Quick Guide to Conducting CHD Reviews

The QOF indicators CHD001 (Protected), CHD005, CHD015, and CHD016 relate to Coronary Heart Disease (CHD). As a pharmacy professional in general practice, particularly one who has had training in cardiovascular examinations, you may have to undertake CHD reviews. CHD reviews are crucial for the ongoing management of patients with cardiovascular conditions. In this guide we look at the key components involved in a CHD review, including the need for antiplatelets or anticoagulants, blood pressure targets, and other critical aspects of patient care.

Definition and Conditions Covered Under Coronary Heart Disease (CHD):

Coronary Heart Disease encompasses several conditions related to the narrowing or blockage of coronary arteries, which can lead to reduced blood flow to the heart muscle. Conditions include:

• Stable Angina: Chest pain or discomfort due to reduced blood flow to the heart.
• Unstable Angina: Sudden and unpredictable chest pain, often occurring at rest.
• Myocardial Infarction (Heart Attack): Blockage of blood flow causing damage to the heart muscle.
• Silent Ischemia: Reduced blood flow without noticeable symptoms.
• Coronary Artery Spasm: Temporary, sudden narrowing of the coronary arteries.

Key Components of a CHD Review:

1. Patient Assessment:
   • History and Symptoms: Review the patient’s medical history, current symptoms, and any changes since the last visit. Assess for chest pain, dyspnea, palpitations, and fatigue.
   • Medication Review: Check adherence, side effects, and the need for any changes or adjustments in therapy.
   • Risk Factors: Assess and document risk factors such as smoking, cholesterol levels, diabetes, hypertension, and family history of heart disease.
2. Physical Examination:
   • Conduct a thorough physical examination, focusing on cardiovascular signs such as heart sounds, peripheral pulses, signs of heart failure (e.g., edema, jugular venous distension), and any other relevant findings.
3. Blood Pressure (BP) Monitoring:
   • For patients aged ≤ 79 years:
     • Target BP: ≤ 140/90 mmHg (or equivalent Home Blood Pressure Monitoring [HBPM] values).
   • For patients aged ≥ 80 years:
     • Target BP: ≤ 150/90 mmHg (or equivalent HBPM values).
   • Use accurate and calibrated devices for measuring blood pressure, and consider multiple readings to confirm the diagnosis.
4. Blood Tests:
   • Monitor lipid profiles (total cholesterol, LDL, HDL, triglycerides), renal function (e.g., creatinine, eGFR), liver function tests, and HbA1c (if diabetic).
5. ECG:
   • Consider performing an ECG to detect any ischaemic changes, arrhythmias, or other abnormalities. Compare with previous ECGs to identify new or worsening issues.
6. Lifestyle Advice:
   • Provide comprehensive guidance on diet (e.g., reducing saturated fats, increasing fiber, maintaining a balanced diet), regular physical activity (at least 150 minutes of moderate exercise per week), smoking cessation, and alcohol consumption (limit intake to within recommended guidelines).

Antiplatelet and Anticoagulant Therapy:

1. Antiplatelets:
   • Indication: Recommended for all patients with CHD unless contraindicated.
   • Common Drugs:
     • Aspirin: 75-100 mg daily.
     • Clopidogrel: 75 mg daily, used as an alternative to aspirin if not tolerated.
     • Prasugrel: Usually prescribed for patients undergoing percutaneous coronary intervention (PCI), at a dose of 10 mg daily (5 mg daily for patients weighing <60 kg or aged ≥75 years).
   • Purpose: Prevent thrombotic events by inhibiting platelet aggregation.
   • Duration of Dual Antiplatelet Therapy (DAPT): Typically 12 months post-acute coronary syndrome (ACS) or stent placement, unless there is a high risk of bleeding. After 12 months, continue with a single antiplatelet agent, usually aspirin.
2. Anticoagulants:
   • Indication: For patients with CHD who have additional risk factors such as atrial fibrillation, mechanical heart valves, or a history of thromboembolic events.
   • Common Drugs:
     • Warfarin: Dose adjusted to maintain INR within therapeutic range (usually 2.0-3.0).
     • Direct Oral Anticoagulants (DOACs): Dabigatran, Rivaroxaban, Apixaban, Edoxaban.
   • Purpose: Reduce the risk of thromboembolism by inhibiting blood clot formation.

Regular Monitoring and Follow-up:

1. Frequency:
   • Generally, every 6-12 months for stable patients, but more frequent reviews may be necessary for high-risk patients or those with recent changes in their condition or treatment.
   • Ensure closer monitoring of blood pressure, lipid levels, and any new or persistent symptoms.
2. Patient Education:
   • Inform patients about the importance of adherence to medication, lifestyle modifications, and regular follow-up appointments.
   • Educate on recognising symptoms of worsening CHD, such as increased frequency or severity of angina, shortness of breath, and when to seek immediate medical help.
3. Documentation:
   • Record all findings, management plans, and follow-up schedules in the patient’s medical record.
   • Use standardised templates or checklists (such as the Ardens templates on EMIS-Web and SystmOne) to ensure comprehensive review and consistent monitoring.

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