Article Takeaways:

• Cardiovascular disease is the leading cause of death for American men.
• Men are less likely to seek routine care, which decreases opportunities for patient education.
• Nurse practitioners must be proactive and dedicated when it comes to educating male patients about the risks and signs of CVD.
• Take opportunities to discuss CVD during seemingly unrelated patient visits.
• Maximize patient visits by ordering labs during the visit and scheduling follow-up appointments before the patient leaves.

The Centers for Disease Control (CDC) report cardiovascular disease (CVD) as the leading cause of death for more than 340,000 men in 2017 (“Men and Heart Disease”), and about 7.7% of Caucasian men, 7.1% of African American men, and 5.9% of Hispanic men have coronary heart disease (“Men and Heart Disease”).

By 2035, 45% of the U.S. population are projected to have some form of CVD (Benjamin et al.). The cost for treating CVD and its potential complications (stroke, arterial disease, arrhythmias, heart failure or myocardial infarction) are projected to reach $1.1 trillion in 2035 (Benjamin et al.).

Many of the risk factors (smoking, poor diet, sedentary lifestyle) associated with CVD are preventable with proper intervention and education. The key question for clinicians is how to educate their male patients on prevention or treatment of CVD when men have a tendency to visit primary care providers only when acute issues arise (Rosu, Oliffe & Kelly). Maximizing educational opportunities during patient appointments is imperative to ensure patients have the support and education necessary to improve treatment outcomes related to CVD. 

How Can Primary Care NPs Maximize Education on Cardiovascular Issues?

Discussing cardiovascular health when someone presents for a seemingly unrelated issue requires some planning. Having tools prepared and easily accessible can help expedite the conversation, plant seeds of interest in the patient, and motivate them to participate in developing a plan for improvement. NPs must be proactive and dedicated to educating their patients.

Take a Proactive Approach

With most office visits, vital signs are taken for every patient. This presents an excellent opportunity to educate a male patient on what constitutes a healthy BMI or blood pressure. Even if the blood pressure is normal or the BMI is borderline, clinicians should acknowledge and discuss vital signs with patients. 

This teaching does not have to be time consuming or extensive. Discuss the importance of checking cholesterol and triglyceride levels. Offer guidance on heart health dietary options. Talk briefly about how obesity raises the risk of heart disease. If the patient smokes, discuss smoking cessation options. 

In addition, NPs should consider having some literature prepared for patients to take home and read at their convenience. The literature should be easy to read and follow, like the Fact Sheets available through www.cdc.gov or information on the DASH diet for hypertension management (“In Brief”). Preparation saves time and supports providing a consistent message for patients. 

Tools At Your Fingertips

A quick, but invaluable tool that can be employed while talking to male patients is a cardiovascular risk assessment. The ASCVD Risk Estimator  gauges the patient’s 10-year CVD risk and forecasts the potential impacts of different interventions (Project Risk Reduction by Therapy). Among other data, the tool requires the age, sex, race, blood pressure, HDL, LDL and total cholesterol. If lipid panel results are not available, contrasting normal values with abnormal is still a valuable tool in helping a patient understand how cholesterol can impact CV risk. The risk estimation, forecasts, and advice can be emailed directly to the patient. The tool is available online and as an app on smartphones. 

Another tool that is available in a smartphone application is the USPSTF Prevention Task Force ePSS (USPSTF Prevention Task Force). This application allows the clinician to know specifically which routine screenings (including those related to CV health) are recommended for patients based on age and gender.

While time may be limited during an appointment, patients can be encouraged to leverage technology by tracking heart rate, blood pressure, and pulse through various smartphone applications or watches. Schedule a follow up appointment in the future to discuss this data as well as any lab results that may be available. 

Maximize Opportunities to Educate When Obvious (or Not So Obvious) Risk Factors are Present

Obesity is a significant risk factor for CVD. The prevalence of obesity among American adults in 2017-2018 was 42% (“Adult Obesity Facts”) but a recent survey reported 65% of providers did not discuss patient weight due to concerns of needlessly embarassing the patient (Kaplan et al.) (Taylor, J.). 

If a patient comes in for knee pain, for example, being prepared to discuss how weight loss can improve the knee pain and how weight loss may improve CVD risk is reasonable–particularly for patients with Type 2 Diabetes (Wing et al.). If a male patient shares concerns about excess stress at work or at home, this is the perfect opportunity to review CVD risk and potential evaluation and treatment options. A 20-year-old male patient coming in for URI symptoms may not understand how his family history impacts his CV risk, so take the opportunity to discuss it during his appointment. All of these scenarios open a window for discussion of CV risk and possible mitigation strategies.

Maximize Patient Visits

For convenience, consider consolidating tasks whenever possible. As discussed, men are less likely to seek routine care. If clinicians discuss cardiovascular risk and plan for a follow up appointment in the future, what guarantees the patient will return? Consider ordering labs such as an A1C or lipid panel even if the patient is not fasting. Non-fasting total cholesterol and HDL levels are acceptable when assessing initial CVD risk in an untreated patient or when clarifying the diagnosis of metabolic syndrome (Driver et al.). 

In some cases, the male patient may only consent to having laboratory tests completed because he is present. The goal is to take advantage of immediate diagnostic testing opportunities because the patient may not return for routine ancillary services in the near future. Schedule a follow up appointment for lab review before they leave. When possible, offer telephone or virtual appointments to address lab results. Involve any accompanying family members (spouse, significant other, parents) in the conversation. Loved ones are often important allies in encouraging patients to follow through with recommendations or plans of care.

While a patient may be visiting their clinician for completely unrelated issues, having a plan for follow up may be just the encouragement they need to begin understanding their own CV risk and strategies to improve that risk.  

 

References

Adult Obesity Facts. (2020, February 27). Retrieved June 17, 2020, from https://www.cdc.gov/obesity/data/adult.html 

Benjamin, E., Virani, S., Callaway, C., Chamberlain, A., Chang, A., Cheng, S., Chiuve, S., Chusman, M., Delling, F., Deo, R., de Ferranti, S., Ferguson, J., Fornage, M., Gillespie, C., Isasi, C., Jimenez, M., Jordan, L., Judd, S., Lackland, D., … Muntner, P. (2018). Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association. Circulation, 137(12), e67-e492. https://doi.org/10.1161/CIR.0000000000000558 

Driver, S., Martin, S., Gluckman, T., Clary, J., Blumenthal, R., & Stone, N. (2016, March 15). Fasting or Nonfasting Lipid Measurements. Retrieved June 19, 2020, from https://www.onlinejacc.org/content/67/10/1227?_ga=2.110563011.71685167.1527180849-984926680.1511967792 

In Brief: Your Guide To Lowering Your Blood Pressure With DASH. Retrieved June 19, 2020 from https://www.nhlbi.nih.gov/files/docs/public/heart/dash_brief.pdf 

Kaplan, L., Golden, A., Jinnett, K., Kolotkin, R., Kyle, T., Look, M., . . . Dhurandhar, N. (2017, October 31). Perceptions of Barriers to Effective Obesity Care: Results from the National ACTION Study. Retrieved June 19, 2020, from https://onlinelibrary.wiley.com/doi/10.1002/oby.22054 

Men and Heart Disease. (2020, January 31). Retrieved June 17, 2020, from https://www.cdc.gov/heartdisease/men.htm 

Project Risk Reduction by Therapy. (n.d.). Retrieved June 19, 2020, from http://tools.acc.org/ASCVD-Risk-Estimator-Plus/ 

Rosu, M. B., Oliffe, J. L., & Kelly, M. T. (2017). Nurse Practitioners and Men’s Primary Health Care. American Journal of Men’s Health, 11(5), 1501–1511. https://doi.org/10.1177/1557988315617721. 

Taylor, J. (2020). Looking Beyond Lifestyle: A Comprehensive Approach to the Treatment of Obesity in the Primary Care Setting. The Journal for Nurse Practitioners, 16(1), 74-78. DOI: https://doi.org/10.1016/j.nurpra.2019.09.021

USPSTF Prevention Task Force. (2018). USPSTF (4.0.10) [Mobile app]. App Store. https://apps.apple.com/us/app/uspstf-prevention-taskforce/id311852560

Wing, R. R., Lang, W., Wadden, T. A., Safford, M., Knowler, W. C., Bertoni, A. G., Hill, J. O., Brancati, F. L., Peters, A., Wagenknecht, L., & Look AHEAD Research Group (2011). Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes care, 34(7), 1481–1486. https://doi.org/10.2337/dc10-2415