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Keith Loria is a contributing writer to Medical Economics.
There is convincing evidence that counseling interventions improve blood pressure, lipid and fasting blood glucose levels, body weight/adiposity and eating habits. Improvement in these areas will strengthen heart health.
The American Heart Association warns that cardiovascular disease — be it coronary heart disease, heart attack, congestive heart failure or congenital heart disease — is the leading cause of death for men and women in the United States.
Proper prevention includes not smoking, lowering cholesterol, controlling high blood pressure, maintaining healthy weight and exercising. However, many patients are not going to make these life-changing moves without some persuasion.
According to the United States Preventive Services Task Force, there is convincing evidence that counseling interventions improve blood pressure, lipid and fasting blood glucose levels, body weight/adiposity and eating habits. Improvement in these areas will strengthen heart health. Changing behavior can be difficult, so physicians must have conversations to ensure their patients stay healthy. Such relationships can help patients and providers work through health challenges and reach desired outcomes.
Nicole Harkin, M.D., FACC, founder and cardiologist at Whole Heart Cardiology in San Francisco, says up to 80% of heart disease is considered preventable, so these conversations can literally save lives. “It’s so important to talk with patients about heart disease because it is the No. 1 cause of death in the United States for both men and women,” Harkin says. “We know from studies that patients are more successful with personalized plans. Generalized health guidance is rarely successful, and most people need advice that is applicable and customizable.”
Erica Savage-Jeter, M.D., a primary care physician practicing in South Carolina and regional medical director for Partners in Primary Care, a senior-focused medical practice, notes creating dialogue with patients is vital to establishing relationships and building trust. “In my counseling, it is my goal to understand the patients’ perspective when talking about interventions that lead to proper heart health,” she says. “I need to understand their sense-making related to their health. Until patients have buy-in and feel the advice I am providing is meaningful to their health, I will have very little impact.”
David Cutler, M.D., family medicine physician in Santa Monica, California, says the keys to bringing up the topic of cardiovascular health are being a good listener, providing accurate information and making the discussion relevant to the patient.
“Active listening requires putting the patient’s concerns above those of the health care provider,” he says. “Dispelling inaccurate myths is important to maintain credibility. And recognizing that the cardiovascular health needs of a 40-year-old male with a family history of premature cardiac death are different than a 90-year-old nursing home resident with dementia means a ‘one-size-fits-all’ approach to heart health will not work. Diet, medication and activity modifications must be individualized.”
When talking to patients and their families about heart health, Cutler notes it is important to spend more time listening than talking. “Only after eliciting all their health concerns, prior experiences and fears associated with treatment and changing behaviors is it likely to achieve positive results,” he says. “A comprehensive and continuous approach to care will provide reassurance to them, and they will have a partner in the process of achieving better heart health.”
Heart health during COVID-19
Tiffany Sizemore, D.O., FACC, a cardiologist in Fort Lauderdale, Florida, notes heart disease was proved to be a risk factor for COVID-19, so physicians must do all they can to prevent heart disease. “Seeing that 2020 has been the year of illness, I hope that we have learned the importance of preventive health,” she says. “I encourage all my patients to know their blood pressure, know their blood sugar, know their cholesterol and take charge of their own health. Unlike many illnesses, heart disease is preventable in the vast majority of people.”
Cardiologist and internist Leonard Pianko, M.D., working in Aventura, Florida, says COVID-19 is a vascular disease, so it affects blood vessels, big and small, and it is important to remain focused on all leading causes of health impairment during the pandemic. “By cutting down on the risk factors for COVID, including losing weight, monitoring your blood pressure and cholesterol, etc., you are lowering your risk not only for COVID but also for cardiovascular disease,” he says.
Pianko notes the media has made it easy to bring up the subject with patients, who are confronted daily with sobering statistics on the number of individuals hospitalized with COVID-19 or who have died from the disease. “The COVID conversation provides an easy segue to prevention tips for heart health,” he says. “Even when the vaccine is readily available, it might be anywhere up to (a) year for us to achieve herd immunity. It is unpredictable who will have COVID as well as who will survive COVID.”
Proper health tips have not changed with COVID-19, but patients are more receptive because of ongoing concern about the disease. “My top tip for discussing proper heart health with my patients is tailoring the conversation to their specific health needs,” Pianko says. “By knowing their personal history and their family history as well, I can personalize the experience and focus specifically on those tips that will make a difference in their lives. It’s the investment of time and energy into the doctor-patient relationship which promotes success.”
Tips for the talk
To have dialogue with patients, Savage-Jeter says it is important to create a cadence with appointments to provide that opportunity. “Episodic care does not allow patients the occasion to spend time with their providers that may not be related to an acute issue,” she says. “Creating routine follow-up allows for discussions that are more relaxed and may not compete with pressing issues.”
She also tries to empower her patients to help them succeed. “I want my patients to understand their medical problems, learn how to manage them and avoid complications, and be aware of signs of decompensation or sequelae,” she says. “Empowering my patients will lead to overall increased satisfaction with care, improved adherence to self-management of the treatment and better clinical outcomes.”
Harkin says conversations about heart health should be as patient centered as possible, covering goals, where the patient wants to start and barriers to improving heart health. “Meeting the patient where they are at and working toward incorporating small changes within their current lifestyle are the keys to establishing long-term, sustainable habits,” she says. “I use a lot of motivational interviewing in counseling patients. I also think that focusing on small, sustained goals that are measurable by the next appointment can be great motivators.”
Sizemore says the key to bringing up heart health is to focus on what causes heart disease. “As physicians, we refer to these as modifiable and nonmodifiable risk factors,” she says. “Modifiable risk factors include things we can control, such as high blood pressure, cholesterol and blood sugar. Nonmodifiable risk factors include family history, gender and age. By addressing each risk factor individually, we can help patients to help themselves and understand what they can do on their own to prevent heart disease.” She also feels it is imperative to focus on the positive — for instance, saying things like “you have lost 10 pounds” or “you stopped smoking, good for you.”
“When we focus on the positive, we create a healthier system of reinforcement moving forward for patients,” Sizemore says. “I always tell my patients, ‘I can prescribe a medication, but I can’t make you take it.’ That is my way of saying that the patient ultimately controls their own destiny. I am always happy to and encourage patients to ask questions. I always want them to 100% understand anything that we discuss.”
More frequent appointments in the beginning stages of change are helpful, Harkin notes, and she also recommends a team approach to total heart health. “I love working with registered dieticians and health coaches who can work with the patient more frequently in moving the heart health plan forward, so I always recommend referrals for more focused counseling,” she says.
Cutler conducts yearly wellness evaluations to address obesity, high blood pressure, high cholesterol, diabetes, smoking and family history, all of which can contribute to heart health problems. “We personally notify patients of all their results and make ourselves available with follow-up appointments, virtual visits and telephone consults to review results, answer questions and plan ongoing care,” he says. “The essence of good primary care is being accessible, comprehensive, continuous and high quality. This certainly applies to heart health, but equally to all aspects of patient care.”