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Pharmacists can help improve the sub-optimal management of patients with CHD, says Rani Khatib, senior cardiology pharmacist and lecturer at leeds Teaching Hospitals NHS Trust

Coronary heart disease (CHD) is the UK’s biggest killer with an estimated 2.6m people living with the condition. NICE emphasises the importance of prescribing the appropriate secondary prevention medicines in patients with CHD and the up-titration of beta-blockers and ACE inhibitors to evidence-based target doses or maximum tolerated doses.

Despite an improvement in prescribing secondary prevention medicines, up-titration of doses post-discharge is still poor. Of 37 post-myocardial infarction patients in a recent study who were followed up to six months post-discharge, 85 per cent did not have any up-titration of their beta-blocker doses, nor 47 per cent of their ACE inhibitor doses.

The symptom most commonly experienced by patients with CHD is chest pain. Sub-lingual glyceryl trinitrate (GTN) is often prescribed to alleviate anginal chest pain but various studies have shown that not all angina patients are prescribed it – and many do not seem to know how to use it.

“The team has developed a GTN advice card”

Failure to use

An evaluation of 35 patients with established CHD who were admitted to our cardiology wards revealed that 12 did not use their GTN when they had experienced chest pain, with five citing fear of side-effects as a reason. When knowledge of how to use GTN was assessed, only six patients showed full knowledge, despite being provided with various booklets and educational sessions about their CHD medicines. Advice on how to use GTN was not retained (possibly due to its infrequent use) and patients reported a lack of satisfaction with the GTN written information, which was not readily accessible, nor simple and practical.

The pharmacy teams should include assessment of GTN use as part of their medicines optimisation strategy to ensure that patients who have angina are prescribed GTN, provided with correct advice on how to use it and offered a refresher on its use, possibly once a year or whenever a new GTN supply is dispensed. Verbal advice should be supported with appropriate written material.

GTN advice card

To further reinforce this message the cardiac team, in collaboration with CHD patients, has developed a GTN advice card. NICE has quality assured the development of the card and made the full project available as “shared-learning” on their website.

The UKCPA has also endorsed the card, which is now available for use by all healthcare professionals in primary and secondary care. Orders can be placed with the Leeds Teaching Hospitals NHS Trust Print Unit (peter.hey@leedsth.nhs.uk).