Department / Division Page Number 1 of 1 DIVISION OF ... · PDF filePROCEDURES AND GUIDELINES Date Reviewed May 2014 ... adherence with the Clinical Practice Recommendation of the

PHILIPPINE HEART

CENTER

MEDICAL SERVICES POLICY MANUAL

Department / Division

DIVISION OF PREVENTIVE CARDIOLOGY

Page Number 1 of 1 Policy Number Effective Date

Title

PROCEDURES AND GUIDELINES

Date Reviewed May 2014Date Revised

Revision Number

Date of Next Review 2016

I. Preventive Cardiology Clinic

A. Screening of Patients

In screening patients for admission to the Preventive Cardiology Clinic, the following procedures and

guidelines are followed:

1. Establishment of baseline patient data. All new patients are interviewed and examined using an

Initial Form (see attached form) to initially assess their cardiovascular risk/condition. The interview

and examinations procedures done by the DPC staff and assigned Adult Cardiology Fellow include:

a. Patient interview on demographic characteristics, presenting symptoms and medical history.

b. Blood pressure measurement with the use of mercury sphygmomanometer.

c. Fasting Blood Sugar (FBS) determination through finger-prick test using hand-held blood

sugar testing meter.

d. Total cholesterol determination also through finger-prick test using cholesterol testing meter.

e. Height and weight measurement to determine patient’s Body Mass Index which is computed

with the Formula:

Weight in Kg. Height in m2

f. Waist and hip measurement in cm.

g. ECG taking

h. Physical Examination

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GERARDO S. MANZO, MD Assistant Director for Medical Services

Approved by MANUEL T. CHUA CHIACO, JR, M.D. Executive Director

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2. Based on the results of the aforementioned procedures, a patient may be enrolled in the clinic if

he/she: a) has one or more than one of the major risk factors, or has two or more than two of the

minor risk factors, b) with no end-organ damage, and c) must be 30 or more than 30 years old.

The major risk factors are:

a. Hypertension –JNC 7 Guidelines definition of > 140/90 mmHg

b. Diabetes Mellitus – ADA definition of FBS > 126 mg/dl

c. Serum Total Cholesterol and LDL-C-NCEP-ATPIII-definition: TC > 200 mg/dl and LDL-C >

130 mg/dl

The minor risk factors are:

a. Smoking – any smoking in the past month

b. Family history of CAD – patient had parent or sibling who had MI or died of MI at <55 yrs. old

(Female) or <45 yrs. old (Male)

c. Obesity – IBW > 20%

BMI > 25%

Waist-hip ratio: F > 0.9

M > 1.0

If a patient is not qualified for admission in the Clinic, he/she is either referred to the Out-Patient Division

if he/she is found to have cardiovascular abnormalities/end-organ damage or discharged if he/she is

assessed to have very low or no cardiovascular risk. Depending on the findings, patients may be referred

to the following clinics/centers:

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a. HPN and Lipid Research Clinic – for hypertensive patients with LVH by ECG and x-ray, and

with proteinuria or albuminuria on urinalysis in the absence of UTI and/or hematuria.

b. PHC Out-Patient Division (OPD) – for patients with CAD or those who are (+) with TET or

found to have ischemic patterns on ECG and/or symptoms of angina and for other patients

noted to have other cardiovascular disorders, like valvular heart disease or congenital heart

disease.

c. PHC Peripheral Vascular Clinic – for patients with Peripheral Arterial Occlusive Disease

(PAOD).

d. East Avenue Medical Center – for patients with stroke/CVA, TIA and all other cerebrovascular

syndromes.

3. All patients seen at the clinic whether for enrollment, discharge or referral receive health education

on cardiovascular diseases prevention and control, such as lectures on CVD risk factors, dietary

advice/nutritional counseling, lifestyle modification strategies and compliance with medical regimen.

B. Scheduling of Patient Follow-up

The scheduling of follow-up visit/consultation of a patient registered in the clinic depends on the results of

his/her blood pressure and blood tests, and the clinical assessment of the examining adult cardiology

fellow. It should be noted that a patient may be asked by the examining doctor to have additional

laboratory/diagnostic procedures which may be done in the PHC laboratory or diagnostic units or in other

clinics/hospitals. Below are the guidelines followed in monitoring the patients with hypertension, diabetes

mellitus, dyslipidemia, and obesity.

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Hypertension

For the patients with uncontrolled BP (> 140/90), the follow-up visit is monthly until the BP is

controlled (< 140/90). When the BP is controlled the follow-up is scheduled every 4 months for a

period of one year, then every 6 months thereafter as long as the BP is well controlled. Patients

are encouraged to do BP monitoring at home, record and report the readings to the doctor on

follow-up visit.

Diabetes Mellitus

Patients who have uncontrolled FBS (> 126 mg%) are also scheduled for follow-up once every

month until FBS is controlled (< 126 mg%), and then the schedule of visit becomes every 3

months for a period of one year, and then every 6 months thereafter as long as FBS is well

controlled. In the follow-up of patients, result may glycosylated hemoglobin (HbAIc) may also be

required, in addition to the FBS result.

Dyslipidemia

If dyslipidemia is uncontrolled based on the results of the lipid profile tests of the patient, the

follow-up visit is made every 3 months until all the lipid tests are normal, then the follow-up is

done every 6 months thereafter as long as the lipid profile is well controlled. The normal values

of lipid profile are: Total Cholesterol (TC): < 200 mg%, Triglyceride (TG): < 150 mg%, High

Density Lipoprotein (HDL): > 45 mg%, Low Density Lipoprotein (LDL): < 130 mg% depending

on the risk factor, the desired LDL goals are as follows:

Patients with CAD or CAD risk equivalent: < 100 mg%

Patients with 2 risk factors : < 130 mg%

Patient with no or only one risk factor: < 160 mg%

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Obesity

Monthly weight, waist and hip measurements to see if the patients are reaching their goals.

Target waist circumference:

Male : 90 cm

Female: 80 cm

C. Prevention and Management of Patients

In the prevention and management of the CVD risk factors of the patients, adherence with

established international guidelines is observed. For hypertension, it is adherence with the

guidelines in the seventh report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure (Attachment I); for dyslipidemia, adherence with

the National Cholesterol Education Program guidelines (Attachment 2); and for diabetes mellitus,

adherence with the Clinical Practice Recommendation of the American Diabetes Association. In

implementing existing guidelines for managing the cardiovascular risk factors, health education

forms part of the process.

Lectures on the individual risk factors by the fellows and DPC staff, one-on-one dietary counseling

by the PHC Dietetics and Nutrition Division and monitoring of compliance, appointment, medication

and other behaviors by the DPC staff are undertaken.

During the follow-up, if a patient develop any cardiovascular disease or cardiovascular event (e.g.

chronic stable angina, acute coronary syndrome, stroke, etc.) he/she will be referred to the other

division/department of PHC (i.e. OPD for patient who developed chronic stable angina; Emergency

room for suspected acute coronary syndrome case) or other hospitals/institutions (i.e. East Avenue

Medical Center for patient who suffered a stroke).

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D. Keeping of Patient Records

Systematic patient data collection is done with the use of forms (Initial Form and Follow-up Visit

Form) and logbooks for appointments and other data. Each patient is given a patient chart which is

kept in the DPC office in accordance with the PHC policies on keeping/safeguarding patient records.

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PHILIPPINE HEART CENTER Division of Preventive Cardiology

East Avenue, Quezon City

Follow-up visit #:_________ Date:___________________

I. Patient Data Sheet A. Name:______________________________________________ Age:________ B. Compliance to visit: (Scheduled visit: Date_______________)

Px followed-up earlier or on the exact date of follow-up Px followed-up after < 1 month from the exact date of follow-up

Reason:___________________________________________ Px followed-up >1 month from the exact date of follow-up

Reason:___________________________________________ C. Compliance to medication:

� Px takes his/her medication(s) regularly/daily � Px misses his/her medication < 2x/week � Px misses his/her medication > 3x/week

Reason:________________________________ D. Patient continues to smoke: Yes No NA E. BP monitoring: Not done Px's usual BP:______/_____ mmHg (Px's BP > 60% of the time his/her BP is taken)

Px's highest BP: ______/_____ mmHg

F. Px's previous medication: HPN: DM: Dyslipidemia:

� BB:_____________ � Sulfunyl Urea (SFU):_______________ � Statin:____________

� CCB:____________ � Metformin:_______________________ � Fibrates:__________ � ACE I:___________ � Thiozolindindion (TZD):___________ � Others:___________ � ARB:____________ � Insulin:__________________________ � Diuretics:___________ Other Medications: __________________ _____________________ ___________________ G. Present Problems/Symptoms:___________________________________________________ II. A. Physical Examination: Vital Signs: BP:__________ HR:__________ RR:___________ Ht.___________m Wt.__________kg BMI:__________ Waist ________cm Hips_________cm WHR:_________

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HEENT

NECK

Lungs

Heart

Abdomen

Extremities

B. LABORATORY RESULTS:

FBS _ mg/dl TC _ mg/dl Trigly mg/dl HDL mg/dl LDL mg/dl

Others:

C. ECG: Rhythm: Axis: QTa: Rate: QTc: PR: QRS:

Interpretation: :

D.2DED:

III. Diagnosis: Hypertension Pre-hypertension stage Gr I Gr II controlled* uncontrolled**

Diabetes Mellitus Type I Type 2 controlled*** uncontrolled**** Impaired Fasting Glucose***** Dyslipidemia Obese Smoker

IV. MANAGEMENT:

A. Lifestyle modification: Px was advised dietary modification

salt restriction fat restriction carbohydrate restriction

Px was advised BP monitoring Px was advised to exercise Px was advised to refrain from smoking Px was advised to minimize/refrain from alcohol intake

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Normal

Normal

Normal

Normal

Normal Pale palpebral conjunctivae Neck vein engorgment Others

Icteric sclerae Neck mass

Unequal Chest Expansion Decreased breath sounds Others

Crackles Wheezing

Dynamic precordium S2__soft__loud__

S1 ___soft ___loud S4 S3 murmur

ascites tender

Hypoactive BS organomegaly

Hyperactive BS others

Weak pulse clubbing

Hyperdynamic pulse edema

Cyanotic Others

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B. Drug prescription:

HPN: DM: Dyslipidemia: Other Medications:

BB: SFU: Statin:

CCB: Metformin Fibrates:

ARB: TZD: Others:

Diuretic: Insulin: __ Others: ___________ ACE I:

C. Laboratory request:

D. Next follow-up:

Signature of MD

* BP is controlled if BP is <140/90 mmHg based on usual BP or home BP monitoring ** BP is uncontrolled if BP is > 140/90 mmHg based on usual BP or home BP monitoring *** FBS is < 100 mg/dl **** FBS is > 126 mg/dl ***** FBS is 101-125 mg/dl

ruth3-15-07

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ATTACHMENT 1:

Summary of the Joint National Committee on the Prevention, Detection, Evaluation, and

Treatment of High Blood Pressure Guidelines

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Department / Division Page Number 1 of 1 DIVISION OF ... · PDF filePROCEDURES AND GUIDELINES Date Reviewed May 2014 ... adherence with the Clinical Practice Recommendation of the

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