Preventing heart disease in practice. Case 2
A woman in her forties comes in asking for some patches to help her give up cigarettes. The pharmacist finds out that she is a heavy smoker, 20-30 per day, and has smoked for 25 years. She knows that she is overweight and struggles to keep it down. She managed to stop smoking for about 3 months once, but put on weight. She has a family history of diabetes and two of her grandparents died of heart attack in their seventies. Her uncle who is 60 years has angina. She saw her general practitioner (GP) about 1 year ago who told her that her cholesterol level was mildly raised at 6 and her blood pressure was borderline. She was supposed to go back for a review but hasn’t done so yet.
The pharmacist’s view
I would ask this woman to tell me about her previous attempt to quit, including whether she used Nicotine replacement therapy (NRT) that can be bought OTC; in many parts of the UK and US, pharmacies are part of local NHS smoking cessation services and can provide treatment. Many people are concerned that they will put on weight when they stop smoking and I would talk with her about this. The health benefits of stopping smoking far outweigh any additional risk from being overweight, and discussing the figures can get this point across. Talking about what happened after she stopped smoking last time including her diet and eating patterns might provide some ideas about minimising weight gain this time.
The doctor’s view
It is very encouraging that she wants to do something about her smoking, especially as she has several risk factors for coronary heart disease (CHD). I think the pharmacist is in a good position to counsel and perhaps advise an appropriate NRT It would be useful to ascertain how she managed to stop last time and the reasons for starting cigarettes again. The pharmacist is also in a position to offer advice about her weight and find out about her level of physical exercise. It would also be helpful to suggest a review at her GP’s surgery to follow up her blood pressure and cholesterol. It is likely that the GP would want to do some blood tests: fasting lipid profile, fasting blood glucose, electrolytes and renal function, and liver profile. In addition, a urine test checking for proteinuria and glycosuria would be useful and, possibly, an electrocardiogram. If after three readings she remained hypertensive, medication such as an angiotensin-converting enzyme inhibitor may be advised. Of course, if she were able to lose weight and increase exercise, this would also help to lower her blood pressure.
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