Successful cardiovascular risk reduction in Type 2 diabetes by nurse-led care using an open clinical algorithm

AIM: To implement a protocol-driven, nurse-led cardiovascular risk reduction clinic using an open clinical algorithm. The primary aim of the clinic was to optimize blood pressure (BP) control; secondary aims were to reduce modifiable cardiovascular risk factors.

METHODS: We studied 110 people with Type 2 diabetes attending a diabetes out-patient centre at University Hospital Aintree, Liverpool. Patients taking one or more antihypertensive drugs were selected for referral to the nurse-led clinic if BP was > 140/85 mmHg; there was no age threshold. An open clinical algorithm was designed to direct the nurse on the use of antihypertensive, statin and aspirin therapy plus lifestyle advice and concordance.

RESULTS: Thirty-one percent of patients attending for a first visit to the nurse-led clinic had BP within target when measured to British Hypertension Society standards out of the consultant clinic. Mean BP was 150/76 mmHg compared with 178/88 mmHg (P < 0.001). Subsequently, BP was reduced to 130/68 mmHg (P < 0.001), this reduction being sustained at review 9 months later (mean BP 133/67 mmHg), with 87 (79%) achieving BP <or= 140/85 mmHg. Treatment modalities were adjusted to reduce cardiovascular risk, including antihypertensive medication, lipid-lowering therapy and antiplatelet therapy. High-density lipoprotein-cholesterol improved from 1.2 +/- 0.5 mmol/l to 1.4 +/- 0.5 mmol/l (P = 0.004). The number of patients with microalbuminuria decreased from 41 (47%) to 25 (28%) (P = 0.02), with a fall in urinary albumin:creatinine ratio from 3.0 (1.3-7.9) to 1.8 (1.0-5.0) mg/mmol (P = 0.01). The number of smokers decreased from 22 (20%) to 14 (13%) (P = 0.01). Although not included as an intervention in the protocol, HbA1c improved to 8.1 +/- 1.6% from 8.7 +/- 1.6% (P < 0.001).

CONCLUSION: A protocol-driven, nurse-led clinic using an open clinical algorithm can be used effectively to manage cardiovascular risk reduction in Type 2 diabetes.