Circulatory disorders: The role of primary care physicians

Of the 10 leading causes of death among Americans in 2011 identified by the Centers for Disease Control and Prevention (CDC), five-heart disease, chronic lower respiratory diseases, stroke, diabetes, and nephritis/nephritic syndrome/nephrosis-were related to diseases of the circulatory system. Increasingly, it's falling to primary care physicians (PCPs) to manage these diseases among their patients.

The good news, when it comes to treating these diseases, is that their causes are well known and largely controllable. 

Factors such as genetics, age, and environment play some part in their development and severity, but not nearly as large a role as smoking, obesity, lack of exercise, and poor diet.

The bad news is that these so-called lifestyle factors are very difficult to change, and PCPs are the ones responsible for helping their patients deal with these conditions.

According to the 2010 National Ambulatory Medical Care Survey, 35% of patient visits for circulatory-related problems were to PCPs, compared with only 19% to cardiologists. So it’s PCPs who must find ways to help patients make the lifestyle alterations necessary for coping with these diseases-or better yet, avoid getting them in the first place.

“We can address obesity, smoking, diet, and sedentary lifestyle, and by so doing, change the course of heart disease,” says Kathy Magliato, MD, FACS, board president of the American Heart Association-Greater Los Angeles division and director of women’s cardiac services at St. John’s Health Center in Santa Monica, California. “That’s where the PCP can have the greatest impact both on the clinical level and the economic level. Because by preventing these illnesses they’re also helping to lower healthcare costs overall.”

Next: The importance of developing healthy habits while young

Early prevention is key

The key to minimizing the risk of developing heart disease, diabetes, stroke, and similar diseases is developing healthy lifestyle habits at a young age, says Daniel Spogen, MD, FAAFP, chair of the department of family medicine at the University of Nevada School of Medicine in Reno.

“We know people don’t get obese overnight, they start when they’re kids, with incorrect eating habits and inadequate exercise,” Spogen says. “So if we can get them to be living those healthier lifestyles at a younger age, we can avoid a lot of the chronic disease we see in the 50 and older population.”

According to the CDC, 18% of children aged 6-11 and 21% of adolescents aged 12-19 were obese in 2012, up from 7% and 5%, respectively, in 1980. Overall, more than one-third of children and adolescents were overweight or obese. One positive sign: The percentage of obese children between the ages of 2 and 5 had fallen to 8.4%, compared with 13.9% in 2003-2004.

Spogen, who sees patients in a faculty-run family practice in Reno, says he and his colleagues begin checking body mass index (BMI) and other risk factors for obesity as part of pediatric visits. Later, as adolescents, they expand to other risk factors such as family history of heart disease, stroke, and hypertension, and begin emphasizing the importance of diet, exercise, and smoking avoidance.

The art of discussing weight with patients

Although some PCPs find lifestyle discussions with patients difficult, Spogen looks at them as part of the art of medicine.

“I might say to a patient, ‘I’m seeing on your chart that your BMI is 32, and the recommended level is 25, what can we do to help get your body weight down?’ You don’t want to upset them, but you do want to point out that the road they’re going down will likely lead to things like diabetes and heart attacks.”

Next: Persistence is key when helping patients change habits

Persistence is crucial, he adds. “The first time you have the discussion it usually goes nowhere. The second time maybe a few patients will listen to you, but you keep on revisiting it.” He also advises quizzing patients to find if there are any roadblocks preventing them from attaining their goals. If, for example, the patient hasn’t been exercising due to a knee problem, the doctor could help identify exercises that don’t involve use of the knee. “That’s the kind of discussion you want to have,” he says.

The support of family members is essential for persuading patients to alter their lifestyle and making the change stick, says Charles Cutler, MD, FACP, an internal medicine practitioner in Norristown, Pennsylvania. If a patient needs to lose weight but the patient’s spouse prepares the meals, then the spouse needs to be part of the weight-loss strategy discussion.

The same holds true for smoking. “You can talk all you want about quitting, but it’s much more difficult when someone else in the house is smoking,” he says. Conversely, nonsmoking family members, such as a teenage child, can be enlisted to support the adult trying to quit.

Setting attainable goals

Regardless of the change the patient is trying to achieve, it’s important to set attainable goals-and to have patience in attaining them.

“Huge changes hardly ever happen,” Cutler says. “If a patient needs to lose 50 pounds I would start with a goal of maybe three pounds per month over a couple of months, so we’re talking about 10 pounds to start with, then we can raise the bar for another 10 pounds. I think it’s a mistake to talk about losing a huge amount of weight, even over a long period of time, because it just leads to frustration and noncompliance.”

A dietary log can be an effective tool for helping patients improve their diet and lose weight, says Joseph Giaimo, DO, FCCP,

Joseph Giaimo, DOa pulmonologist in Jupiter, Florida.  He asks patients to record what they eat and when, then reviews the log with them during appointments. “You see they may do great during the day but in the evening routinely eats a candy bar or fast food,” he says. “You try to identify those problem areas for them so they can find solutions that will work for them.”

The role of medication 

Along with counseling, medications remain an important part of any treatment plan for circulatory-related diseases and conditions.

Cutler notes that the range of choices for controlling hypertension, hyperlipidemia, and other conditions has been increasing steadily in recent years. Among the classes of drugs he favors are angiotensin receptor blockers and calcium channel blockers, both of which carry relatively few side effects and are mostly available in generic form, making them more affordable to patients. Thiazide diuretics, while an older class of drugs, remain effective and are very inexpensive, Cutler says.

He also recommends the use of nicotine replacement products, most of which are now available without a prescription, to help patients kick the smoking habit.

Next: Confronting socioeconomic factors in patient health

The role of socioeconomic status

A patient’s socioeconomic status may be a consideration when trying to manage circulatory-related ailments, says Mehdi Shishehbor, DO, MPH, a cardiovascular specialist at the Cleveland Clinic in Cleveland, Ohio.

Mehdi Shishehbor, DOMany of his patients live in inner-city neighborhoods, where they lack access to fresh fruits and vegetables, and where high crime can make it dangerous to walk outside for exercise.

Moreover, such patients often lack the means to come for follow-up visits or group sessions. “So if you tell them to go the smoking cessation clinic or to the nutritionist, they’re not going to do it. So I have to educate them to the best of my ability,” he says. Along with personal counseling, he offers patients brochures and other printed materials prepared by the clinic, and refers them to the clinic’s informational websites.

Even the plethora of educational resources available to patients and physicians at a large hospital system are no substitute for someone spending time with a patient, even if it’s not the physician. “I think patients will listen to folks that listen to them,” Shishehbor says. “It doesn’t matter of it’s the nurse, the technician. Whoever is willing to spend the time, that’s who the patient will listen to.”