolaemia| British Heart Foundation - BHF For the UK FH (Simon Broome ) Register see Project team for the FH Paediatric Register (heartuk.org.uk) For the Heart UK Patient Support group see http://www.heartuk.org.uk/ For the NICE Guideline on FH see Overview | Familial hypercholesterolaemia | Quality standards | NICE 9 With Electronic Blood Pressure Monitors • The patient should be seated for at least 5 minutes, relaxed and not moving or speaking; • The arm must be supported at the level of the heart. Ensure no tight clothing constricts the arm; • Place the cuff on neatly with the centre of the bladder over the brachial artery. The bladder should encircle at least 80% of the arm (but not more than 100%); • Some monitors allow manual blood pressure setting selection where you choose the appropriate setting. Other monitors will automatically inflate and re- inflate to the next setting if required; • Repeat three times and record measurement as displayed. Initially test blood pressure in both arms and use arm with highest reading for subsequent measurement. Indication Width Length BHS Guidelines Bladder Arm circ. (cm)* = (cm)* = width & length (cms)* (cm)* Small Adult/Child 10 - 12 18 – 24 12 x 18 < 23 Cuff Sizes Standard Adult 12 - 13 23 – 35 12 x 26 < 33 Large Adult 12 - 16 35 – 40 12 x 40 < 50 Adult Thigh Cuff** 20 42 < 53 * The range for columns 2 and 3 are derived from recommendations from the British Hypertension society (BHS), European Hypertension Society (ESH) and the American Heart Association. Columns 4 and 5 are derived from only the NHS guidelines. ** Large bladders for arm circumferences over 42cm may be required. = Bladders of varying sizes are available so a range is provided for each indication (applies to columns 2 and 3). Points to note: It is good practice to occasionally check the monitor against other validated devices. It is important to have the monitor serviced and calibrated according to manufacturer’s guidelines. 10What needs to be done next and what do I do? Needs to be done What do you need to do? BP >140/90 mmHg & Assessment for hypertension ABPM/Home BP <179/119 mmHg Check for DM & CKD BP >180/120 mmHg See duty Dr / ANP See GP/ANP/Pharm CVD Risk >20% Start a statin Annual review See GP/ANP/Pharm, recommend a CVD Risk 10-19% statin. If yes, annual review, if no NHS Health Check in 5 years CVD Risk <10% NHS Health Check in 5 years See GP, check full lipid profile, thyroid, liver, kidney, diabetes. TC>7.5 mml/L Consider FH See duty Dr/ANP/Pharm HbA1c >48 Diabetes prevention programme HbA1c 42-48 Lifestyle advice HbA1c 37-42 Lifestyle advice HbA1c <37 Weight management programme BMI >30 Diabetes prevention programme Audit C>5 Complete rest of Audit C Offer advice, Drink Aware app Audit C 8-19 Referral to specialist alcohol services Audit C >20 ECG Irregular pulse Smoker Stop smoking services Lifestyle Local and national services Better Health 10Useful Websites Free LWN Webinars www.learnwithnurses.org MedAll MedAll — Healthcare training for everyone. Alcohol www.drinkaware.co.uk/for-professionals/#health www.e-lfh.org.uk/programmes/alcohol www.alcoholconcern.org.uk/unit-calculator?gclid=CImZu_3KodICFecK0wodYqcLeQ Better Health (was One You) www.nhs.uk/better-health/ British Hypertension Society www.bihsoc.org (Great for validated BP monitors and info for ABPM & HBPM) Charities: www.heartuk.org.uk / Catalogue (learninghub.nhs.uk) (Great for cholesterol) * supporters of our training www.bloodpressureuk.org/Home (Great patient info and blood pressure week) www.bhf.org.uk www.diabetes.org.uk Computerised Brain Games www.stayingsharp.aarp.org/about/brain-health/games www.lumosity.com www.brainHQ.com CVD Risk Calculators www.nhs.uk/conditions/nhs-health-check/pages/check-your-heart-age-tool.aspx www.jbs3risk.com/pages/risk_calculator.htm Dementia Leaflet www.healthcheck.nhs.uk/commissioners_and_providers/training/dementia_training www.healthcheck.nhs.uk/commissioners_and_providers/marketing/dementia_resources Free e-Learning www.e-lfh.org.uk/programmes/all-our-health NHS Health Checks – template letters, posters and data & statistics www.healthcheck.nhs.uk www.healthcheck.nhs.uk/commissioners-and-providers/national-guidance/ www.healthcheck.nhs.uk/commissioners-and-providers/training/competency-framework-and-learner-and- assessor-workbooks/ Obesity www.cks.nice.org.uk/topics/obesity/diagnosis/identification-classification RCN - Accountability and Delegation www.rcn.org.uk/professional-development/accountability-and-delegation Skills for Health www.skillsforhealth.org.uk/info-hub/category/the-care-certificate/ Registered office: 2-6 Boundary Row, London, SE1 8HPTel: 0330 124 1966 www.smarthealthsolutions.co.ukNOTES