Identification of cardiac risk factors, in particular modifiable risk factors, is a fundamental component of the assessment of patients with CVD and HF so that timely intervention can halt disease progression. Encourage patients to think about their needs by using the Cardiac Rehabilitation Needs Assessment Tool.

Based on the assessment undertaken, identify cardiac risk factors that require attention.

Behaviour change and patient education strategies are critical to supporting risk factor modification.

The clinician should act as a lifestyle coach working with patients to prioritise goals as multiple life-style changes can be overwhelming. Usually it is more effective to encourage the patient to start with one or two behaviour changes and to set lower, short term achievable goals to enhance confidence and motivation.

Assessment and management for each cardiac risk factor are outlined below. Detailed interventions are provided in the National Heart Foundation of Australia reducing risk in heart disease expert guide to clinical practice for secondary prevention of coronary heart disease. [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

The General Practice (GP) management plan provides a template for overall intervention and is suitable for use by all rehabilitation professionals.

• Age and gender: CVD is more common with increasing age. Men are at greater risk of heart disease than pre-menopausal women, however once past menopause, the risk for women is similar to that of men. There is similar risk of stroke for both men and women
• Family history: Risk is increased for a first-degree blood relative that has had coronary heart disease (CHD) or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative)

It is therefore, important to note family history of CAD, MI, cardiomyopathy, sudden cardiac death, congenital heart disease, valvular heart disease, or Marfan’s syndrome.

The following should be recorded:

• Body Mass Index (BMI). Record height and weight with the patient wearing minimal clothing and removal of shoes and calculate BMI using the calculator
• Waist circumference. Target for women is <80cm and for men is <94cm. See Waist size calculator
• Usual weight. Post event weight, particularly post cardiac surgery, may reduce, temporarily, so it is important to establish the patient’s usual weight to generate discussion about realistic goals
• Rapid weight changes (i.e., 2 kg over 1-2 days) can indicate fluid overload or dehydration, particularly with concomitant HF

If overweight, investigate the following areas:

• The person’s perception of their weight and ideal healthy weight
• Weight history: Identify factors potentially causing increasing weight as well as precursors such as smoking cessation, divorce, pregnancy, menopause, new medications; previous attempts and methods of losing weight
• Previous consultation with a  dietitian or other health professional regarding diet or weight

Aim for: [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

• Waist measurement <94cm (men) and <80cm (women)
• Body mass index (BMI) = 18.5–24.9 kg/m2

Aiming to reach a BMI below 25 kg/m2 may be unrealistic or unachievable for some people. In such cases smaller, realistic targets may be chosen. A weight loss of 5-10% of the patient’s original weight can produce improvements in cardiovascular and metabolic health.

BMI and waist circumference calculators can help patients monitor progress.

Identify influences on food choices such travel, finances, convenience, irregular meals, culture, or religion

Be aware of patients at risk of malnutrition.

Nutrition Education Materials Online (NEMO): Weight control resources

Obtain an overview of the person’s usual diet by asking for recent typical examples. Note:

• Fruit and vegetable intake
• Regularity and type of take away food eaten
• Addition of sugar, salt, fat to food
• Methods of cooking
• Portion sizes
• Type of saturated fat eaten
• Impact of culture, religion or income on food choices
• Use of over the counter dietary supplements
• Ability to read and understand food labelling

Aim to establish and maintain healthy eating. This includes: [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

• Limiting saturated fatty acid (SFA) intake to <7% and trans fatty acid (tFA) intake to <1% of total energy intake
• Consuming 1 g eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) and >2 g alpha linolenic acid (ALA) daily
• Limiting salt intake to ≤ 4 g/day (1550 mg sodium)
• Limiting caffeine intake

ALA is an omega 3 fatty acid found in canola or soybean based oils and margarine spreads, seeds, nuts, legumes, eggs and green leafy vegetables. [#national-heart-foundation-of-australia.-2009]

EPA and DHA requirements can be achieved by eating 2-3 servings of 150 g of oily fish a week and supplementing intake with fish oil and omega-3 enriched foods.

Some cultures use products that are high in salt and may not consider reducing intake unless foods are specifically mentioned such as soya sauce, fish sauce, and dried foods preserved in sugar or salt.

Limit the intake of caffeinated beverages to 1-2 cups a day as excessive caffeine may exacerbate arrhythmias and increase heart rate (HR) and blood pressure (BP).

Diet is associated with strong beliefs, attitudes and habits. Customs and festivities can also strongly influence our dietary behaviours. There are also common myths surrounding foods, for example some people think that some forms of sodium are better than others such as rock salt, whereas the impact of all sodium is the same.

If the heart condition is secondary to alcohol (e.g., alcoholic cardiomyopathy), advise abstention.

Establish as accurately as possible:

• Drinking habits before and after the cardiac event and also what they are currently
• Estimated intake of standard drinks per day by asking the patient directly about the amount and type of alcohol imbibed
• Total alcohol free days per week

Aim to limit consumption of alcohol to a low-risk level for patients with CVD who drink. [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

See Australian national guidelines for alcohol consumption.

For information see the Smoking cessation section. The Cost of smoking calculator and Fagerström test for nicotine dependence are useful tools.

Unless contraindicated, structured exercise training and regular physical activity should be part of the health management plan for all patients with cardiovascular disease.

Determine the following:

• Type, volume, and intensity of physical activity pre and post cardiac event
• Patient’s understanding of physical activity intensity (e.g., gardening vs. walking)
• Presence of comorbid health conditions that impact on the patient’s ability to exercise (e.g., musculoskeletal disorders)
• Perceived barriers and limitations to exercise

Aim for at least 30 minutes of moderate-intensity physical activity on most, if not all, days of the week (i.e., 150 minutes/week minimum). This amount can be accumulated in shorter bursts of 10 minutes duration and can be built up over time. For patients with advanced CVD, the target amount of physical activity may need to be reduced. [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

Any progress towards reaching the recommended goal is beneficial. See changing exercise and activity behaviour. [#national-heart-foundation-of-australia.-2009] See Exercise for more information.

Assess:

• Fasting lipid profile prior to cardiac event (if possible) as test results post MI are unreliable for up to 2 months
• Current cholesterol lowering medicines prescribed and date of commencement
• Patient’s understanding of healthy/good cholesterol (HDL) and damaging/bad cholesterol (LDL)
  
  Lipid profiles and target levels to aim for in patients with CVD are shown in the table below.

Table 1: Lipid profiles and associated target levels for patients with known cardiovascular disease (CVD) [#national-heart-foundation-of-australia.-2009]

More information is available in Cardiac Society of Australia and New Zealand guidelines for the diagnosis and management of familial hypercholesterolaemia. [#cardiac-society-of-australia-and-new-zealand-2013]

Target blood pressure (BP) for those with known CVD is <130/80 mmHg. This includes patients with or without diabetes and/or stroke/transient ischemic attack (TIA) and/or microalbuminuria (men >2.5 mg/mmol, women >3.5 mg/mmol).  [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

For people with hypertension note:

• Use of antihypertensive medications and date initiated

Any factors that could be contributing to hypertension such as recent medication changes or lifestyle factors (e.g., sodium intake, weight gain, alcohol use, activity level)

For tools and information see hypertension management.

 The diabetes risk assessment tool rates the risk of developing type 2 diabetes over the next five years

Known diabetics

Record :

• Fasting blood glucose level, glycosylated haemoglobin (HbA1c), oral glucose tolerance test (OGTT) prior to cardiac event, if available, or review inpatient fasting glucose assessment, if performed
• Whether the person has been reviewed by an ophthalmologist or  optometrist in the previous 2 years
• Date of last podiatry review (this should also be done yearly)
• Note the patient’s access to a diabetic expert and diabetes care providers.
• It is important that patients with previously undiagnosed type 2 diabetes are identified.

For inpatients with known diabetes, aim to maintain optimal blood glucose level (HbA1c ≤7%), but be mindful of the potential harmful effects of optimising blood glucose control (particularly weight gain). [#national-heart-foundation-of-australia-and-the-cardiac-society-2012]

• See Australian diabetes guidelines
• Ensure patient follows appropriate foot, eye care etc., with relevant specialist follow up

Patients with depression or other signs of psychological distress should receive appropriate psychological and medical management. [#national-heart-foundation-of-australia-and-the-cardiac-society-2012] See Treating psychological distress