Cardiovascular disease is the most important cause of death in world today with life time risk at 40 of 1 in 2 for men and 1 in 3 for women in developed countries¹. It is also emerging as a leading problem in the developing world and it is expected that by 2010 cardiovascular diseases will be the leading cause of death in developing countries². W.H.O has drawn attention to the fact that C.H.D is our modern epidemic i.e. a disease that effects the population and not an unavoidable attribute of aging³. The number of people who suffer from heart diseases in United Arab Emirates is not known and only some data is available. However coronary heart disease has been established as a number one killer in United Arab Emirates and number of deaths attributed to C.A.D. is 25%. This is expected to increase to 35% during the next 5 years if there is lack of concentrated effort to contain this disease.

Cardiovascular disease is non-communicable, preventable, predictable and curable. The etiology of C.H.D is multi-factorial. Apart from obvious ones such as increasing age and male sex, studies have identified a number of modifiable risk factors which could be managed by primary prevention strategies. Presence of anyone of the risk factors places an individual at high-risk category for developing CHD. The important thing about risk factors is that they are identifiable and manageable prior to the event they predict. Recent trials in high-risk subjects demonstrated dramatic reduction in risk of approximately 35 %- 55% in 5 years with risk reduction therapies. This provides strong support for the concept that coronary artery disease and its complications can be prevented by therapeutic lifestyle changes along with the medical therapy.

The need for the preventive strategies to overcome the growing menace of CHD is well recognized. General practitioner's role in meeting this challenge is to identify patients at risk and provide comprehensive advice and appropriate management to reduce their risks. Although general practitioners appear to be in an excellent position to offer preventive care, there is evidence that they currently don't detect or intervene for common risk behaviours⁴. The aim of this study is to explore the current practice of general practitioner detection and management of CVD risk factors in their patients, in one of the rural health centers in Abu Dhabi.

This study was conducted in one of the rural health centers in Abu Dhabi. This is a government run health center staffed with six general practitioners and serving a population of approximately 35 thousand people.

One hundred medical records of all the patients (male & female) in the age group of
25-65 years who attended the Primary Health Centre for routine consultation from
4-11-02 to 25-11-02.

The medical records were scrutinized for detection and management of 12 CVD risk factors and the extracted information was entered in the audit sheet. Scrutinized files were marked with my personal signature at the back so that the same files are not audited again in the study. Audited patients were not seen by a single general practitioner but shared by various general practitioners who worked in the Primary health centre from time to time during the last 2 years.

The target standard set was that risk factors will be recorded in all patient files at least once in last 2 years.

Table - 1 shows the total number of risk factors recorded as present or absent, risk factors present, risk factors managed, risk factors not recorded. Out of twelve cardiovascular risk factors for which a hundred files were scrutinized, blood pressure was well monitored and recorded in 97% of patients at least once during last two years. Hypertension was found to be present in 15 patients and managed in 12 patients. Blood sugar was recorded in 35 patients and Diabetes Mellitus was noted in 19 patients out of which 15 patients received drug treatment.

Cholesterol, smoking and BMI /weight was checked in 25, 19 & 12 patients and risk factor was present in 9, 10 & 6 patients respectively.

All other risk factors were recorded in less than 10% of the patients.

Table - 2 shows risk factors recorded in different age groups. In group 1 (25 - 34 years) 33 risk factors were recorded in 31 patients (approximately 1 risk factor per patient). In group 2 (35-44 years) 61 risk factors were recorded for 35 patients. (1.75 per patient). In group 3 (45-54 years) 88 risk factors were recorded for 27 patients (3.25 per patient). In group 4 (54-65 years) 38 risk factors were recorded for 12 patients (3.1).

This is a small retrospective clinical audit of medical records of 100 patients in one of the health centres in Abu Dhabi and was subject to the limitations that affect all such studies. The aim of the study was to explore current practice in general practitioner detection and management of CVD risk factors in their patients. The major problem of assessing level of preventive practice by auditing medical records is that only a proportion of what takes place in the consultation is documented in the records⁵ and this leads to under estimation of preventive activities in the practice. The result of this study seems to follow the same pattern.

Among 12 cardiovascular risk factors (Age, sex, personal history of CVD, diabetes, family history of AMI < 60, smoking, blood pressure, cholesterol, alcohol, physical activity, diet, weight/BMI ) Blood Pressure was well monitored with 97% of patients aged 25-65 years having their Blood Pressure taken and recorded in their files. Diabetes mellitus, Cholesterol, smoking and weight was recorded in 35, 25%, 19% and 12% of patient files respectively. All other risk factors were recorded in less than 10% of patients.

Thus the common important and remedial risk factor of Blood Pressure was well recorded. This is consistent with recommended practice of assessing blood pressure of all adults. It is worthwhile to mention here that blood pressure is recorded by the practice nurse. General practitioners do not have the policy of performing routine risk assessment of all adult patients, however guidelines do exist for the detailed risk assessment of high-risk patients. Among the risk factors recorded hypertension was noted to be present in 12 and Diabetes Mellitus in 19, smoking in 10 patients and hyperlipidaemia in 9 patients.

In our practice population, almost all of our 25-65 old patients have a high fat diet, the vast majority do not exercise, significant numbers are overweight and indulge in smoking, yet these important & remedial risk factors are poorly documented in medical records. Personal history of CHD which increases the risk of future coronary event 5-7 fold and family history CVD before the age of 60 which doubles the risk of CVD, were hardly documented in the medical record.

One cannot assume that because risk factors have not been documented General practitioners are unaware of their existence and indeed the problem has not been adequately managed during the consultation⁶. However good records are fundamental for good patient care and greatly facilitate the practice of prevention.

Role of General Practitioner in prevention
General practitioners have ready access to a wide section of the community and can therefore deliver preventive care to the majority of the population.

The people who visit general practitioners are relatively representative of the general population. There is evidence to suggest that general practitioners can be instrumental in bringing change in patient's risk behaviour. It has been seen that general practitioners are seen by their patients as a credible source of information and are receptive to their advice⁷. Thus general practice has great potential to be an effective setting for delivering preventive care.

Barriers to Prevention
Despite the fact that disease prevention is an integral part of the good medical practice by general practitioners there is evidence that their detection or intervention for common risk behaviour is less optimal8. However various studies have identified several barriers to adequate practice of prevention by the general practitioner.

A useful classification of the barriers to the implementation of the clinical prevention has been devised by Frame⁹. He has divided barriers into issues related to:

• Patient barriers
  
• Physician barriers
  
• Health system barriers (Details appendix A)
  

Most important barriers which operate in our health centre are :

(i) Lack of time.
(ii) Lack of updated guidelines.
(iii) Lack of patient motivation.
(iv) General practitioner attitude towards practice of prevention.
(v) Disorganized medical records.
(vi) Frequent shifting of doctors from one health centre to other.
(vii) Patients with multiple physicians.
(viii) Population mobility.
(ix) Social and Cultural norms of the patients.

Over coming the barriers
Strategies need to be developed to overcome these barriers in order to ensure effective practice of prevention in general and cardiovascular disease risk assessment in particular.

Following recommendations are made

1. Programs should be developed which encourage general practitioners to routinely assess CVD risk factors and provide advice about lifestyle factors to the patients especially those at high risk.
   
2. Provide ongoing education and training programs to develop general practitioner counselling and health promotion skills.
   
3. Develop guidelines on prevention of coronary artery disease and monitoring the use these guidelines by general practitioner.
   
4. Maintaining a practice CVD register which is actively used to provide structured care to people with coronary artery disease.
5. Introducing an appointment system to overcome time constraints of the consultation.

Implications of this study
This clinical audit has identified numerous deficiencies in cardiovascular risk assessment and management.

In order to meet the challenge of the growing epidemic of CHD, general practitioners and primary health care teams should identify all the people at significant risk of CHD as well as established CHD and offer them comprehensive advice to reduce the risk..

General practitioners should engage more and more in clinical audits. Results of various studies suggest that clinical audit can produce significant improvement in practice among family physicians as well as encourage them to reflect on their practice¹⁰.

Table 1

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Table 2

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