Cardiovascular Therapeutic Guidelines

Objectives

Provide Fiji’s third edition of cardiovascular drug guidelines as an evidence-based clinical reference for public- and private-sector healthcare workers, principally caring for adults, across prevention, diagnosis, treatment, referral, patient education and self-management.[1][2]The guidance combines pharmacological and non-pharmacological management to reduce initial and recurrent cardiovascular events and improve care for people with cardiovascular disease.[2][3]

• Assess absolute 10-year cardiovascular risk using the World Health Organization chart for the Western Pacific Region, while managing people with established cardiovascular disease or specified high-risk conditions as high risk without formal stratification.[4]
• Reduce modifiable risk through tobacco cessation, healthy diet, safer alcohol consumption, physical activity, weight management and stress-management support, alongside risk-based initiation of drug therapy.[5][6][7][8]
• Manage diabetes, obesity, hypertension and dyslipidaemia by addressing overall cardiometabolic risk, individualising glycaemic and weight goals, and using treatment targets and medicines appropriate to clinical risk.[9][10][11][12]
• Deliver urgent, protocol-based care for acute coronary syndromes, heart failure, arrhythmias, venous thromboembolism, acute limb ischaemia and other cardiovascular emergencies.[13][14][15][16][17]
• Strengthen secondary prevention after acute coronary syndrome through long-term medicines, cardiac rehabilitation where available, lifestyle support, adherence promotion and individualised exercise and dietary advice.[18][19][20]
• Prevent, detect and manage acute rheumatic fever and rheumatic heart disease through prompt treatment of suspected streptococcal infection, secondary penicillin prophylaxis, echocardiographic assessment and specialist follow-up.[21][22][23]
• Support safe perioperative cardiovascular and antithrombotic management by assessing cardiac, thromboembolic and bleeding risks before non-cardiac surgery.[24][25][26]

Implementation

Implement the guideline through the Fiji Ministry of Health and Medical Services, led by the Medical Clinical Services Network and developed through the Cardiovascular Guidelines Committee and related clinical networks.[2][27]Apply evidence-based or universally accepted treatment standards, using medicines largely drawn from the Fiji Essential Medicines List and identifying relevant availability constraints.[2]The document does not specify a detailed implementation timetable, dedicated workforce plan, programme budget or formal governance framework beyond the named institutions and clinical referral arrangements.[28][2]

• Deliver risk assessment, prevention and routine management through primary healthcare teams, using regular reassessment and progressively more intensive lifestyle advice, treatment and follow-up as cardiovascular risk increases.[4][29]
• Provide patient-centred counselling, shared decisions and written medicine information, including treatment purpose, expected benefits, harms, duration, adverse effects, missed-dose advice and blood-test requirements for antithrombotic therapy.[30][31]
• Support adherence through family or friend support where appropriate, pharmacy involvement, simplified once-daily regimens where possible, alignment with daily routines and information in the most appropriate language.[31]
• Refer newly diagnosed established cardiovascular disease and patients with a calculated risk of 40% to specialist care, and refer pregnant women, children and other special groups to Divisional Hospital specialties where specific management is required.[4][2]
• Use Divisional Hospital Medical, Cardiac, Paediatric, Obstetric and Surgical Units for escalation of complex hypertension, acute coronary syndromes, arrhythmias, rheumatic heart disease, threatened limbs and perioperative cardiac risk.[11][32][33][23][17][24]
• Use structured emergency pathways and clinical protocols, including urgent electrocardiography for suspected myocardial infarction, rapid reperfusion assessment for ST-elevation myocardial infarction, monitored anticoagulation, and hospital transfer for acute pulmonary oedema or other unstable presentations.[13][34][35][36][14]
• Monitor clinical response and treatment safety through risk-factor review, blood pressure measurement, renal function and electrolyte testing where indicated, lipid and glycaemic assessment, anticoagulation testing, electrocardiography and echocardiography according to the relevant condition.[29][37][38][39][16][23]
• Notify acute rheumatic fever before discharge and submit patient details to the National Rheumatic Heart Disease Prevention and Control Programme for inclusion in the national rheumatic heart disease database.[22]
• Invite healthcare workers to submit comments and suggestions to improve future standard treatment guidelines.[2]

Monitoring & Evaluation

Monitoring is principally clinical and risk-based, with specified reassessment intervals, laboratory testing, safety checks and referral triggers across cardiovascular conditions; however, a document-wide monitoring and evaluation framework, consolidated performance indicators, routine audit cycle and formal accountability structure are not specified.[2][40]

• Assess absolute cardiovascular risk at least every two years for adults aged 30 years or older without established cardiovascular disease or automatically high-risk conditions, and use the World Health Organization cardiovascular risk chart to guide treatment.[4]Reassess risk annually for people above 30% 10-year risk and every two years where risk is below 20%, with risk-factor monitoring at intervals of three to 12 months according to risk and severity.[29]
• Monitor established vascular disease through at least annual full clinical assessment and three-monthly risk-factor review when stable, aiming to reduce recalculated 10-year risk below 20% in people initially above that threshold.[29]Monitor adverse effects and reconsider therapy if harms become problematic.[5]
• Use clinical measures including blood pressure, body mass index, waist circumference, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides and glycated haemoglobin to assess cardiometabolic risk and treatment response.[9][41][40]
• Monitor hypertension through repeat blood-pressure measurement, serum creatinine and electrolytes within two months of diagnosis and annually thereafter unless more frequent review is indicated; perform electrocardiography at diagnosis and subsequently as required.[42]Measure electrolytes and creatinine at baseline and two weeks after starting an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker where testing is available.[37]
• Monitor lipid-modifying treatment through alanine aminotransferase and creatine kinase testing at baseline and one to two months after initiation or dose adjustment, with subsequent testing only if symptoms or signs develop.[38]
• Monitor acute coronary syndromes through urgent and repeat electrocardiography, clinical observation, respiratory and conscious-state checks where morphine is used, and close surveillance for arrhythmias, bleeding and allergic reactions during thrombolysis.[13][32]In emergency chest-pain pathways, reassess pain and vital signs after each intervention, repeat troponin where initial results are normal or indeterminate, and use the HEART Score to determine disposition.[34][43]
• Monitor heart failure through symptoms, fluid status, daily weight, kidney function and electrolytes during diuretic or disease-modifying treatment.[44][45]Monitor plasma digoxin concentrations where possible and monitor the international normalised ratio carefully for people receiving warfarin.[45][14]
• Monitor anticoagulation through activated partial thromboplastin time for intravenous unfractionated heparin, platelet counts from day three to detect heparin-induced thrombocytopenia, and international normalised ratio testing for warfarin adjustment.[16][46][47]During warfarin initiation, use daily morning international normalised ratio measurements to guide dose adjustment.[48]
• Assess anticoagulation decisions individually by balancing thromboembolic and bleeding risks, confirming access to international normalised ratio monitoring and documenting reasons where indicated anticoagulation is not provided.[39]Educate patients receiving antithrombotic medicines about bleeding symptoms, treatment duration, testing requirements and steps before dental or surgical procedures.[30]
• Record and report acute rheumatic fever as a notifiable disease using the Notifiable Disease Form before discharge, and submit the acute rheumatic fever/rheumatic heart disease pre-discharge form to the National Rheumatic Heart Disease Prevention and Control Programme for entry in the national rheumatic heart disease database.[22]Monitor rheumatic heart disease clinically and by echocardiography for prophylaxis adherence, valve-disease progression and possible surgical need.[23]
• Invite healthcare workers to submit comments and suggestions to inform future improvements to standard treatment guidelines.[2]Beyond disease notification and clinical follow-up, the guideline does not specify reporting schedules, surveillance targets, programme-level indicators, evaluation methods or formal accountability mechanisms.[2][22]

Costing & Financing

Financing information is limited to external assistance for guideline development and production; no total budget, costed implementation plan, annual allocation, expenditure, funding gap, resource-mobilisation target or economic assumption is provided.[28][2][27]

• Recognise financial assistance from the Fiji Health Sector Support Program and Australian Aid, including support for guideline production.[28][2]
• Note that the first edition was supported through a month-long World Health Organization-funded consultancy, while the template was supplied without a fee.[27]
• Recognise medicine and equipment availability constraints rather than quantified costs, including selected medicines unavailable on the Fiji Essential Medicines List, unavailable graduated compression stockings in the clinical products catalogue, and limited routine availability of some specialist cardiac procedures.[13][49][50][15][16]
• Address patient-level affordability and access barriers, as financial burden and prescription costs may contribute to non-adherence.[31]
• Consider overseas referral for electrophysiological studies or implantable cardioverter defibrillator insertion only where affordable; no price, financing source or eligibility funding mechanism is specified.[51]