The presence of cardiovascular risk factors in patients with arterial hypertension has been examined in many studies. According to Badego et al (2020), the most frequent risk factors in people with hypertension are obesity and smoking, and de Souza Filho et al (2018) found that people with hypertension had higher values of body mass index, waist circumference, visceral fat and body fat than non-hypertensive individuals. At the same time, studies have demonstrated that patients with hypertension have very low levels of adherence to recommended guidance on managing their cardiovascular risk factors. For example, in Warren-Findlow and Seymour's (2011) study 58.6% of patients adhered to their medication regimen, less than 25% followed the recommended diet guidance, 25% continued to smoke and less than 30% maintained a recommended body weight.
Evidence that patients with hypertension demonstrate poor management of cardiovascular risk factors has highlighted the need for a tool that can be used to assess an individual's total cardiovascular risk.
The European Society of Hypertension (ESH) (Mancia et al, 2013) recommended that the assessment of total cardiovascular risk is essential for the risk stratification of patients with hypertension. The major cardiovascular risk factors are smoking, diabetes mellitus, sedentary lifestyle, total cholesterol, obesity, age and sex; more specifically, men have a higher risk of cardiovascular diseases than women (Hayen et al, 2010). A patient's health history and clinical assessment are therefore significant factors for assessing the presence of cardiovascular risk factors in patients' lives (Williams et al, 2018). The development of scales and algorithms to assess total cardiovascular risk is essential for health professionals to enable them to both evaluate a patient's risk of a cardiac event and recommend the most appropriate therapeutic regimen that patients should follow (D'Agostino et al, 2013; Woringer et al, 2017).
The European Society of Cardiology (ESC) (2021) recommends the Systematic COronary Risk Evaluation (SCORE) (Figure 1) as the most appropriate tool for clinicians to use to assess a patient's total cardiovascular risk (Mancia et al, 2013). The SCORE tool enables practitioners to estimate a patient's 10-year risk of fatal cardiovascular disease after the first atherosclerotic event, taking into account their sex, age, smoking habits, cholesterol levels and systolic blood pressure (Piepoli et al, 2016).
Figure 1. Score: European risk chart. 10-year risk of fatal cardiovascular disease in high risk regions of Europe by gender, smoking status, age, systolic blood pressure and total cholesterol
Based on the SCORE project, the ESC and the European Association for Preventive Cardiology (EAPC) developed HeartScore® (EAPC, 2021), an online risk calculator that clinicians can use to assess a patient's risk of cardiac events and stroke. To estimate a patient's risk, the HeartScore calculatory requires the clinician to input the following information:
- Date of birth (to assess age)
- Sex,
- Systolic blood pressure reading
- Total cholesterol and high-density lipoprotein (HDL) levels
- Body mass index
- Whether the patient is a smoker.
It is important to note that the European guidelines on the prevention of cardiovascular diseases recommend that treatment should be initiated in individuals whose cardiovascular risk has been assessed as being above 5% (Mancia et al, 2013). The patient's risk is calculated by matching the individual's level of cholesterol (4-8 mmol/L) to their level of systolic blood pressure (120-180mmHg) and cross-referencing to their age (40-65 years) and smoking status. If a patient's score falls into a red area, then their total cardiovascular disease (CVD) risk is above 5%.
The HeartScore tool has been used in many studies to estimate the cardiovascular risk of patients with chronic diseases such as coronary artery disease and in those who have undergone kidney transplantation (Sørensen et al, 2012; Jankowski, 2013; Diederichsen et al, 2015; Gozdowska et al, 2016; Kawińska-Hamala et al, 2017). In Greece, the authors' country, three studies in which HeartScore was used were identified. Two studies included patients with coronary artery disease, and the third included patients with hypertension (Stamatelopoulos, 2008; Lambrinoudaki, 2013; Papadopoulou, 2016). However, none of the studies investigated how an educational intervention provided by nurses could contribute to reducing a patient's total cardiovascular risk.
It is urgent that health professionals develop and implement methods and strategies with the aim of reducing cardiovascular risk factors in patients with hypertension. Pladevall et al (2010) showed that educational interventions can lead to a decrease in systolic and diastolic blood pressures (P=0.013). They also found that patients with hypotension who received the educational intervention experienced fewer cardiac events than those who did not take part in the educational intervention (16% versus 19% respectively, P=0.0012).
The aim of the study described in this article was to assess the impact of an educational intervention on the total cardiovascular risk of patients with arterial hypertension with the aid of the HeartScore tool.
Methods
Design
This interventional randomised study was conducted at a general hospital in Athens, Greece. At the time of the study, a total of 424 patients with hypertension were registered in the hypertension unit and were reviewed in the unit every 3 months. However, an important variance (2–5 years) was observed regarding the duration of the patients' follow-up in the unit.
Participants
The researchers recruited a total of 92 hypertensive participants who visited the Clinical Hypertension Unit between 10 December 2017 and 23 March 2018. Patients were randomised into two groups, a control and an intervention group, with the selection of participants for both groups standardised for sex, age and education level. The inclusion and exclusion criteria were that patients:
- Were aged between 40-65 years
- Were Greek nationals
- Were native Greek speakers
- Were able to communicate verbally
- Had been taking antihypertensive medication for at least 1 year prior to the study.
Data collection
Demographic and socioeconomic questionnaire
The questionnaire consisted of several items to obtain information on each patient's age, gender, educational level, employment status, current marital status, the heredity of hypertension, and lifestyle factors (sedentary, active).
HeartScore
HeartScore, the online interactive counterpart of the original SCORE risk charts, is an important tool in predicting and controlling the risk for any cardiac event and stroke. It is based on the 2003 European Guidelines on Cardiovascular Disease Prevention (Conroy et al, 2003). HeartScore is a quick tool that provides a visual representation of CVD risk. With the help of the health professional, patients can match their systolic blood pressure and cholesterol levels with their age and smoking habits to estimate their risk of CVD. Being able to visualise where they fall on the CVD risk chart enables patients to understand their individual level of risk, which ranges from green, or low risk, to red, or high risk. In addition, a visual representation of a patient's status on the chart at baseline and follow-up visits enables the health professional to assess the effectiveness of an intervention and encourages patients to make behavioural changes (Piepoli et al, 2016). The score is based on measurements of systolic blood pressure, total cholesterol, and smoking habits. It is important to note that the actual risk for some patients will be higher than that calculated using the tool in some groups, namely:
- Patients who have a sedentary lifestyle
- Individuals who are overweight,
- Those who are socially isolated
- Patients with a family history of sudden cardiac death,
- Patients with diabetes mellitus, high LDL cholesterol and/or high triglyceride levels
- The risk will also be higher in patients without any symptoms, but in whom the presence of atherosclerosis has been identified via diagnostic methods, such as heart catheterisation.
Figure 1 provides the classification of cardiovascular risk based on systolic blood pressure, total cholesterol and smoking habits for men and women, according to the European Society of Cardiology (Piepoli et al, 2016). It should be noted that the HeartScore model is suitable for use only with patients aged 40-65 years and that the tool classifies as smokers those who smoke more than seven cigarettes a week.
In the present study, the authors used the Greek version of the HeartScore tool, which is available in country-specific versions (Williams et al, 2018). The researchers distributed the demographic questionnaire in the clinical environment, which took patients about 2–3 minutes to complete. In addition, for both the intervention and control group each patient's medical history was retrieved from the records, providing past information on blood pressure, blood lipids, blood glucose and smoking habits.
Following this, hypertension specialist nurses with academic and clinical experience in the management of hypertension provided patients in the intervention group with education and counselling about the definition of hypertension, and the appropriate manner and importance of measuring their blood pressure at home. Information was also provided regarding patients' medication regimen and non-pharmaceutical measures for managing hypertension. More specifically, the nurses highlighted the importance of patients adhering to their medication regimens in order to both manage their blood pressure and prevent a cardiac event. Patients were also provided with specific information about diet, salt and alcohol consumption, the management of bodyweight, and physical activity. For example, it was stressed that recommended daily salt intake should be below 5 g and patients also received guidance on daily alcohol consumption: women should not consume more than 10-20 g of alcohol a day and men no more than 20-30 g a day. With reference to medication regimen, researchers highlighted the importance of patients taking their medication as prescribed. Smokers were referred to relevant services to help them quit; however, there are few services in Greece and the waiting times are long.
Finally, the nurses provided patients with an educational handbook for patients to use as a reminder of the information provided any time they wished, along with a printout of their HeartScore risk infographic.
The intervention took place once at baseline assessment. The data were collected at baseline assessment, then after 3 months and 12 months. The nurses in the research team were trained in methods of counselling and motivational interviews, and delivered the patient education and counselling in face-to-face sessions.
Ethical considerations
The study was approved by the ethics committee of the hospital (17929/19-7-13). A written consent form was obtained from all participants. The investigation conformed to the principles outlined in the Declaration of Helsinki (Emmett et al, 2005).
Data analysis
Descriptive statistics were used for the demographic and clinical characteristics of the sample. Percentages and frequencies were used for the categorical variables, while means and standard deviations (SD) were calculated for the continuous variables. The mean scores were compared using the t-test, and Student's t-test was applied to compare the qualitative variable between the two groups. The variance of the measurements through the follow-up period was calculated via linear mixed models. The Pearson coefficient (r) was used to test correlation between two quantitative variables. Correlation is weak when the value of r is between 0.1 and 0.3, moderate when r is between 0.31 and 0.5, and strong when r>0.5. The significance level was set at P less than 0.05. All analyses were performed using the statistical software package SPSSv20.0.
Results
Demographic and clinical characteristics
A total of 67 patients were enrolled in the intervention group, with 47 participating in the 3-month and 12-month follow-ups and completing the study. In the control group of 59 patients 45 attended both follow-ups and completed the study (Figure 2). The participants lost to both groups chose to visit alternative hospitals closer to their residence and so did not complete their follow-up as part of the research groups. Most participants in both groups were women: 56.6% in the control group and 55.4% in the intervention group; however the difference was not statistically significant between or within each group (P>0.05). Regarding the stage of hypertension, the majority of patients in both groups had stage I hypertension, but this did not affect the effectiveness of the intervention (P=0.019). The demographic and clinical characteristics of the sample are presented in Table 1.
Figure 2. Participation and attrition in the intervention and control patient groups
Table 1. Demographic and clinical characteristic of the sample.
| Group | P Pearson's χ2 test | |||||
|---|---|---|---|---|---|---|
| Control | Intervention | |||||
| n | % | n | % | |||
| Gender | Men | 21 | 43.3 | 21 | 44.6 | 0.563 |
| Women | 24 | 56.6 | 26 | 55.4 | ||
| Age (years) (SD) | 64.4 | 66.2 | 0.085 | |||
| Stage of hypertension | Pre-hypertension | 12 | 26.6 | 13 | 27.6 | >0.05 |
| Stage I | 21 | 46.8 | 21 | 44.7 | >0.05 | |
| Stage II | 7 | 15.5 | 7 | 14.9 | >0.05 | |
| Isolated high systolic blood pressure | 5 | 11.1 | 6 | 12.8 | >0.05 | |
HeartScore
At baseline assessment, systolic blood pressure was at the same level in the two groups, as was rate of variation during the 12-month follow-up period (P>0.050). Regarding total cholesterol, at baseline, participants in the intervention group (n=67) had higher levels of cholesterol than the controls (n=59). Although there was a reduction in cholesterol levels in both groups during follow-up period, the rate of decrease in intervention group patients who completed the study (n=47) was significantly higher than in the controls who completed it (n=45) (P<0.05). Finally, 8.0% of the control group had smoked at baseline assessment, a percentage that dropped to 5.3% over the 12 months (P>0.050). In contrast, the percentage of smokers in the intervention group had been 10.6% at baseline assessment, increasing to 13.6% over the 12 months. Few of the patients were able to attend smoking cessation services due to the lack of such initiatives in Greece. However, the difference was not statistically significant (P>0.050).
Table 2 and Table 3 show systolic blood pressure, total cholesterol and smoking habits in both groups over the 12-month follow-up period.
Table 2. Mean of clinical characteristics of individuals with hypertension
| Time | ||||
|---|---|---|---|---|
| Baseline | 3 months | 12 months | ||
| Group | Mean (SD) | Mean (SD) | Mean (SD) | |
| Systolic blood pressure (mmHg) | Control | 146.3 (15.4) | 147.6 (16.1) | 146.8 (15.5) |
| Intervention | 142.8 (11.6) | 144.1 (12.6) | 143.1 (11.7) | |
| Diastolic blood pressure (mmHg) | Control | 87.4 (10.8) | 86.9 (11.7) | 86.2 (11.5) |
| Intervention | 87.8 (8.9) | 88.6 (8.2) | 87.9 (9.5) | |
| Total cholesterol (mg/dL) | Control | 206.7 (53.4) | 200.1 (50.9) | 176.1 (23.9) |
| Intervention | 215.6 (41.4) | 206.9 (40.0) | 198.4 (39.1) | |
| Smoking (%) | Control | 25.0 | 22.0 | 22.0 |
| Intervention | 20.0 | 18.0 | 21.0 | |
SD=standard deviation
Table 3. Mixed linear model clinical characteristics of patients with hypertension
| Time | Group | Interact time-group | ||||
|---|---|---|---|---|---|---|
| β (SE) | P value | β (SE)* | P value | β (SE) | P value | |
| Systolic blood pressure | 0.02 (0.07) | 0.789 | -2.95 (1.65) | 0.073 | ||
| Total cholesterol | -1.56 (0.35) | <0.001 | -7.43 (5.64) | 0.188 | -1.21 (0.49) | 0.013 |
| Smoking | -1.71 (0.22) | <0.001 | -14.43 (7.37) | 0.050 | ||
SE=standard error
In terms of total cardiovascular risk, at baseline assessment, the score was higher in the control group than the intervention group, 9% versus 7%, but this difference was not statistically significant (P>0.05). Over the 12-month follow-up period, however, there was a reduction in total cardiovascular risk in the intervention group, from 4.75 to 4.33 (P>0.05), compared with the controls, whose risk increased from 10.03 (n=55) to 12.65 (n=45) (P=0.035).
Discussion
The present study aimed to assess the contribution of a nurse-led educational intervention in managing total cardiovascular risk in individuals with hypertension. At baseline assessment, systolic blood pressure and total cholesterol were at the same levels in the two groups.
Past studies have examined the impact of educational interventions on the management of blood pressure, with most reporting that patients who received the intervention achieved better management of blood pressure (Glynn et al, 2010; Rahimdel et al, 2019). For instance, a Cochrane review by Glynn et al (2010) found that studies that applied the theory of planned behaviour improved the adherence of individuals with hypertension. In three of the studies reviewed, patients' urinary sodium and potassium levels and systolic and diastolic blood pressures were measured over 24 hours to assess the impact of the interventions (Glynn et al, 2010). The review found that patients in the studies' intervention groups achieved a significant reduction in urinary sodium and potassium levels, resulting in a decrease in both systolic and diastolic blood pressures.
A study by Rahimdel et al (2019) tested the impact of reminder devices on patients' medication adherence and, consequently, the management of blood pressure. The researchers concluded that patients achieved a higher level of adherence, which in turn resulted in better management of blood pressure. These findings are supported by the results of a study by Williams et al (2018), who found that each educational intervention is effective to the parameter that the education is negotiated. For instance, an educational intervention results in an improvement in medication adherence, when it focuses on the medications, their side-effects and the significance of the medication taken. However, according to the World Health Organization (2013, age, gender, educational status and religion are the main factors that influence patients' adherence to clinicians' recommendations.
The results of these studies reinforce, and are in keeping with, the findings of the study described in this article, since the intervention used by the authors aimed to educate patients about the context of the recommendations for managing their chronic disease. Moreover, emphasis was placed on the importance of patients following recommended therapeutic regimens, with the authors aiming to increase patient adherence. Another common thread between the findings of this study and those of previous studies is that both the intervention in the present study and the interventions in the studies cited above aimed to change patient behaviours with regard to the management of arterial hypertension.
In addition, the educational intervention, which included advice on diet, alcohol consumption and physical activity provided in the present study, resulted in a decrease in total cholesterol in both groups; however, the improvement was greater in the intervention group. A literature review undertaken by the authors via electronic databases identified very few studies that looked at the effects of educational interventions on blood lipids in individuals with hypertension. One study, by Al-Wehedy et al (2014), showed a significant decrease in total cholesterol, triglycerides and LDL, and an increase in HDL. The findings of Cicolini et al (2014) showed that a nurse-led educational intervention resulted in a 40% reduction in total cholesterol and a 56% reduction in LDL among people with hypertension. Another study by Wong et al (2015) showed that although an educational intervention decreased the level of blood lipids, the difference was not statistically significant (Wong et al, 2015). Nonetheless, a knowledge gap is observed in this specific field and more studies are needed.
Concerning the main outcome of the study, the educational intervention was found to have significantly reduced total cardiovascular risk in the intervention group. More specifically, total cardiovascular risk dropped from 4.75% to 4.33,% whereas it increased in the control patients by 2.62% (P=0.035). As already mentioned, the HeartScore tool estimates total cardiovascular risk based on systolic blood pressure, total cholesterol and smoking habits. Even though the present study showed a significantly greater reduction in the intervention group for level of cholesterol only, and failed to reduce blood pressure and smoking habits compared with the control patients (P<0.05), the analysis deduced an important decrease in total cardiovascular risk.
It is important to note that many studies have examined total cardiovascular risk in patients with cardiovascular diseases. However, only a few have investigated the effects of educational interventions on total cardiovascular risk. For example, Davies et al (2008) found a reduction in HeartScore values among patients receiving an educational intervention. Meanwhile, a study by Law et al (1994) demonstrated that a 10% reduction in total cholesterol is associated with a 50% decrease in total cardiovascular risk for patients aged 40 years, a 40% fall for those aged 40–50 years old, and a 30% fall for those aged over 60 years.
Another study (Poldervaart et al, 2017) concluded that the calculation of HeartScore in patients with chest pain leads to a decrease in major adverse cardiac events. More specifically, the incidence of major adverse cardiac events was 1.3% in patients to whom the HeartScore was applied and 2.0% among those receiving usual care. The study also indicated that the use of the HeartScore tool could lead to a reduction of €40 million for healthcare costs each year in the Netherlands (Poldervaart et al, 2017).
The small sample size in this study could affect the generalisation of the findings, so there is a need to conduct a similar study involving greater cohorts of participants.
Conclusion
It is clear that the use of the HeartScore tool in clinical practice is a valuable addition to the prevention of any cardiac event, and also contributes to reducing healthcare costs. However, the application of HeartScore to estimate an individual patient's cardiovascular risk was enhanced by the educational intervention provided by nurses. Previous studies have shown that patients tend to adopt and follow suggested self-care behaviours provided by health professionals, thereby achieving better management of hypertension.
KEY POINTS
- The assessment of a patient's total cardiovascular disease (CVD) risk is important in the management of hypertension
- Although many studies have examined the impact of educational interventions on the management of hypertension, only a few have looked at the outcomes within the context of total CVD risk
- The results of this study showed that a nurse-led educational intervention resulted in significant improvement in the management of hypertension and thereby reducing patients' overall CVD risk
CPD reflective questions
- Nurses have an important role in managing hypertension. How could the nurse's role be extended?
- Consider the obstacles that might prevent nurses providing educational interventions to patients and how these could be overcome
- It is vital that health professionals understand the importance of patients adhering to a therapeutic regimen and the information that patients require to encourage them to do this. What issues should be covered as part of patient education to improve adherence?