Dr Nigel Watson describes an audit carried out in his practice to improve the care of CHD patients and hence reduce the associated mortality and morbidity


The prevention and management of coronary heart disease (CHD) was identified as a major priority for the Government in the Health of the Nation document,1 and reinforced in the National Service Framework for Coronary Heart Disease2 published last year.

CHD is a major cause of death in both men and women below 75 years of age. Reduction in deaths from CHD is a local and national priority.

The purpose of this audit was to establish the baseline of current care provided to patients aged <75 with established CHD. Having identified the problems with the current system, we would then put in place an action plan and repeat the audit.

Aims of care

The aims of care for patients with established CHD in the practice are to reduce the morbidity and mortality associated with CHD.


  • To recognise the symptoms of CHD and initiate appropriate investigations, management and treatment.
  • To encourage compliance with lifestyle changes and therapy.
  • To review all patients with CHD at least annually.
  • To maintain a disease register for all patients with CHD.
  • To encourage patients to take responsibility for their health.

Definition of CHD

The category of CHD includes a diagnosis of one or more of the following:

  • Myocardial infarction (MI)
  • Angina pectoris
  • Heart failure.

All patients aged <75 years with CHD should:

  • Be on a CHD database.
  • Have blood pressure measured in the past 12 months.
  • Take aspirin unless contraindicated.
  • Be screened for diabetes mellitus in the past 5 years.
  • Have a serum cholesterol measured in the past 5 years.
  • Have smoking status recorded in the past 5 years.
  • Have BMI measured and recorded in the past 5 years.


Table 1 (below) shows standards for the audit of patients aged <75 with CHD.

Table 1: Standards for the audit

All patients aged <75 with coronary heart disease:
  • To be on a coronary heart disease database
  • To have blood pressure measured in the past 12 months
  • To be taking aspirin unless contraindicated
  • To be screened for diabetes mellitus in the past 5 years
  • To have cholesterol measured in the past 5 years
  • To have smoking status recorded in the past 5 years
  • To have body mass index recorded in the past 5 years

Criteria for annual follow-up

Record blood pressure

Hypertension is an independent risk factor for CHD and there is a progressive increase in MI, angina pectoris and sudden death associated with an increase in blood pressure.

Control of blood pressure should follow the British Hypertension Society Guidelines for hypertension management 1999.3

The targets for blood pressure measured in the clinic are:

Optimum <140/85mmHg
Suboptimum <150/90mmHg

Optimum <140/80mmHg
Suboptimum <150/90mmHg

Check patient is taking aspirin unless contraindicated

All patients with CHD should receive aspirin indefinitely, unless there are contraindications. Aspirin reduces the absolute risk of vascular events by 3.6%, and also decreases non-fatal MIs, non-fatal strokes, vascular deaths and all-cause mortality.4 Doses of 75–150mg of aspirin are effective.

Test and record urine for glucose

Diabetes mellitus is an independent risk factor for CHD. There is also an increased incidence of diabetes mellitus in patients with CHD.

Check lipid levels

There is good evidence that all patients with established CHD benefit from a reduction in cholesterol levels. Dietary advice and modification will reduce cholesterol level by 5–10%.

If drug treatment is required, a statin is the best form of treatment.

The target is to reduce cholesterol levels to <5mmol/l and total cholesterol/HDL ratio to <3.

If cholesterol level is <5mmol/l, repeat measurement every 3 years. If cholesterol level is 5 mmol/l repeat measurement annually, and consider treating with a statin.

Record smoking status and advice given to smokers

Smoking is an independent risk factor for heart attacks and stroke and sudden death. Repeated advice, guidance and support on how to stop smoking are thus of major importance.

If a patient with CHD stops smoking their risk of death is reduced by around 50% over a 5-year period.2

Record BMI

BMI >30 is associated with an increased risk of hypertension and diabetes mellitus. It is therefore suggested that the target should be to achieve a BMI <30 and preferably <25.2

It should be noted that there are no randomised controlled trials to show that a reduction in weight improves the outcome in CHD.

A computerised search of all patient computer records to identify all those with a history of CHD was undertaken in November 1999 and repeated in September 2000 (see Table 2 and Figure 1, below). The records of these patients were then searched for the above data.

Table 2: Comparison of results of the two computer searches

  Nov 1999 Sep 2000
Total no. patients aged <75 10555 10185
Total no. patients aged <75 with CHD 406 (3.9%) 353 (3.5%)
No. patients with myocardial infarction 147 135
No. patients with angina pectoris 268 233
No. patients with heart failure 57 45


Figure 1: Age and sex distribution of patients with known CHD, Sep 2000
bar chart


The results of the computer searches carried out in November 1999 and September 2000 are summarised in Table 3 and Figure 2 (below).

Table 3: Audit summary – comparison of achievement vs standards

Aim: To improve current monitoring of patients aged <75 years with coronary heart disease
  November 1999 September 2000 Change in % Standard
All patients aged <75 with CHD 406 354   100%
  Total % Total %    
BP recorded in past 12 months 277 68% 294 83% +15 90%
Currently taking aspirin or aspirin contraindicated 214 53% 275 78% +25 90%
Screened for diabetes in past 5 years 263 65% 268 76% +11 90%
Cholesterol measured in past 5 years 265 65% 280 79% +14 90%
Smoking status recorded in past 5 years 229 56% 291 82% +26 90%
BMI measured in past 5 years 234 58% 229 65% +7 75%


Figure 2: Improvement in care
bar chart

The disease database reflects the fact that the practice is 'paperless' and all data are entered on the computer.

There was no formal call/recall system for patients with CHD until April 2000.

Monitoring of patients had probably largely relied on symptom control and thought was not always given to specific monitoring measures.

Cholesterol levels are surprisingly low, but may also reflect poor data received from the hospital.

Aspirin recording largely reflects prescriptions and few patients have code entries for over-the-counter aspirin or aspirin contraindicated.

The low levels of recording of smoking status, BMI and blood pressure reflect the poor uptake of the well person clinic.

Action taken following the first audit

  • The results of the audit were fed back to the doctors and nurses.
  • A practice protocol was agreed and distributed.
  • All nurses attended CHD training.
  • A call/recall system was developed for all patients with CHD.

The decrease in total patients aged <75 years reflects closure of the practice list to new registrations in August 1999.

The decrease in total patients with CHD is partly due to closure of the practice to new registrations, but also reflects the fact that all patient records have been reviewed. The review revealed a number of patients with incorrect computer entries for CHD. The second audit excluded these patients.


Initially the practice needed to ensure that all patients were being reviewed regularly and that there is a standard data set. This has been achieved through the call/recall system.

The call/recall system has only been in operation for 6 months. Initially, high-risk patients or those who had not been seen for more than 1 year were targeted.

GPs are monitoring some patients with CHD during routine follow-up appointments, but are poor at checking BMIs and updating health promotion data, e.g. smoking status. The monitoring is better done by the practice nurses.


  1. Department of Health. The Health of the Nation: A Strategy for Health in England. London: HMSO, 1995.
  2. Department of Health. National Service Framework for Coronary Heart Disease. London: The Stationery Office, March 2000.
  3. Ramsay LE, Williams B, Johnston GD et al British Hypertension Society guidelines for hypertension management 1999: summary. Br Med J 1999; 319: 630-5.
  4. MeReC Bulletin: Secondary prevention of myocardial infarction. Number 2, 1999, Vol 10.

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Guidelines in Practice, February 2001, Volume 4(2)
© 2001 MGP Ltd
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