coronary heart desease

8/13/2019 Coronary Heart Desease

1/8december 8/vol19/no13/2004 nursing standard 47

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Coronary heart disease:

risk factor managementNS271 Foxton J et al (2004) Coronary heart disease: risk factor management.Nursing Standard. 19, 13, 47-54. Date of acceptance: November 9 2004.

AuthorJulie Foxton RGN, RM, is sen-ior nurse adviser, HEART UK,Maidenhead, Berkshire;Michaela Nuttall RN, DipN,MSc, is CHD Co-ordinator,Bromley Primary Care Trust,Kent; and Jillian Riley RGN,RM, BA(Hons), MSc, is headof postgraduate educationfor nurses and allied healthprofessionals, Royal

Brompton Hospital, andhonorary lecturer, ImperialCollege, London.Email: [email protected]

SummaryCoronary heart disease is theleading cause of mortalityand morbidity in the UK.Nurses have a pivotal role inthe management of high-riskpatients and the modificationof risk factors.

Key words Cardiovascular system and

disorders Health promotion

These key words are basedon subject headings from theBritish Nursing Index. Thisarticle has been subject todouble-blind review.

In brief

For related articles visit ouronline archive at:

www.nursing-standard.co.ukand search using the key

words above.

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The aim of this article is to provide an overview of

coronary heart disease (CHD) risk factors and their

management. After reading this article you should

be able to:

Explain the rationale behind the treatment targets

to reduce the incidence of CHD in the population. Describe the risk factors for CHD.

Use the coronary risk calculator to identify people

at high risk of developing CHD.

Identify those who are at moderate risk of CHD.

Discuss the role of lifestyle advice in the manage-

ment of cholesterol.

Describe the drug therapy that may be used to

reduce cholesterol.

CHD is the leading cause of mortality and morbid-ity in the UK and the single most common cause

of premature death. Despite a fall in CHD mortal-

ity in recent years, the UK death rate is among the

highest in the world at around 120,000 per year

(British Heart Foundation (BHF) 2003). CHD, together

with cancer and stroke, accounts for 35 per cent

of life years lost before the age of 75 (BHF 2003).

In addition, more than 1.5 million people in the UK

are living with angina and 500,000 have heart fail-

ure (Department of Health (DoH) 2004) frequently,

although not exclusively, caused by CHD. This high

incidence is not unique to the UK and a similar

pattern is being observed worldwide (Yusuf et al

2002). The World Health Organization (WHO) has

predicted that by 2020, CHD will be the greatest

cause of death and disability throughout the world

(Tunstall-Pedoe et al1999). The increasing number

of people living with the disease is of concern to

healthcare professionals. Strategies to prevent this

are therefore of great importance.

The National Service Framework (NSF) for CHD

(DoH 2000a) laid the foundations for dramatic

improvements in the prevention and treatment of

heart disease, and 1.8 million people are now receiv-

ing lipid-lowering drugs, with lifestyle advice a keyfeature of primary and secondary prevention appoint-

ments. However, there is room for improvement

and the NHS Improvement Plan (DoH 2004) sets

an ambitious target to reduce death rates from

CHD and stroke in the under-75s by at least 40 per

cent by 2010.

CHD can develop at any age. Initially, an area of

atheromatous plaque forms in the coronary artery.

The mechanism for plaque formation is unclear,although the predominant view is that lipid accu-

mulates under the lining of the coronary artery

(Samar 1999). Because the lipid infiltrate is a for-

eign matter, white blood cells called macrophages

engulf it, and create foam cells (Samar 1999).

Smooth muscle cells then invade the area, which

enlarges. It is not until the plaque obstructs more

than 50 per cent of the lumen of the coronary artery

that the flow of blood to the heart muscle, the

myocardium, is reduced. This usually means that

when resting, or undertaking minimal activity, the

blood supply to the heart is adequate. However,

when the heart requires a greater supply of oxy-

gen, as occurs during exercise or emotional episodes,

the blood supply cannot increase sufficiently and

the person will experience chest discomfort. This is

referred to as angina pectoris. Once plaque has

Pathophysiology

Incidence and prevalence

Aim and intended learning outcomes

Coronary heart disease:risk factor management

pages 47-54

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2/848 nursing standard december 8/vol19/no13/2004

formed, the wall of the coronary artery is damaged

and irregular in shape and platelets cluster around

the obstruction. This reduces the size of the lumen

still further and consequently the blood supply is

also reduced. Sometimes platelet aggregation can

be sudden causing an abrupt and total occlusion

of the coronary artery. At this time the person willexperience a myocardial infarction (MI).

A number of factors are thought to increase the

likelihood of developing CHD. The three major

risk factors are smoking, hypertension and abnor-

mal cholesterol levels. However, additional risk

factors include a family history of CHD, diabetes,

abdominal obesity, lack of fruit and vegetables in

the diet and lack of exercise (Yusuf et al2004).

These risk factors are common, regardless of sex,

ethnic group or age and are frequently not found

in isolation, thereby increasing the risk (Yusuf et

al2004). Some risk factors are modifiable, for

example, cholesterol, diabetes, hypertension, obe-

sity, physical inactivity and smoking, and efforts

should be made to increase awareness of how to

reduce the likelihood of developing CHD both in

the person who has identified risk factors and in

the population as a whole (Yusuf et al2004).

Modification of risk factors There are a number

of ways in which the risk of developing CHD canbe modified. They include lifestyle advice as well

as the prescription of advice regarding medication.

Abnormal cholesterol levels are a major risk factor

for CHD and are responsible for at least 46 per cent

of all new cases of CHD (BHF 2004). Consequently,

efforts are being made to lower cholesterol levels

in the population to a target level of 5.0 mmol/l or

less for total cholesterol. This may seem hard to

achieve certainly among some sections of the

patient population and in some areas of the coun-

try, for example, where patient concordance with

therapy is poor, there is an inability to tolerate ther-

apy or where sections of the community are unable

or unwilling to access medical services but the

most recent British Hypertension Society guidelines

go further and suggest a total cholesterol of less

than 4.0mmol/l and low-density lipoprotein (LDL)

level of less than 2.0mmol/l (Williams et al2004).

The risk of developing CHD can be calculated

using a risk chart. This forecasts the risk of devel-

oping CHD over the next ten years. High risk is iden-

tified where the risk is calculated as 30 per cent or

higher, whereas moderate risk is calculated as a 10

per cent risk of developing CHD over the next tenyears (Wood et al1998).

The role of the nurse has extended to meet the

changes in health care where increasingly the

emphasis is on health promotion and disease pre-

vention. This is outlined in the documents Making

a Difference (DoH 1999a), the NHS Plan (DoH

2000b), and Shifting the Balance of Power in the

NHS: Securing Delivery(DoH 2001). Government

policies to improve the health of the individual andthe population have emphasised that nurses have

a significant contribution to make. The nursing

profession can assist the shift in responsibility for

health to patients by empowering people to improve

their health outcomes.

Diabetes and obesity are also increasing in the

UK (BHF 2003). The nurses role is pivotal in help-

ing to address this increase. Nurses can proactively

implement preventive strategies and advise on

many aspects of health promotion. They are increas-

ingly using clinical guidelines to ensure a higher

quality of care (Puffer and Rashidian 2004). Thismeans that while nurses are ideally placed to pro-

vide information, the advice given can be more

consistent and evidence-based through the appli-

cation of local and national guidelines. This also

helps to improve equity of care.

In CHD the proactive role of the nurse has been

further reinforced by the publication of the NSF for

CHD (DoH 2000a), which suggests that the ideal

way to implement secondary prevention is through

nurse-led clinics. While nurses in almost all areas

of care have the opportunity to assess and advise

on CHD risk factors, it is particularly pertinent for

nurses working in primary care and the commu-

nity. This is because many people who have CHD

or who are at a high or moderate risk of develop-

ing the disease are cared for in primary care set-

tings. For those people with CHD, there is now

The nurses role

Risk factors

Health promotion

TIME OUT 1Write down, in no more than one

paragraph, your own definition of CHD.

TIME OUT 2Using a separate piece of paper for each

risk factor identified above, write downwhat you are currently doing to reduce

that risk factor either in your own life orin a patients life. Once you have done

this, compare your answers with thesuggestions below.

TIME OUT 3Look at the risk calculator on the

following websites:www.hyp.ac.uk/bhs/Cardiovascular_Risk_Charts_and_Calculators.htm

Consider a patient you have cared forover the past week, who does not

already have a diagnosis of CHD, anduse the calculator to assess his or her

risk of developing CHD over the next

ten years. You may need to read thepatients notes to find some of

the details.



evidence of benefits from four randomised controlled

trials of nurse-led secondary prevention (Allen et al

2002, Cupples and McKnight 1999, Moher et al

2001, Murchie et al 2003). Three of the trials were

in primary care in the UK and one in secondary care

in the United States (US). These show that nurse-

led secondary prevention clinics can improve sec-ondary prevention of CHD risk factors. Wright et

al (2001) also found that nurse-led risk factor man-

agement is acceptable to patients.

There is less evidence that nurse intervention is

effective for those people who are at high or mod-

erate risk of developing CHD but have not been

diagnosed with CHD. The Cochrane Library reviewed

multiple risk-factor interventions for primary pre-

vention of CHD and concluded that effective inter-

ventions on a general population basis would be

mostly ineffective and costly (Ebrahim and Davey

Smith 1999). Therefore, targeting health promo-

tion activities at high-risk individuals should be con-

sidered the first step. Targeted CHD prevention is

also advocated by the joint British recommenda-

tions on CHD prevention (Wood et al 1998). Lifestyle

and pharmacological interventions and goals for

those people at high risk of CHD are similar to those

for people with CHD.

Weight loss There is a twofold increase in the risk

of developing CHD in people who are obese or

overweight. For those who are obese, CHD is the

main cause of excess mortality (British Nutrition

Foundation (BNF) 1999). This is in part because

obese or overweight individuals are more likely to

have hypertension, diabetes and high triglycerideand cholesterol levels, and other abnormalities of

clotting that increase the risk of thrombus forma-

tion or MI (Meade et al1993).

Weight control is important and can be achieved

in a variety of ways. Eating less fat, sugar and alco-

hol is helpful but, to achieve a healthy body weight,

it is also important to incorporate regular, moder-

ate exercise into a daily routine. Various benefits

are associated with weight loss (Box 1).

In people with a body mass index (BMI) greater

than 25kg/m2 (calculated by dividing weight in kilos

by height in metres squared), referral to a dietician

or nutritionist should be considered. Strategies

should be considered that gradually reduce weight

by about 0.5kg per week through a combination

of diet, exercise and behavioural changes.

Reduction of waist circumference is associated

with improvements in cardiovascular risk (Han et

al 1997). Unlike BMI, which does not take into

account body fat distribution, waist measurement

can give a better indication of android obesity

(central distribution of excess adipose tissue)

(Donahue et al1987). It is recommended that weight

reduction is required when waist circumference ismore than 102cm in men and more than 88cm in

women (Lean et al1995).

Dietary advice Nurses can also advise on a healthy

diet (Figure 1) which may include the following:

Calorie intake 1,200-1,600kcal per day, mod-

erate fat intake by eating less fatty meat, fatty

cheese, full-cream milk, fried food and lard (Tang

et al1998).

Consider eating more vegetables, fruit, cereals,

wholegrain bread, poultry, fish, rice, skimmed or

semi-skimmed milk, grilled food, lean meat or

pasta.

Fried food should be discouraged, but steam fry-

ing or using a vegetable oil high in polyunsatu-

rates, such as sunflower or rapeseed oil or one

containing plant sterols or stanols could be con-

sidered (see below).

Use low-fat spreads suggest considering a

low-fat spread that contains plant stanol/sterol

esters. These and other plant stanol/sterol-

containing foods may be useful adjuncts in low-

ering cholesterol levels. Plant sterols and stanols

are sourced from either wood pulp products or

soya bean distillates, rapeseed and sunflower

oils. They inhibit the absorption of cholesterolin the intestines and may achieve total choles-

terol reductions of up to 14 per cent (Miettinen

et al 1995). They are safe and tolerable and are

contained in a variety of ready-to-buy products

ranging from milk and milk drinks, yoghurts

and spreads. However, these products should

be used as described as a constant circulating

level of stanols or sterols is required to achieve

maximum efficiency and effectiveness.

Lifestyle management

Mortality20-25 per cent fall in overall mortality

30-40 per cent fall in diabetes-related deaths40-50 per cent fall in obesity-related cancer deaths

Blood pressure10mmHg fall in diastolic and systolic pressures

DiabetesUp to a 50 per cent fall in fasting blood glucose

Reduces risk of developing diabetes by more than 50 per cent

LipidsFall of 10 per cent total cholesterol, 15 per cent low-density lipoprotein and 30 per

cent triglyceridesIncrease of 8 per cent high-density lipoprotein

(Blenkinsopp 2004)

Box 1. Benefits of 5-10kg weight loss

Health promotion

TIME OUT 4In Time Out 3 you calculated a patients

risk of developing CHD over the next tenyears. List this patients risk factors for

CHD. Under each risk factor, identifysome of the ways in which you mighthelp him or her to reduce this risk.



Health promotion

BEST CHOICE IN MODERATION BEST AVOIDED

Figure 1. The HEART UK diet sheet

Reproduced with the kind permission of HEART UK

Cereals and starchy foods

Potatoes

Vegetables and fruit

Fish

Meat

Vegetarian choice

Eggs and dairy

Oils

Spreads

Meals

Cakes and biscuits

Puddings

Flavourings, sauces,jams and sweets



Physical activity Thirty seven per cent of CHD

deaths in people under the age of 75 are attribut-

able to physical inactivity (BHF 2003). The cardio-

vascular benefits of regular physical activity include

reduced blood pressure and less likelihood of obe-

sity, both of which help to reduce the risk of devel-

oping CHD. However, the Health Survey for England1998 (DoH 1999b) identified that approximately

70 per cent of people were not taking regular phys-

ical activity. Recommended levels to gain cardio-

vascular protection, if you are physically able, are

at least 30 minutes of steady activity on five or more

days a week (American College of Sports Medicine

(ACSM) 2000). This can take the form of walking,

jogging, swimming, cycling and dancing, which

can easily be fitted into a regular day.

Smoking Smoking is the single biggest cause of

preventable death in the UK. Each year, tobacco

smoking accounts for more than 30,000 deaths

from cardiovascular disease (Callum 1998). It is

essential that nurses take a proactive role in help-

ing people to stop smoking and provide advice on

smoking cessation.

Key features of individual smoking cessation are:

Ask about smoking at every opportunity.

Advise all smokers to stop.

Assist smokers to stop.

Arrange follow-up.

Stopping smoking will reduce CHD risk even if a

person has smoked for many years. There are

short and long-term benefits. Within eight hours

nicotine levels will be reduced by half and within24-48 hours carbon monoxide levels will be com-

parable to those of a non-smoker. The long-term

benefits are considerable; excess cardiovascular

risk from smoking reduces by half within one year

and after five years reverts to about the same

level as someone who has never smoked (Critchley

and Capewell 2003).

Alcohol In moderation (one to two units daily for

women, two to three units for men), alcohol may

reduce the risk of CHD by potentially increasing

high-density lipoprotein (HDL) cholesterol slightly

and reducing thrombotic tendencies (Mukamal etal2001). A unit is defined as a half pint of beer,

lager or cider, or a pub measure of wine, sherry or

spirits. However, consuming too much alcohol

places health at risk in a number of ways. When

taken in excess, alcohol can damage the cardiac

muscle, cause arrhythmias, stroke and coagu-

lopathies (Lindsay and Gaw 2004). Additionally it

may contribute to obesity, high triglycerides and

hypertension, risk factors for the development of

CHD (Lindsay and Gaw 2004). Men should drink

no more than three to four units of alcohol and

women no more than two to three units a day.

Stress A certain amount of stress may be desir-

able as it keeps people alert and motivated.

However, as stress levels increase and especially

if prolonged, they can be counter-productive.

Stress can exacerbate symptoms in people with

pre-existing heart disease, and can contribute to

hypertension (Blenkinsopp 2004). Additionally, it

may lead to the adoption of poor eating habits,

smoking and increased alcohol consumption and

non-concordance with prescribed medication.

The nurse can help people to find time for relax-

ation or teach them simple breathing exercisesto help reduce the risk of developing CHD

(Blenkinsopp 2004).

This section examines methods used to control and

correct the lipid profile (Box 2), other than diet and

lifestyle.

Statins These are the most common form of drug

therapy for reducing raised cholesterol levels. The

first statins were produced more than 20 years ago

from fungi, but newer versions are man-made.

Statins include atorvastatin, cerivastatin (now with-

drawn), fluvastatin, lovastatin (not available in the

UK), pravastatin, rosuvastatin and simvastatin, and

others are undergoing clinical and scientific study.

Statins work by inhibiting the action of 3-hydroxy-

3-methylglutaryl-coenzyme A (HMGCoA) reduc-

tase, an enzyme which is involved in cholesterol

synthesis in the liver (BNF 2004). Statin therapy

can reduce low-density lipoprotein (LDL) choles-

terol by up to 60 per cent (McTaggart 2003).

Additionally, statins lower triglycerides (fatty acids

attached to glycerol) in proportion to their LDL-

lowering effect. Different statins vary in their effecton HDL cholesterol but they generally cause a small

rise and because HDL is cardioprotective this is a

beneficial action (Assman et al1995).

Statins have been proven to be effective at low-

ering mortality and morbidity for cardiovascular

disease (DoH 2000a, Gordon 2000, Hebert et al

1997, Minhas 2003, Shepherd et al2002, Wood

et al1998). The Simvastatin Survival Study (also

know as the 4S study) in the late 1980s was the

first trial to provide this information (Shepherd et

al1995). Trials such as this have continued over

subsequent years and prove the safety and efficacyof statins and a reduction in cardiovascular events

following statin therapy (Athyros et al2002, Downs

et al1998, Long-term Intervention with Pravastatin

in Ischaemic Disease (LIPID) Study Group 1998,

Sacks et al1996). A more recent study examined

people with type 2 diabetes who were therefore

at high risk of developing CHD. It demonstrated

Drug therapy

Health promotion

Total cholesterol

Low-density lipoprotein cholesterol

High-density lipoprotein cholesterol

Triglycerides

Box 2. The lipid profile



that, regardless of cholesterol level, lowering cho-

lesterol even further provides additional cardiovas-

cular benefit to the patient (Colhoun et al2004).

A recent initiative, approved by the Medicines and

Healthcare products Regulatory Agency (MHRA),

has been launched to target people at moderate

risk of CHD in the UK. This initiative aims to reducetheir risk factors, including lowering blood choles-

terol levels. Approval has been given for simvas-

tatin 10mg (one of the statin drugs) to be dispensed

by a pharmacist, following a pharmacy screening

protocol, to all men and women where the risk of

developing heart disease over the next ten years

has been estimated as 10 per cent (moderate risk)

(MHRA 2004a).

Screening is offered to all men over 55 years of

age, with no other risk factors for heart disease, to

men 45-54 years of age and women over 55 years

with one or more risk factors. These risk factors are

determined as smoking, obesity, family history of

premature death of CHD (before the age of 65 in

female relatives and age 55 in male relatives) and

people of South Asian origin (MHRA 2004a). Those

who fit the criteria are offered lifestyle advice and

a statin may be dispensed. If people do not fulfil

the pharmacy screening protocol and are not offered

the drug, they should still be offered appropriate

lifestyle advice. If on screening, someone is identi-

fied as high risk he or she should be given lifestyle

advice and encouraged to consult the GP for advice

and management, as further investigation and treat-

ment may be required.When using the pharmacy protocol, it is not essen-

tial to obtain the results of a cholesterol test before

commencing the statin. However, to track how cho-

lesterol levels are responding to the drug, which

may be important to ensure continuation of the

therapy, as well as to monitor its effectiveness, it

may be useful to recommend that a cholesterol test

is performed when therapy is started and possibly

on a yearly basis afterwards.

Statins do differ from each other in molecular

structure and each has a slightly different mode

of action. They may also have different side effects

and cerivastatin was withdrawn, due to excess

cases of rhabdomyolysis (muscle breakdown)caused by a previously unknown metabolic path-

way. The pathway through which the drugs are

metabolised is shown in Table 1, which also out-

lines variations in the reduction of total choles-

terol and LDL cholesterol.

It is thought prudent to use the appropriate statin

for the patients risk profile and in these days of try-

ing to achieve NHS targets (NHS 2004) some statin

drugs are viewed as more able to achieve those tar-

gets than others. However, some patients cannot

tolerate large doses of statins and this may influ-

ence the choice of drug prescribed. Recently, the

manufacturers of rosuvastatin advised all prescribers

to commence rosuvastatin at the starting dose of

10mg and titrate carefully, while patients requiring

doses of 40mg and above should be supervised in

specialist centres (MHRA 2004b). This advice was

given as a result of several cases of rhabdomyolysis

that had occurred at the higher dosage.

Statins are safe and generally well tolerated

(DoH 2000a, Minhas 2003, Sacks et al1996,

Shepherd et al2002). The most common side

effects are usually transient gastrointestinal dis-

turbance, liver function test disturbance of unknown

long-term significance (rare) and a spectrum ofmuscle-related side effects ranging from myalgia

(common), muscle inflammation (myositis) to

rhabdomyolysis, a potentially life-threatening

event (BNF 2004). A number of risk factors for

rhabdomyolysis have been identified: older age;

lower body weight; hypothyroidism; concomitant

therapy and other drugs, and it is therefore wise

Health promotion

Drug Dose range Maximum change (%) Lipophilic Metabolic pathwayLDL HDL TG P450 Metabolism

Atorvastatin 10-80mg 50 6 29 Yes 3A4

Fluvastatin 20-80mg 24 8 10 Yes 2C9

Lovastatin* 20-80mg 34 9 16 Yes 3A4

Pravastatin 10-40mg 34 12 24 No unknown

Rosuvastatin 10-40mg 57 10 28 No 2C9/2C19

Simvastatin 10-80mg 41 12 18 Yes 3A4

* Not available in the UK

LDL = Low-density lipoprotein cholesterol; HDL = High-density lipoprotein cholesterol; TG = Triglycerides

(Reproduced with kind permission of Dr Michael Schachter, Department of Clinical Pharmacology, Imperial College, St Marys Hospital, London)

Table 1. Profile of statins



to monitor patients in these categories more

closely (BNF 2004).

Historically, it was suggested that statin therapy

should be taken at night, when the liver synthe-

sises most of the cholesterol. However, the newer

statins (atorvastatin and rosuvastatin) have long

half-lives, remain in the bloodstream for longer andcan therefore be taken at any time of the day.

Statins are often perceived as first-line therapy

after diet and other lifestyle changes. However,

they are not the only drug available to lower cho-

lesterol. There are several other products that can

be used in combination with statins and in some

cases alone to reduce cholesterol and the corre-

sponding risk of CHD. A 10 per cent reduction in

cholesterol leads to a 30 per cent reduction in risk

of CHD (Law et al1994). Other cholesterol-low-

ering products include nicotinic acid, fibrates, resins,

omega-3 fish oils and ezetimibe.

Nicotinic acid The main effect of nicotinic acid is

to inhibit fatty acid release from fat cells in the body.

This reduces the production and levels of LDL

cholesterol to 17 per cent, while increasing levels

of HDL cholesterol up to 26 per cent (Chapman et

al2004). Doses of 2mg per day are required. One

of the major side effects of nicotinic therapy has

been the severe flushing that accompanies the start

of treatment. However, this has been addressed

and newer formulations of nicotinic therapy have

included a dose titration pack to minimise the side

effects that may be experienced (Capuzzi et al1998).

Fibrates These drugs increase the number of LDL

receptors in the liver and have a small effect on the

clearance of LDL through the liver. Their greatest

effect, however, is lowering very LDL (VLDL) and

triglycerides. Fibrates have been safely used in com-

bination with statin drugs in the past, although this

has predominantly been in specialist centres wherecareful and frequent patient monitoring can take

place (Frick et al1987, Rubins et al1999). Data are

awaited from the FIELD trial (due to report in 2005)

for more information about these drugs.

Resins When cholesterol has been made it is stored

in the bile ducts and mixed with food to aid diges-

tion. Preventing the re-absorption of bile salts will

reduce the amount of cholesterol that is mixed with

the salts being reabsorbed. Hence the small reduction

in cholesterol. However, resins are often unpalatable

they are in powder form and are mixed with fruit

juices or yoghurt and their unpleasant side effects

of flatulence, constipation and diarrhoea often mean

that patients are not keen to take them. They are,

however, licensed for use in children. Their cholesterol-

lowering ability is about 14 per cent. They should be

used with caution in patients with raised triglycerides

as they can exacerbate this problem (BNF 2004).

Omega-3 fish oils The benefits of oily fish in

reducing the risk of coronary heart disease are

well documented (Stone 1996). However, two

separate preparations of polyunsaturated fatty

acids (PUFA fish oil supplements) known as

Maxepa and Omacor are available on prescrip-

Health promotion

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Ezetimibe This drug blocks the absorption ofdietary and biliary cholesterol in the intestines. It

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CHD remains a significant cause of death and dis-

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TIME OUT 5Return to the start of the article and look

at the learning outcomes. Reflect also onyour aims at the beginning of this article.

Write a short paragraph under each ofthe learning outcomes to indicate howyou have achieved these outcomes.

TIME OUT 6Now that you have completed the article,you might like to write a practice profile.Guidelines to help you are on page 56.

coronary heart desease

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