Optimising Medicines in Cardiovascular Care: A Multidisciplinary Approach

April 9, 2024May 16, 2024 Danielle Norton

Medication Adherence in Cardiovascular Disease (CVD)

Medication adherence is a complex multifactorial process, with problems arising when either (a) the medical team fail to start or intensify guideline recommended treatment (therapeutic inertia); or (b) when the patient’s actual intake of medication is sub-optimal.1

Although patient adherence to prescribed medication can vary and wane over time,2 adherence to cardiovascular medications is crucial for risk reduction following a cardiac event, and medication non-adherence is consistently associated with poorer clinical outcomes and subsequent re-hospitalizations. 3,4

Despite the therapeutic benefits, many patients do not persistently adhere to their prescribed cardiovascular medications.5

A recent large meta-analysis estimated that approximately one third of patients after a cardiac event are nonadherent, irrespective of the cardiac medication prescribed.6

Similarly, the European Society of Cardiology (ESC) state that adherence to medication remains sub-optimal, ranging from 50% in primary prevention to 66% in secondary prevention.7 Additionally, 9% of atherosclerotic cardiovascular disease (ASCVD) events in Europe are estimated to occur as a result of sub-optimal medication adherence.7

Cardiac Rehabilitation (CR)

Cardiac rehabilitation (CR) has been identified as an opportune environment to optimise pharmacological therapy & improve long term outcomes in cardiac patients. This model of care for secondary prevention is recognised by the ESC as a Class 1A recommendation to improve outcomes for patients with ASCVD and heart failure.8 CR is primarily delivered in an outpatient setting by a multi-disciplinary team (MDT) of healthcare professionals coordinated by specialist nurses. Several CR core components have been identified which favourably impact mortality and morbidity,9 including patient assessment, blood pressure, weight, diabetes and lipid management, tobacco cessation, psychosocial care, physical activity and nutritional counselling.9 Each of these components may also necessitate the prescription of medications for cardiovascular protection and disease prevention.

CR: an ideal setting to optimise treatment adherence

Due to its systematic process of care delivery, collaborative team approach and emphasis on continuity of care, CR is viewed as the ideal setting to optimise adherence in patients with CVD. For example, a recent cross sectional study of medication adherence in patients with CVD identified that two factors positive beliefs about medication and the ability to refill medications were independently predictive of greater cardiac medication adherence, and the authors concluded that cardiac nurses were ideal candidates to deliver such a service.10 Registered Nurse Prescribers (RNPs) in particular can greatly enhance service provision. In a review of the role of nurse prescribers, Wilson and colleagues identified this practice as safe, cost-effective, and necessary, resulting in “health system and healthcare efficacy gains” and patients receiving “assured, timely and rapid access to needed care”.11 Clinical pharmacist intervention is also strongly linked with improved cardiac outcomes through drug optimisation, avoidance of adverse events, medication reconciliation and patient education.12

Beaumont Hospital’s CR Programme

Our dedicated multi-disciplinary team – comprising of specialist cardiac nurses, nurse prescriber, dietitian, pharmacist and smoking cessation specialist – provides comprehensive care to individuals affected by heart disease. Additionally, the psychologist’s role is fully integrated within the CR programme to provide another facet of comprehensive cardiac care. As well as providing psychological care, the psychologist’s remit extends to targeting ‘normal’ psychological processes underpinning health behaviour change and treatment adherence during CR. Integrated care is ensured by seamless cooperation between MDT members, and the Medical Director (consultant cardiologist) supervises the quality of care provided by the CR team.

CR patients typically attend a 10-week supervised exercise circuit programme (30 exercise sessions) in conjunction with 1-2 group education/self-management sessions per week delivered by either a nurse, dietitian, pharmacist or psychologist. Close monitoring of blood pressure, lipids and glycaemic status is also conducted throughout CR. All patients have their medications reviewed during CR and approximately one in three have their medications adjusted during the programme.13 Interestingly, exercise attendance during CR has been shown to serve as a ‘carrier’ for other important health behaviours. Similar to the dose-response relationship between exercise and mortality,14 greater exercise adherence in CR is associated with greater improvements in (objectively measured) adherence to cardiovascular medications.15,16

The Registered Nurse Prescriber (RNP) in CR

Legislation giving prescriptive authority to nurses and midwives in Ireland was introduced in 2007. Registration is awarded by the regulatory body of the Nursing and Midwifery Board of Ireland (NMBI) when candidates meet the required criteria. The practice standards and guidelines for Nurses and Midwives with Prescriptive Authority from the NMBI (2019) outline the legislation requirements and provide the foundation on which to build an appropriate scope of practice whilst maintaining professional competency.

During CR, risk factor assessment is conducted for each participant with optimal medical treatment as an end goal. This presents the nurse prescriber with optimal conditions to ensure patients are receiving the best possible medical therapy for their diagnosis. The National Institute for Health and Care Excellence (NICE) guidelines for medicines outline the importance of patient involvement in decision-making and how to support patients who are prescribed medicines.17 Non-adherence to medications can result in deteriorating health, limited response to medications that are taken and cost ramifications. NICE outlines the duty of the prescriber to help patients by implementing key principles such as adopting a “no-blame” approach, involving patients in decision-making, reviewing medications & communicating between healthcare professionals.

For the RNP in a CR setting these principles are easily applied and continuity of care facilitates review in a timely manner. Accordingly, a recent study by Thomson and colleagues found that by addressing medication adherence early in CR the odds of treatment persistence at 6 months increased by 13.5 times.18

Working within a multi-disciplinary service is particularly conducive to safe and effective prescribing.

For example, a review by Peterson and colleagues concluded that for patients with heart failure, reduced hospitalizations may be the result of an MDT disease management programme, whereby increased access to the team by patients resulted in high-quality, evidence-based care through education, close follow-up and medication titration as required.19

In addition to the MDT members outlined above, the wider CR community also incorporates Advanced Nurse Practitioners (ANPs) in a variety of related roles such as chest pain management, heart failure, and arrhythmia management. This facilitates excellent clinical leadership, and the support of the MDT enhances collaborative practice, governance, and risk management.

For the new Nurse Prescriber, the responsibility of prescribing for patients can be daunting. Safe prescribing for the patient whilst maintaining professional standards is of paramount importance. To optimise the safety of prescribing in CR certain elements and practices should be integral to the scope of practice. Establishing the correct environment is important. For clinical decision-making, a review of patient medical notes, an open discussion with the patient and a physical examination need to be conducted. Appropriate space that allows for confidentiality is also a requirement. Evaluation and interpretation of test results prior to prescribing will ensure appropriate prescriptive authority, and this may even include the discontinuing of medications for a patient. The scope of practice is determined through consultation and agreement with the CR Medical Director (Consultant Cardiologist).

As Beaumont Hospital’s rehabilitation unit is located within an acute hospital this information is often readily to hand for the team. Thus the practice standard of managing the medication cycle appropriately is easy to implement. As an out-patient department there are no drugs stored within this setting and the prescription of medication can be clearly separated from administration as patients are given the prescription to fill at home.

For the RNP, evaluation of prescribing practice through the medium of audit is a requirement in this setting, and forms part of the scope of practice framework document. National audits are also available for use co-ordinated by the Office of the Nursing and Midwifery Services Director (ONMSD). Auditing allows for the review of prescriber practices and can help identify areas of treatment below the necessary requirements for best practice. For example, if an audit of practice revealed that most RNP prescriptions are for lipid-lowering statin therapy as patients are not at desired targets, this may prompt a review of the current practices of the medical team’s prescribing of these drugs at discharge. Audit also allows the RNP to review prescribing practices and minimise risk, for example, by determining if the writing of the prescription meets the practice standards of the NMBI.20

The Pharmacist in CR

The day-to-day work of the clinical pharmacist assigned to Cardiology in Beaumont Hospital includes working in the Coronary Care Unit (CCU). Here patients are cared for at the very start of their journey, having just experienced a very serious and potentially life-changing event. By contrast, the weekly Cardiac Rehab pharmacy sessions occur in a more positive environment where patients are at the other side of their journey.

This represents an ideal time to provide more in-depth education about medication, as patients have had time to come to terms with what has happened and are typically not as overwhelmed as they would have been when all the medications were first introduced.

Cardiology is a fulfilling speciality to work in as a pharmacist, as there are strong evidence-based treatment guidelines and medications that will benefit our patients immensely if used correctly. There are also clearly defined targets for risk factor reduction, such as LDL cholesterol, to help motivate our patients and guide us in their treatment. Having the opportunity to improve adherence through education sessions is particularly rewarding.

Pharmacy educational intervention: In preparation for each pharmacy group education session, each patient’s history and medication list are reviewed, and the CR nurses are consulted to determine if there are any particular concerns that patients in the group may have. Each small group session (up to 6 patients) begins with the pharmacist’s introduction, and then inviting the patients to introduce themselves and briefly describe the events leading to them coming to CR. This enables the pharmacist to understand the patient’s perception of their condition and to elicit any concerns they might have. Having the patients start off the session themselves helps to open up a discussion rather than taking the form of a formal teaching session or a lecture. Once each participant has had an opportunity to share their experiences, the pharmacist discusses each medication class in turn. Patients receive explanations as to what the medications are, their indication, how they relate to the patient’s condition and how they can be of benefit. As with other disciplines in CR, a variety of behavioural change techniques (BCTs) may be employed by the pharmacist, and sometimes creative descriptions and analogies are required to help patients visualise their condition and its associated treatment. Where there is a wide variety of cardiac conditions in the CR group, a larger number of medications require discussion, and so every session is tailored to the specific group in attendance.

As the session progresses, the pharmacist helps each patient in the group understand which medications are relevant to them personally, as not all patients will be on the same medications or have the same cardiac condition. Common side-effects for each drug class are also discussed and patients are encouraged to share anything unusual that they may have experienced. Possible barriers to adherence are discussed and problem-solved collaboratively with patients, and tips to improve adherence are also shared among the group.

Practicalities such as the best time to take medications, missed dose procedures, sick-day rules and planning for travel are also discussed. Written material is provided to patients, including the Irish Heart Foundation medication booklet,21 the HSE ‘My Medicines List’22 and anticoagulant information booklets, where applicable. This allows patients to refer back to the information received in the group session when needed.

Every effort is made for patients to feel comfortable sharing issues they have regarding adherence, adverse effects and any medication-related concerns they may have. There is also an opportunity to have a private discussion with the pharmacist if the patient would rather not share something in a group setting. This way, any identified problems can be addressed by providing reassurance or advice and/or referring to CR nursing colleagues as needed. A key strength of Beaumont’s CR programme is having an RNP as part of the MDT, which allows for prompt changes to medication to be made as appropriate.

Once the discussion starts, most patient groups will have plenty of questions. It is always gratifying to hear someone say “I’m glad I asked you that” which is heard at least once at every session! It’s also rewarding to see that someone’s mind has been put at ease by providing an open environment and adequate time to answer their questions. A key objective of the pharmacy session is to try to instil in each patient a sense of ownership over their medication. It is emphasised that medications will be part of their long-term management and that they can, and should, regularly ask their GP to ensure the dose and choice of each medication is still right for them once they have moved on from hospital-based care. Patients are also reassured that if they do develop adverse effects in the future, there are actions that can be taken to alleviate these. A change in drug or dose is often possible, so they never need to suffer in silence or be afraid to say they can no longer tolerate a medication. Having this information empowers patients to advocate for themselves and their health long after Cardiac Rehabilitation has finished.

The Role of the Psychologist in Treatment Adherence

A growing evidence base suggests that adherence to cardiovascular treatment is largely a psychological phenomenon influenced by the nature of the event itself, perceptions of illness and beliefs about medicines.23,24 As an example, depression is a strong predictor of non-adherence to CVD medications25 with depressed cardiac patients up to three times more likely to be non-adherent.26-28 Furthermore, it has been estimated that up to 70% of medication non-adherence is intentional.29 Beliefs about medications significantly impact treatment adherence in cardiac patients, particularly perceptions of personal need for treatment (necessity beliefs) and concerns about the potential adverse consequences of taking medications. Perceived necessity for and concerns about cardiovascular medicines have been independently associated with adherence to statins, beta-blockers and ACEi/ARBs respectively.30-32

Both illness perceptions and treatment beliefs are targeted as part of the Psychosocial Management component of Beaumont Hospital’s CR programme. A selection of strategies are outlined below:

Screening:

Brief validated screening measures assessing both beliefs about cardiac medication and self-reported adherence are administered to all patients at baseline assessment.33,34
The screening tools themselves are patient-centred in that their very wording normalizes medication non-adherence, reinforcing a ‘no-blame’ approach to discussing medication concerns during CR.
Screening results are used to identify patients at risk of medication non-adherence, and this is discussed with the CR nurse and/or pharmacist as appropriate.

Psychoeducational Group Sessions (Health Behaviour Change)

Adaptive beliefs about heart disease which foster medication adherence are also targeted:
Helping patients to adopt a view of heart disease as primarily caused by modifiable risk factors35
Adopting a ‘chronic’ (as opposed to ‘acute’) model of illness which is linked with greater treatment adherence36
The group dynamic in CR is particularly useful to facilitate medication adherence if moderated skillfully. As most patients are adherent, a discussion of adherence in this context can be gently guided so that non-adherers are exposed to important ‘pro-adherence’ feedback from their peers. For example:
A patient describing how initial side-effects experienced disappeared after a short period.
A patient describing how they worked successfully with their doctor to address side-effects by changing / reducing the dose of medications.
A group member attributing their own repeat cardiac event to having suddenly discontinued cardiac medications by themselves.
During CR patients also learn to psychologically ‘reframe’ adhering to their medications as a form of empowerment (i.e. an action they choose to take whereby they feel more in control of their health) as opposed to evoking feelings of dependence or reminders of a compromised health status.
Where therapeutic alliance is well established, the ‘nocebo effect’ and symptom attribution (e.g. overlap with other factors) may be discussed with patients.
Teaching patients how to ‘google’ effectively (e.g. obtaining accurate information from reputable medical sites).
Addressing unintentional nonadherence (e.g. forgetting): teaching strategies to help routinise medication taking and increase habit strength (e.g. ‘implementation plans’).
In individual patient consultations with the psychologist (or other MDT member), motivational interviewing may also be employed with ‘flagged’ at-risk individuals.

Digital Health: Use of Multimedia

A series of smart screens are utilised in both our CR waiting area and exercise gym to exploit the educational opportunities presented when patients wait between each hourly exercise class and/or during the exercise sessions themselves (i.e. make every contact count). Thus, medication adherence intervention(s) in CR are further reinforced by a series of motivational audio-visual content directly targeting this topic as part of the CR patient education curriculum.

To conclude, interventions that address patient beliefs such as self-reported low necessity and high concerns about medications are likely to improve both adherence and clinical outcomes,37 particularly if depression is targeted concurrently.

While strategies for improving adherence are generally recommended to adopt a multifaceted approach, simple one-component interventions have shown similar results when compared to more complex interventions.39 In CR, the challenge is to deliver effective interventions that are seamless, efficient and exploit the synergy of the MDT.

References available on request