UNIVERSIDAD COMPLUTENSE DE MADRID 
FACULTAD DE FARMACIA 

 
 

 
 
 

TESIS DOCTORAL 
 

Estudio para la calculadora de edad vascular como 
herramienta para reducir el riesgo cardiovascular de la 

farmacia comunitaria 
 

Study of the vascular age calculator as a tool to reduce 
cardiovascular risk in community pharmacies 

 
MEMORIA PARA OPTAR AL GRADO DE DOCTOR 

 
PRESENTADA POR 

 
Marjan Manouchehri 

 
Directoras 

 
María Soledad Fernández Alfonso 

Marta Gil Ortega 
 
 

Madrid 
 
 

© Marjan Manouchehri, 2021 



 

UNIVERSIDAD COMPLUTENSE DE MADRID 
FACULTAD DE FARMACIA 

 
 
 
 
 
 
 
 

 
 

TESIS DOCTORAL 
 

ESTUDIO DE LA CALCULADORA DE EDAD VASCULAR COMO 
HERRAMIENTA PARA REDUCIR EL RIESGO CARDIOVASCULAR DE LA 

FARMACIA COMUNITARIA 
 
 

STUDY OF THE VASCULAR AGE CALCULATOR AS A TOOL TO REDUCE 
CARDIOVASCULAR RISK IN COMMUNITY PHARMACIES 

 
                          

MEMORIA PARA OPTAR AL GRADO DE DOCTOR 

 

PRESENTADA POR 
 

Marjan Manouchehri 
 

DIRECTOR/AS 

 

María Soledad Fernández Alfonso y Marta Gil Ortega 

 

Madrid, 2021 

 



 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

To my lovely family who believed in me. 
 
 
 
 
 
 



 

 
Acknowledgements 
 
I would like to express my special thanks of gratitude to my tutor Prof. María S. Fernández-

Alfonso, who gave me the lifetime opportunity to be part of her splendid research group, who 

unveiled some of the most important lessons of my life and taught me how to be a better 

scientist. I would like to express my appreciation for my director Dr Marta Gil Ortega, whose 

guidance, support and encouragement have been invaluable throughout this thesis, 

especially in correcting protocols and helping me in Spanish. I like to take this opportunity to 

give my immense gratitude to my kind father and mother for believing in me, financially 

supporting me and I am forever in depth for their kindness. I can never repay my brother, 

Víctor and Tara for their ongoing support and passionate encouragement, without whom I 

would not have been able to complete this PhD and would not have made it through the 

pandemic. I would like to give special thanks to my partner Víctor for his dedicated support 

extended with love, continuous encouragement, and willingness to assist in any way. I also 

like to give my thanks to my wonderful and kind mother and father-in-law for their support 

and kindness. I like to extend my special gratitude to Dr Leonor Huete González for her 

continuous kind support and professional guidance, for providing insight and documents 

related to pharmacy practice in Spain. My biggest thanks to my friend and fellow PhD student 

Francisco Javier Manzano Lista for assisting me in launching the vascular age calculator on the 

website and for his supportive guidance during my doctorate.  I submit my heartiest gratitude 

to Dr Lucia Cea Soriano for her sincere guidance on data analysis and pharmacoepidemiology. 

I like to thank my colleagues in laboratory Elena, Marta, Anna, Jose Luis and Dani for being 

my friend and supporting me throughout the PhD program and for their technical assistance 

and guidance. I thank my friend and fellow PhD students Mahdiye for her help in data 

collection. I further like to extend my gratitude to all the pharmacists who took the time to 



 

assess the vascular age website and fill out the survey without whom I would have no content 

for my thesis. I am deeply indebted to my best friend Yvonne and Ehsan, Maryam, Mahya, 

Sanam, Motahare, Mohsen, Susan, Wayne, Anisa, Atosa, Shahriyar and many more for their 

words of encouragement and support with extended love. A sincere thank you to Gladys 

Livingstone for her diligent proofreading of this thesis. My appreciations to the University of 

Complutense administrators (Víctor and Macarena) for their help and kindness. My biggest 

thanks for Go Fit gym staff for running most wonderful classes (Yoga, Spinning and Plate).  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 

	
	
	
	
	
	
	
 

 
 
 
 
 
 
 
 
 
 
 

“In the fell clutch of circumstance 
I have not winced nor cried aloud. 
Under the bludgeonings of chance 
My head is bloody, but unbowed. 

 
 

It matters not how strait the gate, 
How charged with punishments the scroll, 

I am the master of my fate, 
I am the captain of my soul.” 

 
 

William Ernest Henley  

 

 

 

 

 

 

 

 

 
 
 
 



 

 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 

“In order to reach the moon, you have to start with little steps.”  
 

Prof. María S. Fernández-Alfonso



  

 

Table of Contents 

LIST OF FIGURES ................................................................................................................ 1 

LIST OF TABLES .................................................................................................................. 3 

LIST OF ABBREVIATIONS .................................................................................................... 4 

Abstract ............................................................................................................................ 5 

Resumen ........................................................................................................................... 6 

INTRODUCTION ................................................................................................................. 7 

1. Cardiovascular diseases (CVDs) ...................................................................................... 8 

1.1 Non-modifiable risks factors ........................................................................................ 9 

1.1.1 Age ........................................................................................................................... 9 

1.1.2 Sex/gender ............................................................................................................. 10 

1.1.3 Family history and genomics ................................................................................... 12 

1.1.4 Ethnicity ................................................................................................................. 13 

1.2 Modifiable risk factors ............................................................................................... 14 

1.2.1 Hypertension .......................................................................................................... 14 

1.2.2 Obesity ................................................................................................................... 16 

1.2.3 Dyslipidaemia ......................................................................................................... 17 

1.2.4 Diabetes mellitus .................................................................................................... 18 

1.2.5 Other comorbidities ................................................................................................ 19 

1.2.6 Mental health ......................................................................................................... 20 

1.2.7 COVID-19 ................................................................................................................ 21 

1.2.8 Smoking .................................................................................................................. 23 

1.2.9 Diet ......................................................................................................................... 26 

1.2.10 High alcohol consumption ..................................................................................... 28 



  

1.2.11 Caffeine ................................................................................................................ 29 

1.2.12 Poor medication compliance ................................................................................. 30 

1.2.13 Pharmacological treatments ................................................................................. 33 

1.2.14 Physical activity .................................................................................................... 34 

1.2.15 Health Inequalities ................................................................................................ 34 

1.2.16 Climate change ..................................................................................................... 36 

1.3 Cardiovascular health in Spain ................................................................................... 36 

1.4 Cardiovascular Risk estimation .................................................................................. 37 

1.4.1 Relative risk calculation .......................................................................................... 39 

1.4.2 Absolute risk calculation ......................................................................................... 39 

1.4.3 High-risk or population intervention approach ....................................................... 42 

1.5 Personalisation of intervention according to patient's risk estimation ....................... 42 

1.5.1 Patient's perception of their CVR ............................................................................ 42 

1.6 Empanelment ............................................................................................................ 43 

2. Spanish community pharmacy system ......................................................................... 44 

2.1 Provision of community pharmacist intervention ...................................................... 45 

2.2 Consistency in healthcare provision and coherence in medical records ...................... 46 

2.3 Role of community pharmacists in health empanelment in Spain .............................. 46 

2.3.1 Hypertension control .............................................................................................. 50 

2.3.2 Weight management by community pharmacist via diet and lifestyle advice .......... 51 

2.3.3 Dyslipidaemia management .................................................................................... 53 

2.3.4 Diabetes control ..................................................................................................... 54 

2.3.5 Smoking cessation .................................................................................................. 54 

2.3.6 Alcohol advice ........................................................................................................ 55 

2.3.7 Medicine reconciliation .......................................................................................... 56 

2.3.8 Telepharmacy ......................................................................................................... 57 



  

3. Vascular age calculator (VAC) ...................................................................................... 58 

HYPOTHESIS AND OBJECTIVES ......................................................................................... 59 

MATERIALS AND METHODS ............................................................................................. 61 

1.1. Literature search ...................................................................................................... 62 

1.2. Vascular age questionnaire ....................................................................................... 63 

1.3 Algorithm for vascular age calculator ......................................................................... 63 

1.4 Ethical approval ......................................................................................................... 65 

1.5 Patient confidentiality ............................................................................................... 65 

1.6 Informed consent ...................................................................................................... 66 

1.7 General Data Protection Regulation (GDPR) compliance ............................................ 67 

1.8 Data storage and handling ......................................................................................... 67 

1.9 Study pilot among community pharmacists ............................................................... 67 

1.10 Pilot survey analysis ................................................................................................. 68 

1.11 Adoption of QR barcode for the website and the questionnaire ............................... 69 

RESULTS .......................................................................................................................... 70 

1. Creating a data collection tool ..................................................................................... 71 

1.1 Questionnaire ............................................................................................................ 71 

1.2 Vascular age calculator and interpretation of the results for patients ........................ 77 

1.3 Study protocol ........................................................................................................... 82 

1.4 Study design .............................................................................................................. 83 

1.5 Inclusion criteria ........................................................................................................ 83 

1.6 Exclusion criteria ....................................................................................................... 84 

1.7 Patient recruitment ................................................................................................... 84 

1.8 Sample size ................................................................................................................ 88 

1.9 Standard Operating Procedure (SOP) for patient’s consultation ................................. 89 

1.10 Premises requirements for pharmacies and pharmacist ........................................... 93 



  

1.11 Telepharmacy .......................................................................................................... 95 

1.12 Record management ................................................................................................ 96 

1.13 Data collection process ............................................................................................ 96 

1.14 Referral to the Doctor .............................................................................................. 98 

1.14.1 Red flag symptoms in referral to a doctor ....................................................... 101 

1.15 Detailed pharmacist intervention protocol ............................................................ 102 

1.15.1 Management of patients with obesity ................................................................ 102 

1.15.2 Management of patients with Dyslipidaemia ...................................................... 108 

1.15.2.1 Referral to doctor ........................................................................................ 113 

1.15.3 Management of patients with diabetes .............................................................. 114 

1.15.3.1 Referral to doctor ........................................................................................ 118 

1.15.4 Smoking cessation services ................................................................................. 119 

1.15.4.1 Pre-quit smoking ......................................................................................... 121 

1.15.4.2 Carbon monoxide breath test ...................................................................... 125 

1.15.4.3 Remote consultation for smoking cessation ................................................. 131 

1.15.5 Medication reconciliation ................................................................................... 131 

1.15.6 Hypertension control .......................................................................................... 133 

1.15.7 Advice on reduction of alcohol consumption ...................................................... 138 

1.15.8 Other CVD intervention ...................................................................................... 142 

1.16 Website validation by the community pharmacist ................................................. 146 

1.17 Reflexive thematic analysis results: ........................................................................ 151 

DISCUSSION .................................................................................................................. 153 

1.1 Provoking factors for vascular aging in the Spanish population ................................ 158 

1.2 Interpretation of findings of the vascular age questionnaire .................................... 159 

1.3 Implication of the eHealth vascular age tool on pharmacy practice in Spain ............. 164 

1.4 Limitation ................................................................................................................ 165 

CONCLUSION ................................................................................................................. 166 



  

REFERENCE .................................................................................................................... 168 

APPENDICE .................................................................................................................... 186 

Appendix I: The questionnaire used in the vascular age website pilot ............................ 186 

Appendix II: Community pharmacist responses in Spanish for question 26 of the pilot. . 190 

Appendix III: The themes that merged from the pharmacist’s responses coding ............ 191 

Appendix IV: NVivo analysis of the vascular age website pilot word repetition .............. 193 

Appendix V: Application for the provision of waste management services, SRCL Consenur 

company form. .............................................................................................................. 194 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 



 1 

LIST OF FIGURES 
 
Figure 1: Impact of smoking on major organs in the body ..................................................... 24 
Figure 2: Visual display of empanelment in population health management ......................... 43 
Figure 3: Illustration of appropriateness of healthcare panel size ........................................... 44 
Figure 4: Risk of bias assessment in RCT studies ................................................................... 49 
Figure 5: Risk of bias assessment in NRSIs studies ................................................................ 49 
Figure 6: Vascular age calculated based on the SCORE system ............................................. 64 
Figure 7: Ethical approval documents location on the website ............................................... 65 
Figure 8: Patient’s confidentiality by anonymizing the participants ....................................... 66 
Figure 9: QR barcode for the vascular age website ................................................................. 69 
Figure 10: Questions 1- 6 of the vascular age tool .................................................................. 71 
Figure 11: The anthropometric and biochemical values section of the vascular age tool ....... 72 
Figure 12: The smoking status question .................................................................................. 73 
Figure 13: Women specific risk factor or protective elements data collection ....................... 73 
Figure 14: The question on family history of premature CHD ............................................... 74 
Figure 15: Medical and medication history of the patient ....................................................... 75 
Figure 16: The physical activity question in vascular age tool ............................................... 75 
Figure 17: Alcohol habits assessment ..................................................................................... 76 
Figure 18: Stress assessment test ............................................................................................. 76 
Figure 19: Spanish midday nap habit test ................................................................................ 77 
Figure 20: Dietary habits of Spanish population ..................................................................... 77 
Figure 21: Social interaction assessment ................................................................................. 77 
Figure 22: Illustrate how vascular age tool can improve patient’s comprehension ................ 79 
Figure 23: Vascular age tool improves smoking cessation ..................................................... 79 
Figure 24: Blood pressure reduction by vascular age tool ...................................................... 80 
Figure 25: Blood cholesterol reduction by vascular age tool .................................................. 81 
Figure 26: Improvement of patient’s comprehension by vascular age tool ............................ 81 
Figure 27: Methodology of the study ...................................................................................... 82 
Figure 28: Principal investigator contact details in webpage home section ............................ 85 
Figure 29: Webpage snapshot on study documents ................................................................ 88 
Figure 30: Patient’s consent form ............................................................................................ 89 
Figure 31: Study follow-up schedule ...................................................................................... 91 
Figure 32: ADHFARM questionnaire for patient follow-up ................................................... 92 
Figure 33: Criteria for pharmacies that participate in the cardiovascular health campaign .... 93 
Figure 34: Pharmacists' contract for participation location ..................................................... 95 
Figure 35: Pharmacists access to the Vascular age calculator ................................................. 97 
Figure 36: initial registration of the pharmacy in the database ............................................... 97 
Figure 37: Doctor referral form ............................................................................................... 99 
Figure 38: Webpage snapshot of pharmacist’s intervention guide for obesity control ......... 103 
Figure 39: Webpage snapshot of PIL on obesity prevention ................................................ 106 
Figure 40: Patient information leaflet on obesity .................................................................. 107 
Figure 41: Webpage snapshot of pharmacist’s intervention guide for lipid measurement and 
control .................................................................................................................................... 108 
Figure 42: Webpage snapshot of patient information leaflet for lipid measurement ............ 108 
Figure 43: Patient’s information leaflet in relation to hypercholesteremia ........................... 109 
Figure 44:TC, LDL-C, HDL-C and triglyceride level and related risk of CV ...................... 111 
Figure 45: Pharmacist course of action depends on patient’s LDL-C, total cholesterol, ...... 112 
Figure 46: Webpage snapshot of pharmacist’s intervention guide for diabetes management 
and control ............................................................................................................................. 114 
Figure 47: Webpage snapshot of patient information leaflet for diabetes intervention ........ 114 



 2 

Figure 48: Patient’s information leaflet in relation to diabetes management and control ..... 115 
Figure 49 : Diabetes control protocol .................................................................................... 117 
Figure 50: Webpage snapshot of pharmacist’s intervention on smoking cessation .............. 119 
Figure 51: Webpage snapshot of patient information leaflet on smoking cessation ............. 119 
Figure 52: Patient information leaflet in relation to diabetes management and control ........ 120 
Figure 53: protocol for smoking cessation services .............................................................. 122 
Figure 54: Richmond test ...................................................................................................... 124 
Figure 55: Fagerström Test for Nicotine Dependence (FTND) ............................................ 125 
Figure 56: Direct relation between carbon monoxide (CO) carboxyhemoglobin (CO-Hb) 
exhaled in 15 second and smoking ........................................................................................ 126 
Figure 57: Demonstrate the smoking cession protocol for initial visit ................................. 127 
Figure 58: Patient treatment options according to their level of dependency ....................... 128 
Figure 59: Exhibit the advantages of stopping smoking ....................................................... 129 
Figure 60: Smoking cessation protocol for the community pharmacist ................................ 130 
Figure 61: Protocol for follow up on STOPPING smoking services at 6 months and one year
 ............................................................................................................................................... 130 
Figure 62: Webpage snapshot of pharmacist’s intervention on medication adherence ........ 131 
Figure 63: Morisky-Green test .............................................................................................. 132 
Figure 64: Adopted Morisky Green test for assessing patients’ medication compliance ..... 133 
Figure 65: Webpage snapshot of pharmacist’s intervention on hypertension ....................... 134 
Figure 66: Webpage snapshot of patient information leaflet about hypertension ................. 136 
Figure 67: Patient information leaflet in relation to hypertension management ................... 137 
Figure 68: Webpage glimpse of pharmacist’s intervention on reduction in alcohol use ...... 138 
Figure 69: Guide to unit of alcohol definition ....................................................................... 139 
Figure 70: Alcohol misuse health implications ..................................................................... 140 
Figure 71: Webpage snapshot on patient information leaflet about alcohol consumption ... 140 
Figure 72: Alcohol consumption Patient information leaflet ................................................ 142 
Figure 73: Stress and mental state patient information guide ............................................... 143 
Figure 74: Women & cardiovascular health patient information guide ................................ 144 
Figure 75: Aging and cardiovascular health patient information guide ................................ 145 
Figure 76: Gender distribution for vascular age pilot participants. ....................................... 146 
Figure 77: Age distribution for vascular age pilot in community pharmacies. ..................... 146 
Figure 78: Ratio of community pharmacists accredited for the provision of pharmaceutical 
care. ....................................................................................................................................... 147 
Figure 79: Community pharmacist’s various form of accreditation for providing 
pharmaceutical care. .............................................................................................................. 148 
Figure 80: Accreditation bodies for pharmaceutical care across Spain. ................................ 148 
Figure 81: Patient’s visiting time from community pharmacy with vascular age services, Data 
are expressed in percentage of the total number of participants. ........................................... 150 
Figure 82: Relation between community pharmacists’ increase in workload and vascular age 
intervention.  Data are expressed in percentage of the total number of participants. ............ 150 
Figure 83: Reflective thematic analysis for qualitative research ........................................... 151 
Figure 84: Vascular age pilot from community pharmacist’s viewpoint world cloud .......... 152 
 

 
 
 
 



 3 

LIST OF TABLES  
 
Table 1. Diagnostic criteria for diabetes mellitus .................................................................... 19 
Table 2: Initiating consultation by using I2C6 technique ....................................................... 90 
Table 3: WHO classification for BMI (kg/m2) measures in white Caucasian adult ............. 103 
Table 4: Classification of patient’s risk based on waist circumference in cm ...................... 104 
Table 5: Classification of patient’s risk by BMI, waist circumference & comorbidities ...... 104 
Table 6: The choice of intervention adequate for patient’s risk ............................................ 104 
Table 7: Suggested regimen for therapeutical treatment protocol ......................................... 129 
Table 8: Exercise protocol in the elderly ............................................................................... 135 
Table 9: Scoring system to quantify the patients’ risk based on their weekly alcohol 
consumption .......................................................................................................................... 141 
Table 10: Age and gender distribution for vascular age pilot participants ............................ 146 
Table 11: Stratification of pharmacists according to the age group, level of training and 
provision of pharmaceutical care ........................................................................................... 147 
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



 4 

LIST OF ABBREVIATIONS 
 
ABPM       Ambulatory blood pressure monitoring  
ACC/AHA  American College of Cardiology/American Heart Association 
ADRs         Adverse drug reactions  
ALT        Alanine Aminotransferase  
ASCVD     Atherosclerotic cardiovascular diseases  
AST        Aspartate transaminase 
BMI        Body mass index  
BP        Blood pressure  
CHD        Coronary heart disease  
CKD  Chronic kidney disease   
CMPs         Cardiomyopathies  
CP        Community pharmacist 
CVDs        Cardiovascular diseases 
CVR        Cardiovascular risks 
DALYs      Disability-adjusted life years 
DBP        Diastolic Blood Pressure 
DASH  Dietary Approaches to Stop Hypertension 
FBG        Fasting blood glucose 
FHS           Framingham Heart Study   
HbA1c       Glycated haemoglobin   
HDL-C         High-density lipoprotein cholesterol 
HOMA-IR  Homeostatic Model of Assessment-Insulin Resistance Index 
HVA        Healthy vascular aging  
IGT         Impaired glucose tolerance  
IHD        Ischemic heart disease 
LDL-C         Low-density lipoprotein cholesterol 
MedDiet    Mediterranean diet 
MI              Myocardial Ischemia  
MONICA  Multinational Monitoring of Trends and Determinates in Cardiovascular Disease 
NICE         National Institute for Health and Care Excellence 
NCDs        Non-communicable diseases 
NSAIDs  Non-steroidal anti-inflammatory drugs 
OGTT        Oral glucose tolerance test 
OTC  Over the counter 
PCS        Pharmaceutical care services  
QALY       Quality-adjusted life year  
RR        Relative risk or risk ratio  
RCT  Randomized controlled trial  
SBP        Systolic Blood Pressure 
SCORE     Systematic Coronary Risk Evaluation  
SNS        Spanish national health system 
SPD        Sistemas Personalizados de Dosificación    
T2DM      Type 2 diabetes mellitus  
TG       Triglycerides  
VA       Vascular age 
VAC        Vascular age calculator  
WHO        World Health Organization 



 5 

Abstract  

Background: Cardiovascular disease (CVD) is one of the leading causes of morbidity and 
mortality in Spain. According to the World Health Organization (WHO), 80% of these 
premature deaths are avoidable by reducing the modifiable risk factors of CVD. Research 
indicates that patients better understand their true risk when information is presented to 
them in vascular age (VA). Community pharmacists (CP) are well situated to assess patients 
VA, provide professional educational advice, and implement interventions for reducing 
cardiovascular risk (CVR).   
 
Aim: The explicit objective of this thesis was to create a patient-centred, accurate and 
accessible tool that allows the CPs in Spain to estimate the VA and design a personalized 
intervention aimed at reducing the patient’s VA. 
 
Method: A website was created and included an original questionnaire, the vascular age 
calculator (VAC), detailed protocols for the pharmacist’s intervention and the patient’s 
information leaflets on CVR factors. The webpage user’s perceptions were analysed via a 26-
item self-completion online survey distributed among CPs using a Google forum. Informed 
consent was taken from the CPs to participate in the study. The responses to the survey were 
collected anonymously. Open and closed questions were used to gain a wide range of replies 
and an in-depth understanding. The questionnaire from the pilot study was available online 
from the 1st August 2020to the 31st of February 2021. The results were analysed using the 
STATA package version 12.0 (StataCorp LP, College Station, TX, USA). The NVivo software was 
used for assessing the descriptive findings. 
 
Results: The website included a questionnaire of 35 items to assess individual’s different CVR 
profiles, the VAC, pharmacists’ interventional protocols for hypertension, obesity, 
dyslipidaemia, diabetes, smoking cessation, alcohol reduction and medicine reconciliation, as 
well as patient information leaflets. A total of 24 pharmacists from Madrid were included in 
the pilot study, of whom 54% were female. Most participants were in the 20-29 (50%) age 
group. 66% of the participants had prior training or been accredited for providing 
pharmaceutical care services (PCS), but only six (25%) claimed to be actively involved in 
providing those services. The majority of CPs claimed that the website is straightforward to 
use, the design and protocols to be easy to follow. Most CPs said that the patient information 
designed is appropriate in terms of language and content. 62% of pharmacists, all in the group 
already providing PCS, strongly agreed that the time to fill out the VA questionnaire is 
reasonable. Most pharmacists (87%) claimed that they would recommend the VA tool to their 
colleagues. About the barriers pharmacists face in providing CV services, the majority claimed 
that this tool could improve their sense of job satisfaction, professional image with patients 
and the pharmacist’s relation with doctors. Very interestingly, 79% claimed that the VA tool 
would improve pharmaceutical care delivery. 
 
Conclusion: The VA tool can constitute a key component in cardiovascular health promotion 
services by CPs throughout Spain. Further studies are required to explore its use in CPs across 
Spain in the post-COVID era.  
 
 
 



 6 

Resumen 

Antecedentes: La enfermedad cardiovascular (ECV) es una de las principales causas de 
morbilidad y mortalidad en España. Según la Organización Mundial de la Salud, el 80% de 
estas muertes prematuras se podrían evitar reduciendo los factores de riesgo cardiovascular 
modificables. Diversos estudios indican que los pacientes entienden mejor su riesgo real 
cuando se les presenta la información en forma de edad vascular. Los farmacéuticos 
comunitarios (FC) están bien posicionados para evaluar la edad vascular de los pacientes, 
proporcionar asesoramiento educativo profesional y aplicar intervenciones para reducir el 
riesgo cardiovascular (RCV). 
Objetivo: El objetivo explícito de esta tesis fue crear una herramienta centrada en el paciente, 
precisa y accesible que permita a los FC de España estimar la edad vascular y diseñar un plan 
de intervención personalizado encaminado a reducirla. 
Método: Se creó una página web que incluía un cuestionario original, la calculadora de la 
edad vascular, protocolos detallados para la intervención del farmacéutico y folletos 
informativos para el paciente sobre factores de RCV. Se analizó la percepción de los usuarios 
sobre la página web a través de una encuesta online de veintiséis preguntas distribuida entre 
los FC mediante un formulario de Google. Se obtuvo el consentimiento informado de los FC 
para participar en el estudio. Las respuestas a la encuesta se recogieron de forma anónima. 
Se utilizaron preguntas abiertas y cerradas para obtener una amplia gama de respuestas y de 
mayor profundidad. El cuestionario del estudio piloto estuvo disponible en línea desde el 1 
de agosto de 2020 hasta el 31 de febrero de 2021. Los resultados se analizaron con el paquete 
STATA versión 12.0 (StataCorp LP, College Station, TX, USA). Para evaluar los resultados 
descriptivos se utilizó el programa informático NVivo.  
Resultados: La página web incluye un cuestionario de 35 preguntas para evaluar los 
diferentes perfiles de RCV, la calculadora de la edad vascular, los protocolos de intervención 
de los farmacéuticos para el manejo de la hipertensión, la obesidad, la dislipidemia, la 
diabetes, la deshabituación tabáquica, la reducción del consumo de alcohol y la conciliación 
de medicamentos, así como, folletos informativos para los pacientes. Un total de 24 
farmacéuticos de Madrid fueron incluidos en el estudio piloto, de los cuales el 54% eran 
mujeres. La mayoría de los participantes estaban en el grupo de edad de 20 a 29 años (50%). 
El 66% de los participantes tenían formación previa o estaban acreditados para la prestación 
de servicios de atención farmacéutica, pero sólo 6 (25%) afirmaron estar involucrados 
activamente en la prestación de dichos servicios. La mayoría de los FC afirmaron que el sitio 
web es sencillo de utilizar y que el diseño y los protocolos son fáciles de seguir. La mayoría de 
los FC afirmaron que la información diseñada para el paciente es apropiada tanto en términos 
de lenguaje como de contenido. El 62% de los farmacéuticos del grupo que ya prestaba 
servicios de atención farmacéutica consideraban que el tiempo empleado para rellenar el 
cuestionario de la edad vascular es razonable. La mayoría de los farmacéuticos (87%) afirmó 
que recomendaría la herramienta de edad vascular a sus colegas. Con respecto a las barreras 
a las que se enfrentan los FC en la prestación de servicios a nivel cardiovascular, la mayoría 
afirmó que esta herramienta tiene potencial para mejorar su grado de satisfacción en el 
trabajo, la imagen profesional con los pacientes y la relación del farmacéutico con los 
médicos. Es interesante señalar que el 79% afirmó que la herramienta de la edad vascular 
mejorará la prestación de los servicios de atención farmacéutica. 
Conclusión: La herramienta de la edad vascular puede constituir un componente clave en los 
servicios de promoción de la salud cardiovascular por parte de los FC en toda España. Se 
necesitan más estudios para explorar su uso con los FC de toda España en la era post COVID.  



 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                          INTRODUCTION 
 



 8 

 
Introduction 

1. Cardiovascular diseases (CVDs) 

Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality globally. 

CVDs are defined as a collection of disorders affecting the heart and its blood vessels, caused 

by the process of endothelial dysfunction and/or atherosclerosis (1). CVDs can be further 

classified into coronary heart disease (CHD), cerebrovascular disease, peripheral arterial 

disease, rheumatic heart disease, congenital heart disease, as well as, deep vein thrombosis 

and pulmonary embolism. However, ischemic heart disease (IHD) and stroke are among the 

most common significant public health issues which took 15.2 million lives worldwide in 2016 

(2). 

Development of CVD as a heterogeneous non-communicable disease (NCDs) is due to a 

mixture of genetic predisposition and environmental exposure of the patients. The first study 

to use the population-based approach on a large scale to investigate the possible risk factors 

of CVD was the Framingham study, which began in 1948. The original cohort of this study was 

5,209 men and women aged between 30 and 62 years, from a town in Framingham, 

Massachusetts. The study subjects were initially assessed and observed for development of 

CVD such as a heart attack or stroke over 20 years (3). Another scientific milestone for the 

identification of CVD's risk factors was the WHO MONICA (Multinational Monitoring of Trends 

and Determinates in Cardiovascular Disease) project. The unique characteristic of the 

MONICA study was the large multinational study cohort and the long period of follow up, 

which have made it ideal for risk estimate analysis (4). They placed a heavy emphasis on the 

accumulated risk that leads to the development of CVDs. The risk factors for CVD can further 



 9 

be classified into modifiable and non-modifiable causes. The healthcare system currently 

focuses on implementing measures to control the modifiable causes in order to reduce the 

prevalence of CVDs.  

1.1 Non-modifiable risks factors  

1.1.1 Age  

Research has shown that an advanced age is an independent and most potent risk factor in 

the development of CVD (5). On the other hand, the extent of a patient’s comorbidity and, in 

turn, the number of medicines they consume increases with age. The age-associated changes 

were predictable. For instance, in the study done by Strait et al. 2012, the age-associated 

changes in the cardiovascular system were described as being manifold. According to Strait, 

aging causes structural changes such as vascular rigidity, thickening of the left ventricle 

muscles, slight increase of the heart in size and fibrosis, leading to diastolic dysfunction. On 

the other hand, functional changes, reduction in the cardio-protection and repair processes 

of the heart is conducive to CVD development. According to the WHO report from 2020, Spain 

which is the third largest country in western Europe, had one of the highest average life 

expectancies in the world with 80.6 years for men and 85.6 years for women (6). The NCDs 

report of the WHO showed that CVD with a 28% proportional mortality is the leading cause 

of death throughout Spain (7).  

The WHO has defined the term geriatric to be the chronological age of 65 and above (8). More 

advanced age is associated with deterioration of multiple organs known as multimorbidity. 

According to the United Nations advanced age above 70 years is associated with at least 2 or 

more chronic diseases (9). Another ground-breaking study of 1,741,841 individuals in 



 10 

Scotland showed that multimorbidity increased with age and was present in most people 

aged 65 years and over (10). They have reported that the world’s elderly population will 

increase to one in five people by 2050 (8). Research has shown advanced age is the most 

potent risk factor for CVD. Older age is associated with comorbidities such as hypertension, 

diabetes mellitus, chronic heart disease, lipid disturbances and renal diseases, etc. (11). These 

individuals take various medications which give rise to the phenomena of polypharmacy or 

polymedicated (12). Polymedicated, as defined by the WHO, is concomitant use of five or 

more medicines by the same individual (13). It is a real public health challenge, especially in 

geriatric patients. The negative impact of polypharmacy covers poor medication adherence, 

potential chance of developing drug-drug or drug-disease interaction or greater risk of 

adverse drug reactions (ADRs). Research has shown these, in turn, lead to increased patient 

hospital admission, healthcare cost and mortality. This is due to pharmacokinetic and 

pharmacodynamic differences within the general population. Aging causes metabolic 

fluctuations and reduced drug clearance by kidneys which may lead to the development of 

various unwanted side effects (14).  

1.1.2 Sex/gender   
 
Aetiology and clinical presentation of CVD differs between female and male subjects. Sex is 

the biological characteristic that marks male, female, and/or intersexuality in individuals. Sex 

can be defined by various factors such as chromosomes, reproductive system, or hormones 

or environmental disposition (15). Females are XX and males are XY chromosome holders. On 

the other hand, gender is distinct from sex, and it is multidimensional. It can be defined by 

sociocultural norms, individual behaviours, identities, and relations. Indeed, testosterone in 

men and 17beta-estradiol and progesterone in women cause CVD sex-based differences (16). 



 11 

Although estrogens have a cardioprotective effect, they will wear off naturally in post-

menopausal women. Thereafter, these individuals require extra cardiac protection and 

precaution which is often dismissed in interventional risk prevention (17, 18) . Heart disease 

has been principally defined to be male dominant. Therefore, risk estimation metrics and 

treatments have been previously tailored more for the male gender. However, advancements 

in science have proven that women and gender-diverse individuals can get underdiagnosed 

by using such gender-blind diagnostic and treatment tools.  

Sex and gender segregation in research studies is crucial. The biological differences between 

male and female will produce considerable differences in the outcome of the research. 

However, a gender-blind positioning is a common practice among researchers and has caused 

poor scientific outcome and misleading results. Heidari et al. 2016 have provided an outline 

for researchers to take into account these differences from research method design to 

reporting of final results (19). Most academic research use sex and gender as interchangeable 

terms. The researchers ask participants to indicate if they are male or female. However, this 

gender binary framework does not consider the sexually dimorphic hormonal system defined 

by both sex and gender explicitly. To overcome this shortcoming, Strafford university, as well 

as scholars such as Heidari, suggested a two-step method in which the researcher first asks 

the sex assigned at birth and then the gender identity of the study subjects. This method of 

conducting a survey, allows the researcher to reach a conclusion based on direct investigation 

and reasoning rather than from the explicit sexual orientation or even the appearance of 

subjects (20). Although research in gender-related differences in terms of CVD has shown a 

lower rate of CVDs in women up to the age of the menopause, research has shown women 

have higher mortality and a worse prognosis after acute cardiovascular events (21). 

Furthermore, the risk of CVDs is underestimated in women, leading to a delay in diagnosis 



 12 

and a poor prognosis. This highlights the need for healthcare to use more robust and gender-

specific risk estimate tools for prevention and management of CVD' risk in women.  

Several studies have outlined woman-specific risk factors in developing atherosclerotic 

cardiovascular diseases (ASCVD). Examples are preterm delivery, hypertensive pregnancy 

disorders, gestational diabetes, breast cancer treatments, autoimmune diseases and 

depression (22). Vascular aging starts with arterial stiffening which differs in the sexes, with 

stiffer vessels detected in men from adolescence to age 58 (years) and in women after the 

age of the menopause. Interestingly, elderly women showed stiffer vessels than men after 

the age of 58 (23). Some have argued that conventional risk factors such as diabetes mellitus, 

hypertension, dyslipidaemia, obesity, physical inactivity and smoking have an excessively fatal 

risk and a far more significantly negative impact on the CV system of women compared to 

men (22). Yet studies indicate that women receive less aggressive treatment, such as lipid-

lowering therapy or aspirin, and less educational advice, than men with a similar CV risk 

profile (24-26).  

The 2018 AHA/American College of Obstetricians and Gynecologists advisory board 

emphasized the importance of the use of a gender specific guideline known as “Life's Simple 

7” cardiovascular health  metrics to assess women's cardiovascular risks (27). This guideline 

was initially developed and published by the AHA in 2010, and includes advice on diet, 

physical activity, smoking cessation, body mass index (BMI), blood pressure (BP), total 

cholesterol (TC), and fasting glucose reduction, specifically tailored for women (28). 

1.1.3 Family history and genomics  

Family history can be an essential factor contributing to the development of CVD. Genetic 

CVDs may manifest themselves in the form of chromosomal disorders (such as congenital 



 13 

heart defects or congenital heart disease) or single-gene diseases (i.e., cardiomyopathies 

(CMPs) or heritable aortic diseases); it can also show itself in form of multi-gene disorders 

such as IHD, atherosclerosis and diabetes. Research has shown that when a first-degree male 

relative has suffered a heart attack before the age of 55, or if a first-degree female relative 

has suffered from a heart attack before the age of 65, the patient is at increased risk of CVD 

development (29). In cases where both parents have suffered from heart disease before the 

age of 55, the patient has an increased risk of developing heart disease of up to 50%. In terms 

of treatment options also genetic testing can be used to identify the patient's unique variation 

and suggest the best preventative or treatment approach. However, genetic testing for 

individual susceptibility to CVD is not yet available broadly, especially at primary care level 

setting such as community pharmacies (CPs); neither is someone’s genotype the only 

determinant factor in the development of heart disease. Other factors such as environment 

can also impact the individual CVD risk profile (30). 

1.1.4 Ethnicity  

The terms race and ethnicity are used interchangeably among scientists. However, each plays 

a different role in the predisposition of an individual toward CVD. The Oxford Dictionary has 

defined race as the biological variation among individuals based on physical characteristics or 

shared ancestry. Ethnicity refers to people’s cultural expression and identification; it is 

determined by many factors including race, national and tribal origin, religious background, 

linguistic abilities, and cultural and family background. Ethnicity is a widely used term as a 

health determinant of an individual but is indeed a manifold and complex issue to be 

considered. In today's world where relocation for work, migration and interracial marriage 

are quite common, the real risk that human diversities can impose upon an individual’s 



 14 

cardiovascular health can not only be defined by their country of origin but also by other 

factors such as religion, cultural background, linguistic abilities, socioeconomic situation, 

biology, geographical location and race  (31-33). According to the most recent “Health System 

Review”, in Spain 86.4% of the population are Spanish registered citizens, 1.8% are from 

Morocco, 1.3% are Romanians, another 10.5% are from many diverse ethnicity (34). Each of 

these backgrounds carries dissimilar risks of developing CVDs due to various factors, including 

inequalities with regards to health provision (35). The same report disclosed that the general 

health status indicator1 for CVD among Spanish residents is 4% and in foreign residents is 

worse (9%) (36).   

1.2 Modifiable risk factors  

1.2.1 Hypertension  
 
Hypertension, also known as the “silent killer”, is the most prevalent CVR factor and a growing 

public health problem. It is associated with increased risk of morbidity and mortality. 

Hypertension is characterised by a persistently systolic blood pressure (SBP) over 140 mmHg 

and diastolic blood pressure (DBP) over 90 mmHg recorded in 2 separate measurements (37, 

38). Uncontrolled BP can put at risk heart, brain, kidney, and other organs (involvements and 

injury) (37, 38). According to Di@bet.es, a population-based cross-sectional study, 42% of the 

Spanish adult population aged over ≥ 18 (years) suffered from hypertension, of which 49% 

were men. This article has stated that among the hypertensive individuals, 67% were 

prediabetics, and 79% were people with diabetes. Another interesting finding of this ongoing 

study was that there were 37% of Spaniards with undiagnosed hypertension, which was 

 
1 General health status indicators are defined by five elements: morbidity, mortality, and disability data, quality of life or functional status. 
For example, physical functioning, mental and emotional well-being, social functioning, general health perceptions been used. 
 



 15 

observed more amongst men (43%). Furthermore, they identified that 88% of the 

hypertensive patients were receiving drug therapy, but only 30% of them were well-

controlled and there was a higher proportion of women (24%) (39). This study has highlighted 

the need for an interventional program in Spain to target the unidentified hypertensive 

individuals in the community. This study claims that there is a move to improve medication 

compliance among diagnosed hypertensive patients.  

Despite the national attempt to diagnose and treat hypertension in Spain, some patients may 

present elevated BP in the clinic but normal ones at home. This is known as white-coat 

syndrome and should be taken into count by pharmacists who provide interventional services 

to reduce a patient’s CVR.  

On the other hand, it has long been known that there is a group of patients who present a 

normal clinic BP but elevated ambulatory or home measurements. This phenomenon is 

known as masked hypertension. The European Society of Cardiology’s 2018 guideline defined 

the BP cut-off value of 135/85 mmHg for out-of-office daytime or home BP and 130/80 mmHg 

for 24-h BP for clinical decision making (38). The prevalence of masked hypertension in Spain 

was investigated by the study of masked hypertension (ESTHEN). The researcher has 

identified a 48% (95%CI 42-53) prevalence of this syndrome among Spaniards. The risk factors 

that caused the masked hypertension were abdominal obesity (39%), smoking (24%), 

relatives with premature CVD (22%), and diabetes (11%) (40). Similarly, a more recent study 

in the geriatric population also found masked hypertension syndrome among 43% of the 

study cohort (41). Another review article looked at studies with a total of 51,573 hypertensive 

patients included in the Spanish ambulatory blood pressure monitoring (ABPM) Registry. 

Their results suggested a daytime variation of more than ≈20/10 mmHg when comparing 

office and 24 h BPs, lending additional support to the previous study findings (42). 



 16 

Furthermore, one meta-analysis reported subjects with masked hypertension have a higher 

risk of cardiovascular accidents (hazard ratios: 1.92 (1.51–2.44)) than normotensive subjects 

(43). There is abundant evidence for the benefit of provision of the (ABPM) devices that 

recognise hypertensive patients and provide appropriate treatment options. However, this 

will be associated with a high cost for the healthcare system. The Spanish ABPM Registry was 

developed in 2004 to promote the use of ABPM in primary care settings. However, 

pharmacists have not been utilized by the Spanish healthcare system in making a contribution 

to the ABPM Registry (44, 45).  

1.2.2 Obesity  

Individuals diagnosed with obesity ( BMI ≥30 kg/m2) or being overweight (BMI 25-29.9 kg/m2) 

are at an amplified risk of diabetes, hypertension, dyslipidaemia, and CHD (46). On the other 

hand, men and women who have waist circumferences greater than 102 cm and 88 cm, 

respectively, are considered to be at greater risk of cardiometabolic disease (47). Waist 

circumference measurement used to monitor the effectiveness of interventional services 

provided by the community pharmacy for overweight and obese patients results in 

improvement of anthropometric, clinical and therapeutic parameters in patients (48). A 

recent study revealed an estimate of 39.3% of overweight in the Spanish adult population 

aged between 25-64 years. Further, there has been a 21.6% general obesity with an 

increasingly higher trend among men (22.8%). More dangerously the prevalence of 

abdominal obesity was estimated as 33.4% and was higher among women (43.3%). Both 

abdominal and general obesity rose with age among the Spanish population (49). Obesity may 

lead to the development of CVD and diabetes with time depending on patients’ metabolic 

profile (50). Patients are divided into metabolically unhealthy obese and metabolically 



 17 

healthy obese. Research revealed that the metabolically unhealthy obese were subjected to 

higher risk of developing type 2 diabetes mellitus (T2DM) and other comorbidities such as 

CVDs (51). Metabolically healthy obese individuals were defined by BMI ≥30 kg/m, 

Homeostatic Model of Assessment-Insulin Resistance Index (HOMA-IR) <90 %, HDL >40 mg/dL 

in men and HDL>50 mg/dL in women, TG <150 mg/dL, fasting blood glucose (FBG) <110 

mg/dL, and BP ≤140/90 mmHg (52). Although patients with metabolically healthy obesity 

have a lower risk of developing other comorbidities, their risk remains high and increases with 

time (53).  Childhood obesity is another major public health challenge in Spain. Children from 

families with a lower level of education (35%) and immigrants (19%) have a higher level of 

unhealthy weight (54). 

1.2.3 Dyslipidaemia 

Recent research has revealed that 1 in 2 Spaniards have high TC serum levels and more than 

44.9 % suffer from elevated levels of low-density lipoprotein cholesterol (LDL-C ≥130mg / dL 

or drug treatment), irrespective of their gender (55). Elevated TC of >200 mg/dl and LDL-C 

>70 mg/dl have been shown to act as an independent risk factor of CVD (56). Therefore, early 

identification and management of these parameters among the Spanish population can 

reduce the burden of CVD significantly. Various trials have investigated the initiation of statins 

to reduce TC and LDL-C impact on the development of CVD (57). Initially the West of Scotland 

Coronary Prevention Study (WOSCOPS) trial and AFCAPS/TexCAPS proved the positive impact 

of pravastatin and lovastatin use on the primary prevention of coronary artery disease (58) 

(59). Later the ASCOT-LLA trial proved that statin reduced the rate of nonfatal myocardial 

infarction (MI) and coronary artery disease-induced mortality in hypertensive patients (60). 

Dyslipidaemia can be described as a number of conditions, such as: 



 18 

1. Hypercholesterolaemia (presence of high concentrations of TC in the blood, typically 

including elevated low-density lipoprotein cholesterol (LDL-C)). 

2. Hypertriglyceridemia (presence of elevated triglyceride (TG) levels in the blood). 

3. Mixed dyslipidaemia (elevations in LDL-C, TC and TG levels accompanied by low levels 

of high-density lipoprotein cholesterol (HDL-C). 

1.2.4 Diabetes mellitus  
 
Diabetes mellitus is a chronic metabolic disease caused by the inability of pancreatic cells to 

produce enough insulin which causes a permanent rise in blood glucose level. In Type 1 

diabetes mellitus the body is unable to synthesis insulin genetically whereas in T2DM the body 

is resistant to the use of insulin. Research has shown high prevalence of diabetic and 

prediabetic state among patients newly diagnosed with an acute MI (61). The International 

Diabetes Federation report suggested that by 2045 we will have a 15% increase in diabetes 

among the 20-79 age group across Europe (62). The Finnish diabetes prevention study has 

shown that a weight reduction of >5% by decreasing the fat intake by <30% and the saturated 

fat consumption by <10% of energy intake, a fibre intake of ≥ 15g/1000kcl along with regular 

exercise 4 times a week or more can prevent T2DM in high-risk patients by more than half 

(63). Another interesting investigation demonstrated that the cumulative incidence of 

developing T2DM and weight reduction is lower in patients who have received education and 

metformin in comparison with the control group (64). All this evidence emphases the 

importance of a plan for patient education, support, and personalised care. The American 

Diabetes Association guidelines have suggested that primary care professionals must 

routinely screen CV patients at high risk of developing T2DM by measuring their FBG and 

glycated haemoglobin (HbA1c). However, EUROASPIRE IV, a cross-sectional survey of patients 



 19 

aged 18-80 years with coronary artery disease in 24 European countries, suggested that an 

oral glucose tolerance test (OGTT) is a better indicator of impaired glucose tolerance (IGT) 

with established coronary artery disease. 4004 of the patients in this study had no reported 

history of diabetes (65). Table 1 outlines the diagnostic criteria for diabetes mellitus and pre-

diabetes according to the 2019 American Diabetes Association recommendations. However, 

pharmacists must consider the possible variation and limitation that HbA1c has, such as 

increase in the result due to haemoglobin variants and anaemia (66).  

 

Table 1. Diagnostic criteria for diabetes mellitus  
 

Parameters Values  

Diabetes mellitus  

HbA1c ≥6.5% (48 mmol/mol) 

FBG ≥7.0 mmol/L (126 mg/dL) 

Diagnose impaired glucose tolerance (IGT) 

FBG <7.0 mmol/L (<126 mg/dL) 

2hPG ≥7.8 to <11.0 mmol/L (≥140–199 mg/dL) 

 

1.2.5 Other comorbidities   

Different comorbidities are associated with CVD occurrences. Poor vision, diabetes, 

back/neck problems, osteoarthritis, chronic obstructive pulmonary disease, and cancer are 

significantly more associated with CVDs when compared with patients without those 

cardiovascular conditions (67, 68). A large number of publications have also reported the 

increased association of arterial stiffening and vascular aging with physiological conditions 

such as low birth weight (69), menstrual cycle (70), metabolic syndrome (71), rheumatoid 



 20 

arthritis (72), systemic lupus erythematosus (73), etc. Risk-reducing strategies for ASCVD 

must incorporate the patient’s comorbidities in the estimation of lifelong risk. The 2019 

ACC/AHA guidelines asked practitioners to pay special attention to patients who have a family 

history of premature ASCVD (males aged <55 years; females aged <65 years), primary 

hypercholesterolemia (LDL-C = 4.1-4.8 mmol/L); (HDL-C = 4.9-5.6 mmol/L), metabolic 

syndrome, elevated TG  (>150 mg/dL), elevated BP, raised glycemia, and low HDL-C (<40 

mg/dL in men; <50 mg/dL in women), chronic kidney disease (CKD), chronic inflammatory 

conditions (psoriasis, rheumatoid arthritis, lupus, or human immunodeficiency virus), a 

history of premature menopause (before age of 40) and pregnancy-associated disorders 

(preeclampsia) and persistently raised primary hypertriglyceridemia (≥175 mg/dL) during risk 

estimation (46).     

1.2.6 Mental health  

Empirical research done by cardiologists Friedman and Rosenman (1976) argued that patients 

with a “Type A personality” typically characterised by a competitive, ambitious, work-driven, 

easily stressed, anxious, time-conscious, and aggressive personality are at higher risk of CHD 

(74). This claim was later scientifically proved by the Western Collaborative Group Study and 

the Framingham study (75-77). However, mental health aspects were not later included in 

the Framingham cardiovascular risk CVR estimation tool. Stress as one of the most common 

psychological problems in the modern world is an influencing factor directly linked with CVDs. 

Stress can be acute (e.g., natural disasters) or long term (e.g., occupational stress).  In a report 

by Gullette et al. negative emotions such as tension, sadness and frustration, which lead to 

chronic stress are directly correlated with double the risk of myocardial ischemia (MI) 

subsequently (78).  



 21 

The research indicates that emotional stress can cause an upsurgence of the sympathetic 

nervous system, damages endothelial function and create favours coagulation in the vascular 

system, resulting in MI or sudden death (79). Similarly, researchers have found that stress 

triggers the consumption of a higher amount of calorie-rich food such as sweet and fatty 

foods. That in turn causes a lower amount of micronutrient consumption beneficial to the 

individual’s health & and causes a higher rate of cardiovascular incidents (80, 81). One of the 

suggested approaches for managing the prevention of CVD caused by stress and other 

psychological risk factors is routine screening for early detection and timely management. A 

number of studies have proved the positive impact of CPs’ services on early detection and 

management of stress (82). One of these studies used a 4-item screen for the detection of 

post-traumatic stress disorder in the community pharmacy setting. The investigation 

provided evidence on the effectiveness of CP’s screening and identification of stress among 

service users (83). On the other hand, patients with mental health conditions have a low 

adherence rate with their medication. CPs can give them support to in order to increase their 

compliance (84). The prevalence of psychological distress in Spain has decreased slightly. 

Variations are observed in psychiatric abnormalities in Spain based on location and gender 

where women showed poorer outcomes (85). 

 1.2.7 COVID-19  
 
It was initially thought that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) 

only targets pulmonary epithelial cells, it was later scientifically proven that this virus does 

indeed infect many other cell types causing systematic inflammation with cytokine release 

and vascular damaging (86). The endothelial induced end-organ complications of the SARS-

CoV-2 are most recently reported to be vasoplegia, acute respiratory distress syndrome, 



 22 

myocardial injury, thromboembolism, and immune system collapse (87). Furthermore, it has 

been proven that SARS-CoV-2 affects the lipid cholesterol biosynthesis and decreases the 

level of total, HDL-C, and LDL-C as COVID-19 progresses in patients, but the long-term impact 

of this mechanism is still unknown (88). The pathophysiological explanation for developing 

these abnormalities is beyond the scope of this thesis. However, COVID-19 cases have been 

reported to be associated with some modifiable and non-modifiable risk factors. Surveillance 

data has shown that the modifiable risk factors associated with COVID-19 were obesity, 

smoking, slow walking pace indicative of lower fitness/activity and use of BP medication for 

hypertension (89). Also, those of an older age, male gender, low socio-economical level and 

from an ethnic minority were reported to be at greater risk of developing COVID-19 infections 

(90). It seems there is an overlap of risk factors that predispose patients to the development 

of both COVID-19 and cardiovascular abnormalities. Before the COVID-19 outbreak, it was 

expected that more than 30% of the total Spanish population would be over the age of 64 by 

2050 (91). This requires the government to develop an action plan to prevent CVD and 

premature mortality in this population. However, recent statistics have shown the high 

mortality rate among those aged from 60-90 compared to their younger counterparts, since 

the pandemic. In the 60-69 age group, 5.1%; in the 70-79 age group 14.5%; in the 80-89 age 

group 21.2% and over 90s had a more than 22.2% mortality rate during the pandemic (92).   

According to Oxley, the increasing incidence of vascular endothelial dysfunction and large-

vessel stroke has been reported in patients younger than 50 years of age with the COVID-19 

infection (93). Another remarkable article by professor Libby et al states that direct viral 

infection and the inflammatory response elicited causes myocardial injury, which may or may 

not be reversible (94). However, this will raise the question that perhaps in the era post 

COVID-19 healthcare professionals (HCPs) should widen the age range of patients to 



 23 

determine the actual risk of developing future CVD, since the pandemic has affected various 

age groups. Another possibility could be that patients who acquired this virus recently or in 

the past, may carry an additional risk of developing CVDs, and this risk should be included 

when calculating the VA of the patients. However, the statistical weight of risks contributing 

to future CVD is yet to be determined by long term follow-up clinical trials.  

1.2.8 Smoking  

Smoking is a most important modifiable risk factor in developing CVD (95). A smoker can be 

defined as a person who has smoked at least 1 year in his or her life and has smoked within 

the last month (96). Smoking also harms many other major organs in the body as shown in 

Figure 1. 

BP is increased in active smokers or non-smokers exposed to passive smoking. Upon initial 

exposure, nicotine causes vasoconstriction and an instant increase in SBP. Then the 

depressant effects of nicotine cause a decrease in BP. However, carbon monoxide present in 

the cigarette acts directly on the vascular wall causing irreversible vascular stiffening (97). 

This functional alteration of vascular structure leads to long-term BP and increased heart rate 

(98, 99). Similarly, smoking reduces the amount of oxygen that reaches the body's tissues, 

increasing the risk of clot formation and doubling the risk of stroke (100). Smoking is also 

known to decrease the level of HDL-C, total HDL, and large HDL particles, especially in women 

(101). In contrast, smoking was not found to affect LDL-C (101).  

 

 

 

 



 24 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

Figure 1: Impact of smoking on major organs in the body 
 

Harm from smoking can vary in individuals according to their pack history. Pack history is a 

calculation of cigarette smoking employed to measure a person's exposure to tobacco. 

Smokers can be divided into heavy smokers who consume ≥15-20 cigarettes per day, 

moderate smokers who use 10-19 cigarettes per day, and light smokers who smoke <10 

cigarettes per day.  This can be used by primary care practitioners to assess the patient’s risk 

of developing CVDs. Pack history is used for inclusion in smoking cessation programmes 

funded by Social Security in Spain. A recent systematic review showed that substantial 

reduction in smoking can reduce the CVD risks (102).  

In the light of the current COVID-19 pandemic, new studies have demonstrated that smokers 

have a weaker immune system (103). Smokers are at greater risk of getting acute respiratory 

  

Heart 
Double the risk of 

having a heart attack 

 

  

Circulation  
Increase the blood 

pressure and heart rate 

 

Brain  
Increase the risk of 

having a stroke 

Kidney  
Smoking may cause 

 kidney damage  

by its effect 

 on sympathetic  

nervous system   BP 

 



 25 

infections and furthermore, their infection may last longer (104). Smoking is a major risk 

factor in provoking severe infection and even death from severe acute respiratory syndrome 

coronavirus (SARS-CoV-2).  Epidemiological studies claim that active smoking is correlated 

with an increased severity of disease and death in hospitalized COVID-19 patients. The 

pathophysiological mechanism involved is that smoking can upregulate the angiotensin-

converting enzyme-2 receptor. This receptor is used by the SARS-CoV-2 virus to enter the 

human cell. This not only causes an infection but may also activate a 'cytokine storm' which 

can potentially worsen the outcome in COVID-19 patients (105). Research has shown that 

smoking can add 10 years extra to the patient’s VA, lending additional support to the 

hypothesis that smoking may increase the rate of mortality in patients with CVD. Quitting 

smoking should be promoted among patients by healthcare practitioners including 

pharmacists, especially during the COVID-19 pandemic.    

Investigation established that three quarters of smokers have a tendency to quit. However, 

only one third (39%) make an attempt to quit each year of whom only 5% quit successfully 

(106). Adequate behaviour change promoted by CPs can develop an understanding of the 

negative impact of smoking in patients. Smokers who quit smoking with HCPs support and 

medication are up to three times more likely to stop successfully compared to smokers 

without professional support (107). Practical intervention will make a significant difference in 

patients’ lives through becoming permanent ex-smokers. Intervention by CPs should be 

tailored to match the smoker. Evidence shows that a combination of behavioural support and 

pharmacotherapy can increase a smoker’s chances of stopping by up to four times (108).  



 26 

1.2.9 Diet  

The primary protective measure which can be implemented on a community level for primary 

or secondary prevention of CVD is a cardio-protective diet. Various diets have been associated 

with lower cardiovascular incidents. There is abundant evidence for the cardio-protective 

mechanisms of the Mediterranean diet (MedDiet). The ATTICA study suggested that 

adherence to a MedDiet can play a significant role in CVD risk reduction (109). The MedDiet 

mainly consists of fruit, vegetables, fish, and whole grains. It is high in unsaturated fats such 

as olive oil, nuts, and seeds. Moreover, it contains less saturated fats such as red meat and 

full fat dairy products. The traditional food pattern of the Spanish population has long been 

known to follow the MedDiet (110). However, recent nutritional surveillance studies suggest 

that nutrition intake has changed markedly in the last few years across Spain (111). This 

surveillance study has found that a new dietary pattern among the younger generation in 

Spain is now more focused on meat and that consumption of cereals, fruit and vegetables, 

and pulses does not meet the national recommendations for the Spanish population (111). 

Furthermore, this study has reported that the use of traditional Mediterranean foods (olive 

oil) has dramatically declined over the last forty years in light of the dietary recommendations 

by the Spanish Society of Community Nutrition (SENC) (112). This might be the explanation 

for the increasing obesity trends in Spain reported in the WHO NCDs report (7). 

Another aspect that dictates today’s diet across the world and in Spain may be socio-

economic factors as well as climate change. A new published study in 2019 known as the Eat-

Lancet report suggested that individuals can save the planet as well as reduce their risk of 

developing NCDs by following a planetary health diet. This universal healthy reference diet 

suggests that individuals mostly base their diet on plant-based food to save the planet (113). 



 27 

Similarly, the community based cohort study known as the ARIC (Atherosclerosis Risk in 

Communities) study, that followed up patients from 1987 to 2016, lends additional credibility 

to the hypothesis of a planetary health diet benefits in reducing CVD (114).  

Dietary approaches to stop hypertension (DASH) diet is another healthy eating guideline also 

known to prevent and control CVDs. The DASH diet mainly consists of whole grains, fruits and 

vegetables, low-fat dairy products, and nuts. On the other hand, consumption of sweets, 

sodium, and red meats are reduced as part of this dietary habit. The focus of the diet is on 

reduction of sodium intake which has proved to significantly reduce SBP both in individuals 

with and without hypertension (115, 116). Furthermore, this DASH diet has been associated 

with a lower risk of all-cause mortality (117-119). A recent systematic review revealed that 

the DASH dietary pattern related to a decreased rate of CVD, CHD, stroke, and diabetes 

mellitus, lower SBP and DBP, as well as reduced TC, LDL-C, HbA1c, fasting blood insulin, and 

body weight in controlled trials (120). Evidence from a cross-sectional study conducted in 

2008-2010 among 12,948 Spanish individuals with hypertension revealed only 17.3% (95% 

confidence interval (CI) 15.4-19.2%) were following a DASH diet and 17.2% (95% CI 15.4-

19.1%) had a MedDiet (121). This lends additional support to the urgent need for health 

education to be given to patients with existing CVD or high-risk groups.  

A calorie restriction diet that reduces calorie consumption during the day is proven to be 

beneficial to the CV system as well. Similarly, intermittent fasting with a special focus on 

timing can reduce CVR factors too. The intermittent fasting regimens range from 12 to 16-

hour daily fasts to 5:2 strategy (24-hour fasts followed by a 24-hour eating period that can be 

done a few times a week). Thus, the benefit of one type of intermittent fasting regimen over 

another remains uncertain (122).  The benefits of intermittent fasting for the CV system are 

the reducing of weight, hypertension, dyslipidaemia and glycemia (123). The mechanism 



 28 

behind the benefit of this two-dietary restriction on CVD is not fully understood. However, 

there are three main proposed theories:  

1. Oxidative stress hypothesis: reduction in energy intake reduce free radicals’ 

generation by mitochondria and thus, their deleterious effect on the heart (124). 

2. Circadian rhythm hypothesis: it states that insulin levels should be kept lower later in 

the day. Therefore, late dinners can deregulate the body circadian mechanisms and 

lead to chronic disease such as diabetes (122).  

3. A ketogenic state occurs after 6–8 hours of fasting where the body produces ketone 

bodies by breaking down fatty acids and ketogenic amino acids. Increased ketone level 

converts the body into a state of fat utilization with a decrease in LDL-C and an 

increase in HDL-C levels (125).  

1.2.10 High alcohol consumption   

The well-recognised effect of moderate alcohol consumption especially red wine was first 

introduced by Renaud and de Lorgeril in his French paradox phenomena (126). The study 

compared the annual mortality from CHD and related risk factors in MONICA study cohorts, 

with the French patient's data. The results demonstrated long-term cardiovascular benefits 

of moderate alcohol consumption (20-30 g per day) among the French population despite 

high consumption of saturated fat (126). This study was later criticized due to its design 

because of patient genetical predisposition, the lack of control of potential confounding 

factors, and considering similar alcohol consumption levels for all participants rather than 

actual individual intake. However, it had triggered an avalanche of further studies on the 

effect of alcoholic beverage, in particular wine, on CVD development. Advance research 

showed that the presence of flavonoids in red wine has a protective effect on the heart.  



 29 

Alcohol-related harm can have an important personal and social impact. This is a major public 

health problem. In conclusion, the effect of alcohol on CV system has been explained as 

having a J-shaped curve, in which low-to-moderate consumption is correlated with less risk 

than heavy drinkers who have the highest risk. High alcohol consumption on a continual basis 

can greatly increase the risk of dementia, disability, and frailty as well (127). The ACC/AHA 

guideline for preventing CVD suggested moderation in alcohol consumption. They further 

defined ≤2 units of alcohol a day in men and ≤1 unit of alcohol a day in women. In the United 

States, 1 unit is defined as 14 g of pure alcohol, which is typically found in 12 oz of regular 

beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of 

distilled spirits (usually about 40% alcohol) (46). However, the value attributed to for the 

standard drink unit (SDU) varies from country to country. In Spain, one SDU is equivalent to 

10g for wine, 9 g for beer and 20 g for spirits (128). Although one study found variation in SDU 

definition in various Spanish states, primary care uses 10 g that is equivalent to a single 

consumption of wine or beer and a half consumption of liquors on the national level for 

clinical practice (129). The National Institute for Health and Care Excellence (NICE) 

recommended no more than 14 units per week of alcohol for both men and women (130, 

131) . Pharmacists can help individuals make informed choices on their alcohol consumption 

and personalised interventional measures. 

1.2.11 Caffeine  

Coffee is metabolized by the polymorphic cytochrome P450 1A2 (CYP1A2) enzyme.  

Individuals with the CYP1A2*1A allele are rapid caffeine metabolizers, whereas carriers of the 

CYP1A2*1F are slow caffeine metabolizers (132, 133). Cardiovascular incidence rate varies 

depending on the patient’s caffeine metabolism level (134) . Drinking coffee is prevalent in 



 30 

Spain and its consumption is positively associated with educational level, greater BMI (≥30), 

tobacco smoking, higher alcohol, and energy intake (135). A sport cardiologist reported that 

consumption of 200 to 300 mg of caffeine, improves endothelial cell function and causes 

vasodilation at rest (136). The same research argued that consumption of a similar amount of 

caffeine one hour prior to aerobic exercise disrupts the normal physiological mechanisms that 

help increase myocardial blood flow by blocking the adenosine receptors. This can have an 

adverse effect on cardiac functioning specially in the younger population (136). Similarly, a 

recent study which looked at the collective results of the Framingham Heart Study, CHS 

(Cardiovascular Heart Study), and the ARIC study (Atherosclerosis Risk in Communities) 

reported a decreased incidence of heart failure in individuals with a higher consumption of 

caffeine (137). However, this is not to say caffeine can prevent other types of CVD. Collective 

literature may suggest that caffein impact on the heart varies in the individual depending on 

their genetic predisposition (137).  

1.2.12 Poor medication compliance  
 
One of the principal difficulties in the treatment of long-term conditions such as CVD is 

medication non-compliance. Health organizations have reported that approximately 50% or 

more of the patients on long-term treatment, are non-complaint or do not take medication 

appropriately (138). Patient habits in taking medication can be better understood via three 

various terms compliance, concordance, and adherence. The term compliance refers to 

whether or not the patient takes their medicine as directed by the prescriber (138, 139). 

Traditionally doctors used to demand the use of medicines in a particular manner without 

any prior negotiation with patients. However, in recent years this classic model has been 

replaced by a more holistic approach known as concordance. Concordance alternatively is a 



 31 

mutual agreement between patients and doctors, a two-way agreement where patients take 

an active part in the decision-making process according to their preference, beliefs, and 

abilities. Conscious decision making can empower the patient and improves medication 

compliance.  Estimates of compliance or adherence for cardiovascular medications vary 

widely across Spanish studies. According to one recent research paper the mean rate of 

adherence in patients with cardiovascular abnormalities was 45.8% (140). Adherence can be 

achieved when a healthcare professional accepts the patient's preferences and prescribes 

accordingly. Patient medication adherence can be determined in numerous ways (141).  Some 

studies use direct medication counting or determine adherence through serum drug 

concentration. Others rely on administrative data such as the self-report Morisky-Green 

questionnaire first published in 1986 (142). Medication-possession ratio or portion of days 

covered are other possible methods. However, they only indicate the patient's possession of 

their medication not their compliance (141). With the advancement of science, in recent years 

the use of predictive analytics software has been suggested to predict the patient's 

compliance patterns. These machine-learning approaches use the patient's compliance 

history to predict their future adherence behavior. The limitation of this approach is that the 

patient's compliance in one type of medication, for instance pain killers with immediate 

benefit to the patient's health, may be different to preventative medication where they might 

not feel any difference instantly. Another drawback of these machine-learning methods could 

be that most healthcare systems do not have access to the patient's compliance information 

history, and it might take years before the healthcare professional will have access to such 

valuable data. Therefore, the Morisky-Green questionnaire is applicable and currently the 

best possible indicator of patient's medication adherence (143).  



 32 

Various studies have demonstrated that a multidisciplinary approach and direct involvement 

of pharmacists can play a vital role in facilitating patient adherence to their medication (144). 

The pharmacy office in Spain proposes the preparation of weekly pill dispensers, Personalized 

Dosage System known as sistemas personalizados de dosificación (SPD) in Spain, to improve 

patients with chronic disease compliance. However, SPD is still in the implementation phase 

and there are important differences between the different regions (145). A collaborative work 

between the Daroca health center and the CPs investigated the effectiveness of SPD system 

on improvement of patient’s compliance.  Out of 37 CPs located in the area of the study 

(Madrid) only 13 pharmacies offered the SPD preparation service (35.1%), and only 5 of them 

prepared pill dispensers. The remaining 8 pharmacies have not yet started preparing SPD, 

despite the adequate training or infrastructure (145). The finding of this research indicated 

SPD is useful in improving patient’s adherence to medication but only a few CPs offer these 

services. Further, SPD is not fully known among doctors and nurses (145).   

A recent systematic review and meta-analysis on the impact of Spanish CPs' intervention to 

improve patient adherence to statin therapy demonstrated better patient compliance (143). 

One of the limitations of this study was that the researchers did not investigate the reduction 

in lipid levels in the studies included in the systematic review due to a variation in lab results. 

However, the results obtained from the Morisky-Green scales demonstrated the positive 

impact of CPs' intervention on patient medication adherence. One of the obstacles in using 

the Morisky-Green scale is that it works well when assessing single medication or a 

monotherapeutic regimen but may be less accurate in patients with complex regimens 

presented in the form of polypharmacy. However, the practicality and ease of Morisky-Green 

makes it a suitable tool for community pharmacy use (141).  



 33 

1.2.13 Pharmacological treatments  

Some prescription medications (e.g., doxorubicin, daunorubicin, epirubicin, idarubicin for 

cancer treatment, antipsychotic such as clozapine, chlorpromazine, fluphenazine, 

haloperidol, risperidone, anabolic steroids, for example testosterone and methyltestosterone 

etc) and other over the counter (OTC) treatments (e.g., nonsteroidal anti-inflammatory drugs 

(NSAID), etc.) have a negative impact on the heart. For example, antipsychotics 

(chlorpromazine, haloperidol, droperidol, quetiapine, olanzapine, amisulpride, thioridazine), 

type IA antiarrhythmics (quinidine, procainamide, disopyramide), type IC antiarrhythmics 

(flecainide, encainide), class III antiarrhythmics (sotalol, amiodarone, tricyclic 

antidepressants, amitriptyline, doxepin, imipramine, nortriptyline, desipramine and other 

antidepressants (citalopram, escitalopram, venlafaxine, bupropion), antihistamines, 

diphenhydramine, astemizole, loratadine, terfenadine etc. cause drug-induced QT 

prolongation and dangerous life-threatening ventricular arrhythmias (146). A literature 

review in medication consumption in Spain reported a similar number of medicines used in 

comparison with other European countries except for the higher consumption of antiulcer 

drugs, anxiolytics and peripheral vasodilators (147). The CPs in some parts of the Spain have 

limited access to the patient’s medical record and electronic prescription. Although recent 

clinical trials proved CP could contribute to the improvement of patients' health status and to 

reduce their problems related with the incorrect use of medicines or ADR (148). This wide 

access to the patient’s medical record is not fully implemented in Spanish CPs and it lack 

communication with the medical doctors. This is found to be a major limiting factor in 

provision of pharmaceutical care in the privet retailing pharmacy throughout Spain and 

potential cause of ramifications (149). 



 34 

 1.2.14 Physical activity  
 
Regular physical activity can reduce the CVR significantly. According to guidance on primary 

prevention of CVD published in 2019, individuals should perform physical activity including 

resistance exercise for at least 150 minutes per week of moderate-intensity or 75 minutes per 

week of vigorous-intensity (46). However, Spain’s National Health Monitoring and 

Surveillance System published a report under supervision of the Spanish Ministry of Health. 

This Spanish National Health Survey (Encuesta Nacional de Salud de España (ENSE) has shown 

that 66.4% of adults and 68.1% of older adults engage in regular physical activity in 

accordance with the WHO) recommendations on physical activity (150). Similar to the 2019 

ACC/AHA Guideline on the primary prevention of CVD, the WHO has specific advice for the 

prevention of a sedentary lifestyle and obesity among adults aged 18-64. The WHO also has 

guidelines for adults 65 years of age and above, pregnant and postnatal women, patients with 

chronic conditions and disable individuals as well (151).  

1.2.15 Health Inequalities  

Health Inequalities can be defined as unequal opportunity of an individual on a social level to 

have a better access to health amenities, health education and other factors that can establish 

one’s physical and mental health. There are five interlinked domains that are the cause and 

consequence of health inequalities: 

1. Social determinants of health are strongly rooted in unequal economic, and 

environmental conditions (low income, unemployment, poor housing conditions, poor 

education). 

2. The intrapersonal and interpersonal situation dictates the distribution of power and 

resources (age, sex, race, sexual orientation, disability). 



 35 

3. Vulnerability (immigration, being part of a social minority, language barrier, mental health 

issues). 

4. Cultural and behavioural differences. 

5. The geographical location of an individual causes them to be subject to a different political 

and economic climate  (urban and rural living location) (152). 

One of the studies that used the postcode to link the level of deprivation with patient’s VA 

was the Joint British Societies (JBS3)-derived heart age tool. In this study the residential 

location was used to identify areas with patients at higher risk of developing CVDs. These data 

were then employed to develop strategies to focus CP’s interventional services to reduce CVD 

(153). Other major study performed in Scotland measured the cardiovascular outcomes in the 

Scottish Heart Health Extended Cohort against the Framingham CVD score. They concluded 

that considering the social gradients in CVD is essential because the patient likelihood to 

develop CVD are influenced by unattributed risk from inequalities mentioned above (154).  

On one hand, a perfect healthcare model tries to facilitate the patient’s access to health by 

creating a fully integrated community-based care programme not subject to the five domains 

mentioned above. In this case patients will all receive an equal service regardless of location, 

socio-economical or intrapersonal characteristics. In this health model primary care including 

CPs or local general practitioners are well trained and supported to provide the best of care 

for their patients. Communication among practitioners is a key element of this model. All 

healthcare practitioners are valued by the health system for their service provision and get 

paid sufficiently to motivate them further to provide world class services. It is evident that 

creating empanelment (1.6) can breach the gap between primary and secondary care. It also 

serves to reduce inequalities by reaching a wider range of patients who have limited access.  



 36 

1.2.16 Climate change  

Climate change is a global phenomenon that negatively impacts the health of the population 

(155). Numerous studies have indicated that a higher rate of cardiovascular-related hospital 

admissions or emergency cases is seen due to an increase in regional temperature (156). 

Similarly, data from the Disease Surveillance Point System of China, revealed higher CVD, CHD 

and ischaemic and haemorrhagic stroke due to changes in the climate (157). Another study 

in Iran also showed similar findings (158). On the other hand, chronic exposure to ozone 

causes thickening of the carotid artery and formation of carotid plaque. This in turn leads to 

higher CVD rate and stroke (159). The extent of CVD due to outdoor pollutant exposure is 

greater in populations with a low socioeconomic status which HCPs often have no control 

over (160, 161). 

1.3 Cardiovascular health in Spain  
 
Life expectancy in Spain is one of the highest in Europe (7), although the 2019 WHO report 

revealed the decreasing trend in Spanish life expectancy since 2018 (6). NCDs are estimated 

to account for 91% of all deaths in Spain. CVD with 28% prevalence, is one of the top causes 

of mortality. Regarding the lifestyle factors affecting cardiovascular health, consumption of 

tobacco is reported high in Spain, with 24% smokers, 22% daily smokers and quarter of the 

population as former smokers in 2020. The population in Valencia and Andalucía are the 

highest consumers of tobacco.  

On the other hand, alcohol consumption in the Spanish population between 1990 and 2019 

has been variable. In recent years, beer has replaced wine as the preferred alcohol beverage 

and binge drinking among the younger generation has been reported (162, 163).  A recent 

analysis of national consumption data has revealed a decrease of 4.5% per year from 2006 to 



 37 

2011, and a period of no change in alcohol consumption from 2011 onwards (163). However, 

psychological distress triggered by the current pandemic, an upsurge in unemployment and 

the economic crisis may trigger higher alcohol consumption (164). Another theory is that 

regular consumption of alcohol may decrease as people give priority to other expenses. This 

is followed by binge drinking of cheap alcohol to cope with emotional distress (165).  

Obesity and overweight are other considerable risk factors of CVD in Spain. Statistics revealed 

that 62.0% of the adult population (> 20 years old) in Spain were overweight and 26.6% were 

obese. The prevalence of overweight was higher among men (67.7%) than women (56.6%). 

Childhood obesity is another big challenge for the Spanish National Health System (SNS). A 

recent systematic review revealed that between 1987 and 2014, the prevalence of 

overweight and obesity increased in men by 0.28% (P=0.004) and 0.50% (P <0.001) 

accordingly per year. In women also the incidence of overweight rose by 0.10% (P=0.123) and 

obesity 0.25% (P=0.078) each year. This led to expenditure of more than 2% of the 2016 

health budget in Spain. This excess medical cost is predicted to be 58% if the government 

does not implement a national health strategy to tackle the issue (166). Possible causes of 

this increasing trend of obesity among Spanish population could be physical inactivity and 

poor diet. Nevertheless, the government needs to promote early prevention and 

management of this ongoing problem (167). High BP, high salt/sodium intake, diabetes and 

air pollution are other risk factors for CVD in the Spanish population (7).  

1.4 Cardiovascular Risk estimation  

In 1839, William Farr recognised that "diseases are more easily prevented than cured, and 

the first step to their prevention is the discovery of their existing causes" (168). Early 

identification of the multifactorial predisposition of individuals can help us identify possible 



 38 

susceptibility to the development of CVD. Early identification of these variations is being used 

in modern healthcare systems as CVD preventive measures. The National and international 

health agencies have suggested that risk estimation, prevention, and early treatment of the 

causes of CVDs can reduce the effect on the individual's health and reduce the cost to the 

healthcare system and society. According to the WHO analysis in 2010, reducing risk factors 

in young adults and maintaining an optimum risk profile until the age of 50 could prevent 90% 

of CVD rate (169).  

Preventative interventional measures are performed by HCPs in three phases of the patient's 

life. Primordial prevention identifies habits and lifestyle choices that prevent the 

development of CVR factors and educates the individuals on how to avoid them. It targets 

individuals from as early as in utero, follows them up through infancy, childhood, 

adolescence, and adulthood. It mainly focuses on tobacco avoidance, adequate daily activity, 

a healthy diet, and weight management. Primary prevention is defined as a health measure 

targeted at individuals with risk factors, who have not yet developed clinically manifest CVD. 

Finally, secondary prevention is targeting patients with pre-existing CHD, cerebrovascular 

disease and peripheral vascular disease and attempting to reverse the CVD or slow down its 

progression. This prevention of CVDs throughout the lifespan model was suggested by 

Strasser in 1978 (170). This study aimed to ascertain the real impact and efficacy of CPs' 

intervention in primary and secondary prevention of CVD across the Spanish cohort. The 

development of CVD in the general population is due to a cluster of genetic predisposition 

and environmental risk factors as explained in detail above (171, 172). The economic burden 

of CVD on the Spanish healthcare system and the population is described to be enormous 

(35). According to a recent study which has looked at the global burden of diseases, out of 5 

leading causes of death 14.6% belonged to IHD and 7.1% was due to stroke (35).  



 39 

1.4.1 Relative risk calculation  

Risk in the Oxford Dictionary is defined as the probability of encountering an adverse or 

beneficial event. The risk factor of an event can be calculated by cohort or longitudinal studies  

such as randomised controlled trials (RCT) (173).  In these studies, the investigator determines 

the strength of association of each risk factor with CVD incidents (174). Relative risk (RR) or 

risk ratio is obtained by dividing the risk (incidence of CVD) in group one with the risk 

(incidence proportion) in group two (175). The two groups are normally differentiated by 

demographic factors. The formula for RR calculation is:  

    !! = !"#$	&'	("#)*#)	"+	,-&./	&'	/-"0*-1	"+2)-)#2	
!"#$	&'	("#)*#)	"+	3&0/*-"#&+	,-&./     

RR=1.0 indicates similar risk among the two groups. A relative risk greater than 1.0 shows an 

increased risk for the group in the numerator, usually the exposed group. A result of less than   

1.0 indicates a decreased risk for the exposed group (175). However, evidence clearly 

indicates that RR should not be employed for decision-making regarding a patient. This is 

because relative risk only considers a single factor and dismisses other cofounders (variable 

that is associated with both the exposure and the outcome of interest) (176).  

1.4.2 Absolute risk calculation  

The best tool for CVR assessment for effective decision-making is the absolute risk calculator 

which estimates the probability of heart attack or stroke. Absolute risk is calculated by the 

rate of an event occurring in a pre-defined population over a specified time. This estimation 

is useful because although patients might have certain parameters in the range, they have 

more than one CVR factor and absolute risk takes into account the cumulative association of 

age, sex, smoking habits, BP, lipid concentrations and diabetes (177). The first study that 

looked at factors that contribute to CVD development in a large cohort was the Framingham 



 40 

Heart Study (FHS) in 1990. FHS employed the Cox regression2 on data obtained from a long-

term surveillance of an adult population in Framingham, Massachusetts to calculate the 

absolute CVR (172, 178). This on-going study further investigated multigeneration 

predisposition and various racial groups. These findings led to the creation of a Pooled Cohort 

Equations CV Risk Calculator to be used at primary care level to estimate a patient’s 10-year 

ASCVD risk. This calculator which evolved over years considered additional risk factors such 

as patient’s age, sex, race, TC, HDL-C, SBP, use of BP lowering medication, smoking and 

diabetes status, all required to estimate ASCVD. As Lloyd-Jones et al 2018 clearly explained, 

this form of risk calculation allows health care practitioners to estimate the patient’s 

prognosis and identify individuals with higher risk to initiate treatment earlier for the benefit 

of individuals and to reduce total cost to the healthcare system (179). However, scientific 

advance showed that the Framingham risk estimation cannot be used indiscriminately for the 

Europeans. Risk attribution varies with location. For instance,  in the USA the attributed risk 

for IHD is hypertension and dyslipidemia (180, 181), whereas in Spain, obesity and smoking 

are the most significant risk factors (182). It appeared that the Framingham chart 

overestimated the risk in the European population (183). Consequently, the Systematic 

Coronary Risk Evaluation (SCORE) project gathered data from 12 European cohort studies 

with a total of 205,178 subjects in order to understand the regional variation in risk across 

Europe (184). Nevertheless, one limitation of the SCORE system is that in the middle-aged 

population absolute risk is not high even though the relative risk may be high and may lead 

to delay in preventative treatment (185). One solution in order to overcome this limitation is 

the use of percentile risk in which each person will be compared to the individuals without 

 
2 Cox regression (or proportional hazards regression) is a method for assessing the impact of several variables (risk factors) upon the time a 
CV event takes to happen. It assumes that the effects of the variables upon the patient’s survival are constant over time. 



 41 

risk with the same age and gender (186). Similarly, population-based data from general 

practices in England provided data for the QResearch database which led to the creation of a 

risk estimation tool known as the QRISK (187, 188). Although in the SCORE project, data from 

the Catalonia Cohort Study (Barcelona Multifactorial Trial and Factory Heart Study; a total of 

4701 participants with an age range of 25-68) were incorporated, the researcher admitted 

that the overall accuracy for persons whose risk falls in the 2%-5% (low risk) category is 

uncertain (184). Therefore, the researchers adopted the Framingham table for the Spanish 

cohort in 2003 (183, 189, 190). Thereafter, the REGICOR study (Registre Gironí del COR) was 

validated to allow a 5-year coronary event risk estimation in the Spanish population aged 35-

74 years. However, the current updated version of the calculator estimates the 10-year risk 

for patients. The REGICOR calculator uses the sex and age of the patients, smoking and 

diabetes status, TC (mg/dl), HDL-C (mg/dl), SBP (mmHg) and DBP (mmHg) in creating the most 

accurate risk estimation (191, 192) . Another Spanish research group designed a model to 

estimate the lifetime risk of developing CVD (193). Clinical practice guidelines advised primary 

care professionals to use these calculators for clinical decision-making for primary prevention 

of CVD. Despite the development of a population specific assessment tool, factors such as 

patient level of understanding of numerical processes (e.g., %), age, cultural background, etc., 

dictate the accuracy of their risk perception. Research indicates that visual aids (graphs and 

diagrams) and repeating health messages through follow-up can help health professionals 

convey their message more transparently (194, 195).  Improving a patient’s perception of 

their CVR can play a key role in the adaptation of a healthier lifestyle (196).  



 42 

1.4.3 High-risk or population intervention approach  

The main objective of pharmaceutical services is to improve health among the service users 

and reduce inequalities. Interventional services can be delivered in two modes: the high-risk 

approach, which targets and provides intervention for those with the highest CVR and the 

population approach, which  implements strategies to reduce CVR among all individuals (197). 

Considering that CVD is the number one cause of death across the world, a small shift in the 

risk the distribution curve has a considerable impact on reducing morbidity and mortality, and 

so, the population risk approach is the preferred mode of action (198). This theory was first 

explained by Geoffrey Rose as early as 1985, in an article “Sick individuals and sick 

populations” (199). CPs are well situated to deliver a population-based approach (200).   

1.5 Personalisation of intervention according to patient's risk 

estimation 

1.5.1 Patient's perception of their CVR 

According to John Dewey "A problem well-defined is a problem half solved". It is essential for 

HCPs to develop a clear understanding of the patient's perceptions about their specific CVR 

to facilitate the reduction or prevention of CVD. Most healthcare systems stratify patients 

into low, moderate, and high-risk groups and focus their primary care resources on patients 

with moderate to high risk for developing CVD.  It is also notable that according to the well-

established theory of Kuller and Reisler's published in 1971, the relative importance of each 

risk factor can be a determinant of pathophysiology for future CVD development in patients 

(201). This theory emphases that the level of BP, TC and glucose can define subtypes of CVD. 

Patients better understand their true risk and make an informed decision when information 

is presented in simple terminology. Research indicates that HCPs can influence patients to 



 43 

make healthier lifestyle choices by focusing on one or two risks at a time. Also, presenting the 

data in a positive way, employing non-technical language and evaluation including elements 

such as VA, may improve the patient’s outcome (202).  

1.6 Empanelment 
 
Empanelment can be defined as the continuous process of patient care where a group of 

individuals are identified and later assigned to be cared for by a group of healthcare 

professionals. These HCPs will proactively collaborate as part of wider primary health care in 

the prevention and management of the patient’s health. Empanelment is a key aspect for 

population health management and enables health systems to empower patients, reduce 

costs, and improve health outcomes. The general population is split into groups who get 

assigned to be cared for by a panel of HCPs based on geographical situation, and by voluntary 

and insurance-based means (203). 

 

 

Figure 2: Visual display of empanelment in population health management 
 

It is crucial that the healthcare panel is appropriately-sized in terms of manpower and 

specialities to cover the need of all patients (204). 



 44 

 

Figure 3: Illustration of appropriateness of healthcare panel size  
 

2. Spanish community pharmacy system 
 
According to a national statistic in the year 2018, a total of 74,043 pharmaceutical 

professionals were registered in Spain, with a professional profile of 71.6% female and 45.5% 

under 44 years of age. The latest reports have shown that there is a ratio of 4.7 pharmacies 

per 10,000 inhabitants. Out of all the practising registered pharmacists, 87.1% (51,959 

pharmacists) worked in CP (205). All community pharmacies are privately owned (149). Spain 

is divided into 17 communities (149). The regulatory law that determines the principles of 

community pharmacy operation across Spain is Law num. 16/1997 issued on 25th of April 

1997, on the Regulation of Pharmacy Office Services or “Ley 16/1997 de 25 de abril, de 

Regulación de Servicios de las Oficinas de Farmacia” in Spanish (206). The most up to date 

version on pharmaceutical care is defined in “Law 29/2006, of July 26, on guarantees and 

rational use of medicines and health products” or “Ley 29/2006 de de garantías y uso racional 

de los medicamentos y productos sanitarios” in Spanish. This law defined the safe dispensing 

of medication, patient counseling services, pharmacotherapy follow-up, making 

extemporaneous preparations, and pharmacovigilance for all Spanish pharmacies. 

Furthermore, a consensus written by The General Directorate of Pharmacy and Health 

Products defined dispensing, a minor ailments scheme, and medication review as key roles of 



 45 

the CPs (207). However, these services are not commissioned by the local or national 

government. However, although CP are privet services in Spain, the SNS returns to the 

pharmacies a percentage of the dispensed medication costs, but only for medicines covered 

by the SNS. COVID-19 highlighted that the Spanish healthcare system does not acknowledge 

the community pharmacies as healthcare providers but rather as private business entities. 

Nevertheless, the general public expect CPs to deliver pharmaceutical care without any 

additional funding or support (208).  

2.1 Provision of community pharmacist intervention  
 
Pharmacists, as health care professionals, are keen to extend their expertise from the 

traditional dispensing and medication supply to a more clinical role. This has been clearly 

demonstrated by the significant outcome of CP intervention across Spain as part of RCTs, e.g., 

(143, 209-212). Research has shown that the CP’s active involvement in the prevention and 

early detection of diseases, as part of the primary care system, ease the pressure on urgent 

care provided by hospitals. It also has a positive health benefit for the patients and saves costs 

for the healthcare system (211). This is especially valuable in the current pandemic and 

beyond to prevent the healthcare system collapsing due to unnecessary pressure. Community 

pharmacies have a strategic location, extended opening hours in the evening and weekends, 

and accessibility for the elderly, social minorities, and immigrant (213, 214).  They are placed 

in the heart of the community with a high percentage of Spaniards living within walking 

distance of a pharmacy. Therefore, they are a well-suited avenue for the implementation of 

public health services in resource-poor locations with disproportionately high rates of CVD. 

Public healthcare may benefit greatly using the pharmacist’s knowledge and expertise in the 

better management and prevention of CVD.  



 46 

2.2 Consistency in healthcare provision and coherence in medical 

records  
 
In Spain, CPs do not have access to the patient's medical record. This can cause potential 

errors in the provision of pharmaceutical services from dispensing medication with drug-drug 

interactions and beyond. This was recognised as one of the factors leading to inefficiency in 

the Spanish healthcare model (215). There is an urgent need for building an infrastructure 

that transfers health records electronically across different care settings in Spain. Although a 

patient with private healthcare has their clinical record kept and shared across various 

healthcare settings, pharmacists in the community have no means to access these records 

unless the patient is a regular customer and has an existing patient medical record on the local 

pharmacy database. Therefore, future provision of pharmaceutical services across Spain must 

be supported by an electronic system that not only complies with the Human rights Act 1998, 

the Data Protection Act, the Code of Practice for confidential information law and GDPR; but 

also, must facilitate continuity of care between pharmacists and doctors. Effective record-

keeping is vital to increase patient safety. Additionally, good quality record keeping can justify 

the professional decision made by the healthcare professional in the case of investigation for 

negligence. It should have a section to record the patient’s consent to pharmacists handling 

patient sensitive medical information.     

2.3 Role of community pharmacists in health empanelment in Spain 

Over the past few months, the importance of empanelment was evident with the pressure 

that the COVID-19 pandemic had imposed on the healthcare system. Effective empanelment 

with proactive community pharmacies, with long opening hours, covering their patient panel 

significantly reduced the pressure on healthcare settings such as hospitals. One of the 



 47 

important components of empanelment is that not only patients but also all members of the 

care teams including the doctors, recognize pharmacists as partners in care. Empanelment 

also allows the healthcare model to be shifted from waiting for the patient to develop a 

particular disease to actively screening and preventing the occurrence of a particular disease. 

Research showed CPs interventions can improve the cardiovascular health of patients by early 

screening and better pharmaceutical care management (216). Although the role of the CP in 

reducing the effect of CVD and their accessibility to the general public is evident, nevertheless 

many years of commissioned pharmaceutical services are required for building a culture of 

collaboration among doctors and pharmacists in Spain (217).  

According to the WHO, 80% of premature CVD are preventable (218). It appears that Spain 

will have a high percentage of elderly population as a result of low fertility and increased 

longevity by 2050 (219). The projections for prevalent cases of CVD, for example, obesity, 

hypertension, diabetes mellitus, smoking, depression, etc., will more than double by 2050. 

Behavioural risk factors account for more than one-third of the mortality in Spain. Smoking 

and obesity are major public health problems (220). Health spending accounted for 8.9 % of 

GDP3 in 2017, below the EU average of 9.8 %. Although Spaniards are covered by statutory 

health insurance, long waiting times for medical doctor consultation is a persistent issue 

(220). Health care accessibility can be improved by empowering the CPs who have enough 

clinical skills and time to assist patients in reducing their CVR. This part of the thesis intends 

to examine the existing literature on the effectiveness of CP intervention in reducing the 

burden of CVD throughout Spain. The fundamental preventative risk factors in the 

development of CVD were discussed above. The research databases4 were assessed to 

 
3 Gross Domestic Product (GDP) is a measure of the market value of all the products and services produced in a specific time period by a 
country. This is an indicator for a nation´s economic situation. 
4 PubMed/Medline (via PubMed and OVID), SCOPUS (via biblioguias.ucm.es), Cochrane Central Register of Controlled Trials (CENTRAL) 
(via cochranelibrary.com), EMBASE (via OVID), National Regional Database (LILACS BIREME) (via lilacs.bvsalud.org), CINAHL (via 



 48 

identify all randomized/quasi-randomized controlled trials, interventional before-after 

studies, and cross-sectional methodologies on CP’s intervention for CVD prevention. RCTs are 

considered as the preferred tool of hypothesis testing. There was a limited body of evidence 

available on this theme with RCT design, therefore articles with a range of study designs were 

selected. The search resulted in 489 articles both in English and Spanish. A total of 16 articles 

met the inclusion criteria5 with a total of 11,262 participants, age ranging from 18 to 85. The 

research group did not perform a meta-analysis due to substantial variation in studies’ 

methodologies. The Cochrane risk of bias tool, which is a gold standard measure for 

systematic review was employed in finding research with minimum risk of bias. This tool 

considers aspects such as randomization, allocation concealment, blinding of treatment, 

intention to treat analysis or complete follow-up, as potential source of biases. The Cochrane 

risk-of-bias (RoB 2) was used to assess RCTs. On the other hand, the ROBINS-I tool was used 

to assess the non-randomize studies interventions (NRSIs) (221). The Robvis tool was used to 

summarize risk-of-bias in these 16 articles (Figures 4 and 5) (222). The RoB2 tool considers 

aspects such as randomization, deviations from intended intervention, missing outcome data, 

measurement of the outcome, and the selection of the reported result (Figure 4).  

 
EBSCO), Pharm-line (via worldcat.org); ClinicalTrials.gov (via clinicaltrials.gov), ISRCTN (via isrctn.com), DOAJ (Directory of Open 
Access Journals) (via doaj.org/), opengrey.eu International Pharmaceutical Abstracts (IPA) (via ebsco.com), the Spanish National Research 
Council (CSIC) (via digital.csic.es), the WHO ICTRP (via www.who.int/clinical-trials-registry-platform), SCIELO (via scielo.org/es) and 
Google Scholar. 
5 Eligible studies were set as full-text English and Spanish articles on Spanish population from January 2000 onwards for all services 
performed by Spanish community pharmacists in community pharmacies settings based in Spain that were designed to improve the CVD via 
vascular risk reduction. 



 49 

 

Figure 4: Risk of bias assessment in RCT studies  
 

 

 

Figure 5: Risk of bias assessment in NRSIs studies 



 50 

The risk of bias tool ROBINS-I considers aspects such as confounding, selection of participants, 

classification of intervention, deviation from intended interventions, the missing data, 

measurement of outcomes and selection of the reported result (Figure 5).  

 
2.3.1 Hypertension control  
 
Efficient health policies and long-term governmental plans are needed to identify the 

hypertensive individuals at an early stage (39). Phenomena such as masked hypertension is 

another pressing factor leaving to hypertensive patients being unnoticed (40, 41). Five studies 

investigating the impact of community pharmacy services in BP reduction were identified 

(210, 212, 223-225). The duration of these interventions varied from 2 to 24 months, with a 

total of 1,211 patients. Long-term interventional services provided by Spanish community 

pharmacies improved clinical outcomes in patients in terms of their BP, reduced long-term 

CVR and were shown to save costs for the healthcare system and patients. All specific 

objectives of the identified studies were in line with the evaluation of pharmaceutical follow-

up (PFU), drug therapy monitoring and health education in achieving therapeutic targets for 

BP in patients. Only one of the studies was a RCT, which is the gold standard method of 

hypothesis testing (210). The majority of the studies have employed the Dáder Method for 

Pharmaceutical Care which was first created by the Pharmaceutical Care Research Group at 

the University of Granada (Spain) in 1999 (226). This methodology is a simple-to-follow 

operating procedure which aims at detecting, preventing and resolving drug-related 

problems  as well as achieving therapeutical targets (226). In relation to the impact of 

community pharmacy intervention in achieving of therapeutic targets for BP, four looked at 

the direct impact on SBP and DBP (210, 212, 224). In relation to masked hypertension 

detection, only one study looked at nocturnal BP using ABPM (225). Two studies reported 



 51 

lowering of SBP and DBP (210, 224). One has reported controlled BP and a change of 

treatment by doctors (225). All the studies clearly defined their outcome measures, key 

elements of study designs, CP setting criteria, participant selection process, data analysis, 

protocols, etc. A limitation of the studies was that the cluster of CVR factors were targeted by 

CP intervention which may have impacted the BP outcomes. However, according to the 

population strategy theory by Geoffrey Rose published as early as 1985, in an article “Sick 

individuals and sick populations”, the distribution curve of a single risk factor impacts an 

entire population and causes a greater reduction on mortality rates than does treating only 

people with high levels of a single risk factor. Therefore, targeting the cluster of risk factors 

by CP may reduce patient’s CVD on a larger scale. In conclusion, there is a strong body of 

evidence that proves PCS offered by CPs to reduce BP and the rate of CVDs in Spain. Thus, a 

better homogeneous study design (RCT) could lend additional support to this hypothesis.   

2.3.2 Weight management by community pharmacist via diet and lifestyle advice   
 
As explained in a previous section, the prevalence of obesity is increasing in Spain (227). 

According to the 2019 ACC/AHA Guideline on the Primary Prevention of CVD patient with high 

waist circumference have a higher risk of CVD and diabetes, especially if the patient falls into 

a metabolically non-healthy phenotype (46, 52). Similarly, the prevalence of childhood 

obesity is also reported high, lending additional support to the urgent need for developing 

national health strategies to tackle this ongoing problem. Spain went through a financial crisis 

also known as the Great Recession between 2008 and 2014. The current pandemic also 

caused on 11% contraction in Spanish economy (228). The economic crisis and 

unemployment were found to trigger poor mental health problems. This in turn caused 

modification in nutritional status and increased obesity (229). This places Spain at a tipping 



 52 

point where if no further action is taken by the health authority to control obesity, it will get 

out of control.  

The research group identified four recent studies in which Spanish CPs provided 

interventional services for weight management (212, 230-232). The intervention of these 

studies was aligned with providing personalized nutritional advice and promoting regular 

physical exercise to reduce patient’s weight (212, 230, 231). Other guidance on diet was 

provided as a secondary outcome (143). Although all these studies were limited in the sense 

that they relied on the patient’s own reporting for data collection, they revealed a significant 

improvement in the patient’s CVR due to CPs’ services. No study was found on CPs 

intervention that would address obesity in children or those under 18. Data collection was 

based on patients’ reports on dietary habits or exercise, which may be a potential limitation. 

Another limitation was that these studies only included patients with obesity (BMI≥30 kg/ m2) 

or metabolic syndrome with waist circumference greater than 102cm for men or 88cm for 

women. As discussed previously in the introduction, this is known as high-risk group 

prevention technique but intervention which targets a wider range of the population is 

preferred. Although the population level approach requires more resources initially, it 

prevents delay in action for patients in overweight categories and it is cost saving in the long 

term. Similar cost-effective results were reported from country-specific data in Denmark, 

France, Germany, Italy, Poland, and the United Kingdom, saving €14,903 per quality-adjusted 

life year (QALY)6 (233). Offering health checks only to higher-risk (obese) individuals saved 

€10,200 per QALY (234).  

 
6 Quality-Adjusted Life Year (QALY) is a measure of health outcomes in terms of the quality and the quantity of life lived.   

 



 53 

Another factor impacting patient’s weight is their level of physical activity. Three studies were 

identified in the systematic review that investigated the advice given on a patient’s physical 

activity by community pharmacies (231, 235, 236). One looked at the impact of regular 

physical activity on a patient’s cardiovascular medication compliance (236). Another looked 

at the prevalence of metabolic syndrome and the patient’s sedentary level (231). Only one of 

the studies compared physical activity, health education and PFU intervention in patients with 

a CVR factor. This study measured patient’s BP, TC, weight and BMI and found that patients 

in the drug therapy monitoring (DTM) group improved their parameters better than those in 

the health education (HE) group (235). 

2.3.3 Dyslipidaemia management  
 
Four studies looked at the impact of CP’ interventional programs on reducing TC and adjusting 

the lipid profile in the Spanish cohort, to reduce CVD (143, 210, 223, 235, 237). Studies were 

of varying quality and methodologies. For instance, the Amariles et al. randomized control 

trial used the Dáder Method for Pharmaceutical Care dealing with control of TC in outpatients 

with existing CVD or CVR. This study showed a statistically significant reduction in the TC 

(210). Similarly, Oñatibia-Astibia et al. investigated the difference between standard care or 

tailored pharmaceutical intervention in adherence to statins, lending additional support to 

the hypothesis that CP intervention improves statin adherence and reduces TC (143). 

Furthermore, another study by Rodriguez-Chamorro reviewed the effectiveness of PFU in the 

control of hypertension and TC as a secondary outcome and that showed after 6 months of 

continuous PFU, patients had achieved adequate therapeutic targets for TC (223). 

Correspondingly, the FISFTES-PM study investigated the impact of HE and DTM in patients 

with CVR factors (CVRF). TC levels decreased in all study subjects, suggesting that community 

pharmacies delivering a combination of HE and DTM have a positive impact on CVR (235). 



 54 

Thus, from existing literature it seems likely that the CP’ interventional program can improve 

CV health in the Spanish cohort.  

2.3.4 Diabetes control  
 
The review identified five studies on diabetes control and patient education (209, 210, 230, 

235, 236). Two had a long follow-up time of 13 M (209) and 24 M respectively (230). One 

employed the Dáder methodology (209) and the other used Pharmafit protocol (230). 

Pharmafit protocol seems to provide a most rigorous monitoring and patient support with its 

monthly patient’s visit. One researcher monitored the patient’s body weight, BMI, fata mass, 

TC, LDL-C, HDL-C, TG as well as glucose and HbA1c (230). This protocol also measured 

REGICOR CVR estimate, tailored for the Spanish population (238). The other group measured 

five main variables monthly, metabolic control (HbA1c, FBG, TC, HDL-C, LDL-C, 

albumin/creatinine), BP, weight and BMI, patient’s knowledge, and drug-related problems 

(209). Both studies communicated with physicians to improve the patient’s glycaemic control. 

One study also reported the provision of foot care (209). A multidisciplinary approach to 

diabetes care can prevent macrovascular and microvascular complication. 

2.3.5 Smoking cessation  

Smoking is another public health challenge in Spain. A total of four studies were identified for 

smoking cessation services in Spain (239-242). Although primary objective of these studies 

was to promote the stop smoking, many of the other studies in the systematic review had 

smoking cessation as a secondary outcome (231, 235). Evidence showed that the promotional 

campaign for smoking cessation services delivered by the CPs increases the number of 

patients who stop smoking (239). Similarly, another study showed that patients who used  

nicotine replacement therapy offered by CPs were more likely to be successful in quitting 

smoking (240). Also, the Cesación tabáquica desde farmacia comunitaria (CESAR) program 



 55 

offered by the Society of Community Pharmacists in Spain (Sociedad Española de Farmacia 

Familiar y Comunitaria, SEFAC) showed significant improvements in patients’ sense of taste 

and smell, lung capacity, cardiac function (HR and BP), TC and physical activity (241).  

One of the major drawbacks of the identified studies was lack of referral to doctors for 

prescription medicines e.g., varenicline (Champix®), bupropion (Zyban®) to stop smoking. 

Although, in case of the patient’s compliance with varenicline, smoking cessation services will 

be funded by SNS in Spain. Two of the investigations used the Fagerström nicotine 

dependency test to identify the patient's physical dependence on nicotine (239, 240). 

Thereafter, they used motivational interviewing to help patients quit smoking. One study 

used CO oximetry as an aid to quit smoking (239). One research group provided smoking 

cessation advice as a secondary outcome to improve BP (212), another group as part of health 

education and pharmaceutical care (235) and a third group as part of medication 

reconciliation services (236). Smoking is found to be associated with lower medication 

compliance (236). Further studies present a gold standard smoking cessation service that 

involves the whole with healthcare team, regular reviews to assess the failed attempts to stop 

smoking. This holistic approach may reveal whether CPs can reduce the burden of CVD in 

Spain, or not.    

2.3.6 Alcohol advice  
 
A high level of alcohol consumption has been identified as a major CVR factor. A recent study 

assessing the data from Global Information System on Alcohol and Health showed that 

alcohol consumption in Spain has shifted from wine to beer and binge-drinking7 is a common 

practice (163). They reasoned that these new behavioural patterns may be due to a pro-cyclic 

 
7 European Health Interview Survey (EHIS) defined binge drinking as five or more drinks for men and four or more drinks for women, at 
least once a month over the past year. 



 56 

theory8 also observed in other countries due to the  economic crisis (243).  A narrative review 

was conducted to identify the community pharmacy consultation service on alcohol 

consumption. Although there was one study on the alcohol advice services of CPs in Spain, 

the findings must be interpreted with caution due to the short duration of the intervention 

(2 months) and simultaneous provision of patient education on other CVR factors9 that led to 

a reduction of the patient’s CVR (212).  

2.3.7 Medicine reconciliation   
 
Improving patient’s medication compliance and detecting ADRs are key roles of community 

pharmacy services. The researcher critically reviewed the literature for pharmaceutical 

services on the detection of polypharmacy or ADRs and the medication review service in the 

Spanish CP, especially for geriatric patients. A broad automated literature search on published 

articles and a manual review of their references revealed six studies on medication review 

services in CPs (211, 235, 236, 244, 245). The articles originated in various regions in Spain 

and were in English or Spanish. A patient’s treatment adherence was measured by various 

ways which made pooled analysis difficult. One study used the Morisky-Green Levine test as 

well as a blood test (TC) to assess patient’s adherence to their statin (143). Another relied on 

the Morisky-Green test only (236). As explained before, Spain has a high percentage of older 

people so one might assume that the increasing number of research studies are targeted at 

the geriatric population. But the researchers found it difficult to encounter medicine 

reconciliation services directed only at cardiovascular medicines in the geriatric population 

during the literature search. Although the review revealed some studies such as the REVISA 

project that focused on improvement of the elderly’s compliance and the patient’s knowledge 

 
8 Economic fluctuation causes individuals to spend less money on alcohol, which explains the decrease in daily alcohol consumption, but 
may bring about an increase in binge drinking of cheaper alcoholic beverage.  
9 Diet, salt intake and physical exercise 



 57 

regarding their medication, they were not focused on cardiovascular medicines. The REVISA 

project reported high patient satisfaction and a wiliness to pay for service delivery by the 

public, as well as an improvement in doctor-pharmacy relations (246). Similarly, a cluster RCT 

looked at the cost-effectiveness ratio (ICER) of a medication review with follow-up service for 

older adults with polypharmacy in Spanish community pharmacies. Although the medication 

review with follow-up was not only for cardiovascular medicines, it also reported an 

improvement in the quality of life of the elderly and cost effectiveness of the services (247).  

Although, there is abundant evidence for the importance of the CP’s intervention in achieving 

therapeutic goals and preventing unwanted ADRs, the finding must be interpreted with 

caution. There is a need for more studies with similar data collection methods to draw a 

conclusion.   

2.3.8 Telepharmacy   
 
This new modality of pharmacy practice can be defined as the patient’s access to 

pharmaceutical services via telecommunication tools, including telephones, smartphones, 

and  mobile wireless devices, with or without a video connection (248). Telepharmacy comes 

under telemedicine which originated back in 1950 when a Nobel Prize winner, Dutch 

physician Willem Einthoven transmitted an electrocardiogram created in hospital conditions 

to his laboratory over 1 km away via telephone cables (249). Remote pharmaceutical services 

and intervention advanced rapidly during the pandemic especially in rural areas (250). One of 

the advancements in pharmaceutical care delivery during pandemic was that the distribution 

of medication and access to the patient’s medical record was given to CP through patient’s 

identification code (Código de Identificación Personal Autonómico; CIPA). The main benefit of 

this new response strategy was to increase patient access and enable the convenient delivery 

of healthcare (251). Pharmaceutical counselling regarding the VA can act as a tool for 



 58 

telepharmacy to reduce the rate of contamination and increase the access of patients to 

pharmaceutical care.   

3. Vascular age calculator (VAC) 
 
As once said by Thomas Sydenham (1624–1689): “Man Is as Old as His Arteries”(252). One 

form of CVR presentation is comparing individual’s VA with their chronological age, that is 

easy for the patients to understand. Various VA tools have been launched across the world to 

empower patients to proactively manage their risk factors. In England, a calculator based on 

QRisk data was first introduced in 2014 by the Joint British Societies guideline for the 

prevention of CVD (JBS3) (253). It was then made available for public use without supervision 

of HCP in 2015. However, the research group investigating the data from this calculator 

reported some limitations. For example, if patients did not know their anthropometric, 

metabolic, and biochemical values, the national average was applied, thus introducing errors 

in the data collection. This study also reported that although there was a high level of public 

interest in knowing their CVR, 80% of the participants did not know their TC and 50% their BP 

level. They have recommended the use of this risk measurement in the presence of trained 

health professionals to fill the knowledge gap (153). The high proportion of users unaware of 

their risk was also reported in other studies (254). Evidence from this study and other similar 

research has shown that VA has a greater emotional impact on patients which may lead to 

behaviour changes (255). Although the benefit of VA calculator over 10-year risk estimates 

was proven previously, Patel et al. 2016 demonstrated that this version of VA results may 

provide false security because of unknown data being replaced by the national average (153).  

 

 



 59 

        

 

 

 

 

 

 

 

 

 

  HYPOTHESIS AND OBJECTIVES  

 



 60 

Research hypotheses  
 

The VA tool employed under the supervision of CPs, has the potential to improve the patient's 

understanding of their particular risk of long-term CVD. Furthermore, the CP's intervention in 

the areas of BP, TC, diabetes, and weight management, smoking cessation, alcohol 

consumption, as well as medicine reconciliation in cardiovascular medicines, can influence 

the cardiovascular health of the patient by personalising a plan and continuous support via 

motivational interviewing. 

 

General objectives  
 
 
To develop a tool in the form of an interactive VA calculator and educational modules 

embedded on the website to support CPs in reducing VA in Spain.  

 

Specific objectives  
 
 

1. To create an accessible and accurate tool to be used by CPs  

(a) To develop a better understanding in patients of their actual CVR factors and long-

term impact on their heart.  

(b) To assess the Spanish patient's CVRs. 

2. To determine the CPs' perceptions about the usefulness of the tool created.  

3. To determine CP's perception about the feasibility of measuring CVD risks in patients 

at community level.  

4. To identify possible barriers faced by the Spanish CPs in using VA as a tool to improve 

vascular health in patients.  



 61 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

     MATERIALS AND METHODS 
  

 



 62 

Materials and methods  
 
1.1. Literature search 

A webpage was developed in the form of an interactive VAC and educational modules for 

HCPs and information for the patients, to be used as a tool by CPs. The webpage was designed 

with assistance of the Audience Talking Support company. For data extraction electronic 

bibliographic databases including PubMed/Medline (via PubMed and OVID), SCOPUS (via 

biblioguias.ucm.es), EMBASE (via OVID), the Spanish National Research Council (CSIC) (via 

digital.csic.es) and SCIELO (via scielo.org/es) were searched. A comprehensive search was 

performed to identify most up-to-date guidelines. The keywords: cardiovascular disease, 

diabetes, community pharmacist(s)/pharmacy(ies), pharmaceutical services, Spain, Spanish, 

diet, smoking cessation, blood pressure, cholesterol, hypertension, hypercholesterolemia, 

dyslipidaemia, metabolic syndrome, alcohol consumption and medication reconciliation were 

used. All cited guidelines from journals, dissertations, selected conference proceedings, 

standards of practice, and book chapters were screened. The Boolean search operators “AND, 

OR and NOT” were used to include relevant studies or impose limits on the search. Eligible 

guidelines were set as full-text English and Spanish evidence-base that were designed to 

improve the CVD via CVR reduction. English and Spanish guidelines published by the Spanish 

Society of Cardiology for CVD prevention, Spanish Society of Endocrinology and Nutrition, 

European society of Cardiology, the National Institute for Health and Care Excellence (NICE) 

and American College of Cardiology/American Heart Association Clinical Practice Guidelines 

were considered. The search was restricted to guidelines published between January 2010 

and June 2021. Also, the authors searched through the citations of the guidelines to identify 

additional materials.  



 63 

1.2. Vascular age questionnaire 
 
The questionnaire designed to assess the vascular age and is accessible on the website, has 

been based on the algorithm used to calculate the vascular age on the Systematic Coronary 

Risk Evaluation (SCORE) risk estimation tool with additional categories, which is valid for 

women and men aged 35-74. The survey consisted of 34-items that explored the patient’s 

CVR via a mixture of close-ended questions. The first section of the questionnaire investigated 

the sociodemographic characteristics of the participants. The subsequent sections explored 

i) the patient’s anthropometric and biochemical values on weight, height, TC, HDL-C, LDL-C, 

TG, glucose, HbA1C, SBP and DBP; ii) smoking; iii) pregnancy and breastfeeding in women; iv) 

comorbidities; v) medication use; vi) physical activity; vii) alcohol consumption; viii) air 

pollution exposure; ix) stress level; x) food consumption habits and social connection status 

xi). The questionnaire is further explained in result section.  

1.3 Algorithm for vascular age calculator 

VA can be defined as an age that an individual would have if they were to have the same 

absolute risk but controlled risk factors. The CVR estimation across Europe is mostly based on 

the Systematic Coronary Risk Evaluation (SCORE) test which was first acknowledged by the 

cardiovascular prevention and management of dyslipidaemia guidelines in 2016 (256). Later, 

a researcher from Palencia in Spain used this SCORE data to create a vascular speeding or 

aging formula by including the Spanish cohort's low-risk profile (185). The scoring table is 

displayed in the Figure 6. The researcher Francisco Javier Manzano Lista has developed a VAC 

embedded in Microsoft Excel, using the risk percentile based on low-risk countries. The 

calculator handles the variables in two different ways: on one hand, the variables of sex and 

smoking are assigned a binary coding. In the case of sex as the variable the following coding 



 64 

of (female=1, male=0) has been used. Furthermore, code 1 has been employed for yes and 

code 0 for no in relation to smoking status. On the other hand, the variables of TC and SBP 

are coded according to intervals. A range between 116 and 310 mg/dl (codes 4 to 8) for TC, 

and between 100 and 180 mmHg (codes 1 to 4) for BP were assigned to these parameters. In 

this manner of coding for variables such as sex, smoking, TC and SBP, the calculator locates 

the coordinates in the matrix (through horizontal and vertical search functions) and 

establishes a VA based on the CVR factors, as previously established by Cuende et al. (185). 

  

 

Figure 6: Vascular age calculated based on the SCORE system 
 

Once the factor is located, the programme multiplies this value by the biological age of the 

patient to obtain the VA. The assignment of the 10-year CVR has been done according to the 

established VA in Spain. The programme, based on the established age ranges obtained from 

the CVR table of Cuende et al., assigns a coding (from 0 to 5) discriminating according to the 

patient's gender. Subsequently, this code is assigned a percentage increase in CVR and a 



 65 

colour tone that is established by means of a conditional format previously established on the 

screen that shows the result of the VAC. 

1.4 Ethical approval  

The Ethical Committee Board of San Carlos Hospital in Madrid (CEIC Hospital Clínico San 

Carlos) has approved the VA study and registered it with the registration number 19/446-E. 

You can find a copy of the ethical approval letter in section 5 in the "Documentación" section 

under the sub-category “Dictamen favorable comité de ética” demonstrated in Figure 7. A 

copy of the ethical approval letter might be found in appendices I.    

                    

Figure 7: Ethical approval documents location on the website 

1.5 Patient confidentiality  

Patient Confidentiality is a legal duty of the researcher and service providers. The research 

team will maintain patient confidentiality by anonymising the data collection. Only the CPs 

can identify the patients from the unique number given to them on the questionnaire's initial 

section, as shown in Figure 8. The CP oversees keeping this number confidential and can use 

the number later during follow-up.  



 66 

 

                    Figure 8: Patient’s confidentiality by anonymizing the participants  

 1.6 Informed consent  

The word consent can be defined as giving permission. Consent is an essential aspect of 

complying with the person’s right in providing patient-centred care. Also, obtaining consent 

is a legal and professional duty of all HCPs. There are two types of consent: explicit and 

implied.  The researcher will use the exact consent form throughout this study to give specific 

permission in written format. Before initiating the service delivery, the researcher will clearly 

describe the study's nature to the pharmacists. The researcher will obtain written informed 

consent for participation in a contract from all CPs involved. The CPs will then actively obtain 

explicit consent from the patients to participate in the study. Also, the pharmacists delivering 

the intervention will require the patient's agreement to use the information for the research. 

Further, the CPs will need the patient's agreement to discuss the patient’s data with doctors 

as part of the referral scheme to receive more advanced care or prescribed medicines.  

Collecting of data, including biochemical samples, will be with the full consent of the patients. 

Patients must have the mental capacity to give support, act voluntarily, have sufficient 

information about the study to make their decision, and make use of the information 

provided by the pharmacists. All study procedures will be in full compliance with the ethical 

principles for medical research involving humans specified in the Declaration of Helsinki (257). 



 67 

1.7 General Data Protection Regulation (GDPR) compliance  

The General Data Protection Regulation (EU) 2016/679 (GDPR) is a regulation on patient’s 

data safety and confidentiality in the European Union and the European Economic Area. The 

researcher will process the patient’s information data collected by the VAC in compliance 

with the data protection legislation, including the GDPR updated on May 25th, 2018, the 

Human Rights Act 1998, and Data Protection Act (2018). The GDPR includes roles such as 

lawfulness, fairness, transparency, purpose limitation, data minimisation, accuracy, storage 

limitation, integrity, and confidentiality (security) and accountability that set guidelines for 

the collection and processing of personal information from patients who live in the European 

Union (EU). The researcher follows the Spanish patient’s confidentiality laws regulated by 

Spain's data protection authority, also known as “Agencia Española de Protección de Datos 

(AEPD)” (258). Therefore, the researcher made the personally identifiable information (PII) 

anonymous for the pilot study of the pharmacists’ view from the webpage. Further, the CPs 

will camouflage the patient’s data (with the patient’s identity substituted by a number) for 

follow-up purposes. 

1.8 Data storage and handling  

The researcher will securely store the data collected from the study at the University of the 

Complutense database, and only the research team and service provider will have access to 

them.    

1.9 Study pilot among community pharmacists  
 
eHealth is a new phenomenon that can facilitate providing CPs with interventional services 

to improve cardiovascular health. However, there may be some barriers involved in its use. 



 68 

The researcher consulted the webpage user’s opinion via an online survey. The researcher 

created a 26-item self-completion questionnaire to be distributed online among CPs using the 

Google forum. The researcher used open and closed questions to gain a wide range of replies 

and an in-depth understanding. The research members assessed the questionnaire and re-

drafted it to create an assessment tool. The pilot was made available online on 1st August 

2020. The questionnaire was live for seven months before closing on the 31st of February 

2021. Twenty-five pharmacists were randomly selected to try the website and provide their 

opinion. An email preceded by the link to the questionnaire was designed so that participants 

could make an informed decision about their participation. Although the survey responses 

were collected anonymously, participation in the survey was taken as their consent to 

participate in the study. The questionnaire was divided into three sections, one covering 

demographic units, including age, gender, and location. The following section explored the 

pharmacists’ formation, experience, and prior training in providing pharmaceutical care to 

the patients. The final section asked about the pharmacists’ view concerning the webpage. 

The complete questionnaire can be found in the Appendix I. To protect the project's 

originality, the pilot study to evaluate the website was only performed within a limited 

number of CPs.  

1.10 Pilot survey analysis  

Statistical analyses were performed with the STATA package version 12.0 (StataCorp LP, 

College Station, TX, USA). Descriptive statistics were used for the demographic findings and 

the close-ended questions such as NVivo qualitative data analysis software; QSR International 

Pty Ltd. Version 12 was used for analysing the open-ended questions at the end of the survey. 



 69 

Furthermore, the Chi-square test was employed to find the correlation between the 

categorical variables. Statistical significance was set at P <0.05. 

1.11 Adoption of QR barcode for the website and the questionnaire  
 

The SARS-CoV-2 pandemic has made delivering healthcare intervention very difficult. The 

protocol has been adopted to reduce the need for direct contact with the participant. 

Therefore, a QR barcode has been generated for pharmacists to access the webpage faster 

and more efficiently. The researcher can also track the scanning activity anonymously for 

statistical purposes. The QR code to access the VA webpage is displayed below in Figure 9. 

 

Figure 9: QR barcode for the vascular age website 
 
The website can be accessed using the following URL:  

https://edad-vascular.ucm.es/ 

Furthermore, CPs may use this barcode to facilitate the intervention process. They share the 

barcode with the patients to directly enter their data if they deem it necessary and later 

provide their patient the interventional services of the pharmacy based on VA.  

 

 



 70 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESULTS  
 
 
 
 
 
 



 71 

1. Gender 
§ Male 
§ Female 
§ Transgender 
§ Other 

2. Age 
3. Level of the education 

§ No education 
§ Primary education 
§ Secondary education 
§ University studies 

4. Ethnicity: 
§ Caucasian 
§ Hispanic 
§ Black 
§ Asian 
§ Mixed (specify) 

5. Region of residence eg. La Rioja, Galicia … 
6. Postcode 

 

 

1. Creating a data collection tool    
 
A novel website to act as a valuable tool for the Spanish CP’s interventions has been 

developed. The website includes the original questionnaire, the VAC, a detailed protocol for 

the pharmacist’s intervention and the patient’s information leaflets on CVR factors.  

1.1 Questionnaire 
 
A questionnaire of 35 items was designed to assess each participant's different CVR profile. 

Questions are presented with concrete and straightforward options to select from, with open 

fields for numerical inputs. According to the Spanish national guideline (259), the author 

displayed uniform units for biochemical values to facilitate data entry. Patients must consent 

before providing data to the pharmacists. That will be kept anonymous, before the 

questionnaire is filled in. Therefore, pharmacists need to initially enter the patient’s national 

identity number (DNI or NIE) into the database. The interventionist will later use this number 

for the patient’s follow up purposes. Initially, the patient’s demographical data is requested 

in the first section of the questionnaire, as exhibited in Figure 10.   

 

 

 

 

 

 

 

 
 

Figure 10: Questions 1- 6 of the vascular age tool 



 72 

7. Weight (Kg): ______ 
 
8. Height (m): ______ 
 
9. Total cholesterol (mg/dL): _______ 
 
10. HDL cholesterol (mg/dL): _______ 
 
11. LDL cholesterol (mg/dL): _______ 
 
12. Triglyceride (mg/dL) _______ 
 
13. Fasting glucose (mg/dL) _______ 
 
14. HbA1c (mmol/mol) _______ 
 
15. Systolic blood pressure (mmHg): _______ 
 
16. Diastolic blood pressure (mmHg): _______ 

 
It is noteworthy that we would like to collect the patient’s province and postal code for 

possible future epidemiological interpretation of regional differences in VA in Spain.  This data 

may allow us to assess affluence based on the patient’s location and draw possible 

conclusions about the social determinants of CVD, such as inequalities.  

Thenceforth the questions will take pharmacists onto anthropometric and biochemical values 

including weight, height, TC, HDL-C, LDL-C, TG, FBG, HbA1c and SBP, DBP as demonstrated in 

Figure 11. 

 

 

 

 

 

 

 

 

 
 

Figure 11: The anthropometric and biochemical values section of the vascular age tool 
 
 
Thereafter, the questionnaire focuses on the individual’s risk behavioural profile. The 

question moves on to ask about the smoking habits of the patients by calculating the pack-

years, considering that there are 20 cigarettes in a pack. This explores patient’s smoking 

exposure, considering how long and how much they have smoked within the last ten years. 

Initially it is presented in a simple yes/no format but later asks about the details of pack-years. 

Another factor contributing to development of CVD is silent exposure to the toxic substance 



 73 

17. Are you a smoker? 

§ Yes  

§ No   

Þ Pack history  

§ I smoke less than 1 pack per day  

§ I smoke more than 1 pack a day  

Þ Smoking history  
§ I quit less than 10 years ago 

§ I quit more than 10 years ago 

18. Have you been exposed to tobacco smoke or high pollution? (Yes, no, I Don't remember)  

Þ Stage of exposure  
§ Childhood     

§ Adulthood      

§ Housing in a place with high levels of pollution    
 

19. Have you ever been pregnant, if so, please indicate the number of children you have:  
§ No previous pregnancy  
§ 1  
§ 2 
§ 3 
§ 4  
§ more than 4 

20. Have you ever breastfed a child?  
§ Yes  
§ No   

Please Indicate the cumulative months of breastfeeding by counting all the children: 
§ Up to 6 months  
§ Between 6 and 12 months  
§ Over 12 months          

21. Have you reached menopause?  
§ Yes  
§ No   

 

of tobacco or pollution (Figure 12). This factor has been dismissed in previous research but 

plays a huge part in patient’s CVD risk profile.   

 

 

 

 

 

 

 
Figure 12: The smoking status question 

 
Subsequently, the next part of the questionnaire is only applicable for women. It focuses on 

women-specific risk factors, by recognizing female differences in CVD manifestation and the 

huge need for the CP to provide specific intervention for prevention, and management of 

risks in accordance with the history of patient’s reproductive health. This part explores client 

history about maternity, breastfeeding and menopause status (Figure 13).  

 

 

 

 

 

 

 

 
Figure 13: Women specific risk factor or protective elements data collection 

 
 
 



 74 

22. Do you have a family history of cardiovascular disease?  
§ Yes  
§ No   

Next the interview moves on to investigate the individual’s family history of premature CHD 

(Figure 14). This is to identify the cohort of patients with higher risks of developing future CHD 

in the proximity of the community pharmacy and later use the VA tool to develop a better 

understanding in patients about their true CVRs profile. Correspondingly, CPs will proactively 

provide a personalised intervention to prevent patient’s premature morbidity and mortality.  

  

 

Figure 14: The question on family history of premature CHD 
 
The subsequent section investigates the patient’s comorbidity and medication history. This is 

to indicate past medical history as well as regular medication use that constitute a subsequent 

increase in CVR on patients. A strong body of evidence indicates that there is a potential 

association between these comorbidities or medicine consumption with the cardiovascular 

state as explained in section 1.2.5 of the introduction. This section of questions is also 

designed for identifying the potential confounding factors when interpreting the association 

between categories of comorbidities (e.g., migraine) or medicine use (antipsychotics) and the 

VA (Figure 15). The complete explanation about the meaning of confounder can be found in 

the introduction section.  

The next part of the questionnaire explores the physical activity level in patients in terms of 

frequency and intensity (Figure 16). This will allow the CP to measure patient’s activity habits 

and demonstrate its direct impact on VA. 

 

 

 

 



 75 

24. Have you suffered a heart attack? 
§ Yes 
§ No 

25. Are you currently taking any of the following groups of medicines? 
§ Antihypertensive 
§ Oral antidiabetic or insulin 
§ Anti-inflammatory 
§ Anti-migraine 
§ Antipsychotics 
§ Tricyclic 
§ Antidepressants 
§ Amiodarone 
§ Levofloxacin 
§ Digoxin 
§ Thyroid Hormones 
§ Oral contraceptives 
§ Corticoids 
§ Nutritional supplements: 
§ Hormone replacement therapy, please indicate the type of HRT 
 

 
 

26. How often do you exercise (more than 30 minutes)?  
§ Daily 
§ 1-2 days per week 
§ 3-5 days a week 
§ Never 

 
27. With what degree of intensity? 

§ light (walking) 
§ moderate (swimming, cycling, running, Pilates, yoga, etc.) 
§ intense (weights, spinning, etc.) 

23.  Do you have any of the following pathologies? 
§ Cardiovascular diseases 
§ Atrial fibrillation 
§ Ictus 
§ Angina 
§ Intermittent claudication (tired legs) 
§ Heart failure 
§ Hypertension 
§ stenosis, valvular insufficiency 
§ Erectile dysfunction 
§ Chronic renal failure 
§ Thyroid disease 
§ Polycystic ovary syndrome 
§ Migraine 
§ Gout 
§ Autoimmune diseases Depression 
§ Lupus erythematosus 
§ Alzheimer's disease 
§ Diabetes 
§ COVID-19 
 

 
 

 
 
 
 
 
 
 

 
 

 

 

 

 

 

 

 

 

 

 

  

 

  

  

 

 
 
 
 
 

 
 
 
 

Figure 16: The physical activity question in vascular age tool 
 

Figure 15: Medical and medication history of the patient 
 
 
 



 76 

28. How often do you drink alcohol? Consider the last year. 

Þ Quantity  
§ Daily    

§ 1 or 2 glasses  

§ More than 3 glasses 

Þ Frequency  
§ More than 3 times/week 

§ Less than 3 times/week 

§ Never  

29. What type of alcohol do you consume? 

§ Beer 

§ wine  

§ liquors 

30. Do you consider that you usually have a high level of stress? 
§ Yes  
§ No 

The questionnaire then focuses on the alcohol consumption of the individual. It surveys the 

frequency of alcohol consumption and the type of alcohol being consumed (Figure 17). More 

than 14 units a week of alcohol on a regular basis are proven to increase risk of developing of 

CVD.   

These questions and their relation to VA can assist the pharmacist to plan an intervention for 

the patient to achieve drink-free days. 

 

 

 

 

 

 

Figure 17: Alcohol habits assessment 
 
Stress has a major contribution in triggering many diseases including cardiovascular 

abnormalities (260). Therefore, the level of the patient’s stress will be also assessed (Figure 

18).  

 

 
 

Figure 18: Stress assessment test 
 
The next part of the questionnaire investigates midday sleeping patterns, since some of the 

Spanish individuals have a short nap in the early afternoon (Figure 19). It has been shown that 

a 20- minute midday nap is associated with better cardiovascular health, where a longer one 

has a negative impact on the heart (261).  

 



 77 

31. Do you take regular naps?       
§ Yes  
§ No    
§ Please indicate the usual duration  

32. Do you often add salt to meals?  
§ Yes  
§ No  

33. Which of the following food groups do you regularly consume?  
 

Type of food Daily  2-3 times a week > 3 times a week   
Fruits and vegetables     
Red meat     
Pork    
Chicken    
Fish     
Seafood    
Pulses    
Dry fruits    
Olive oil     
Carbohydrates (pasta, rice, bread)    
Dairy    
Soft drinks, biscuits, snacks    
Fast food    

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                          
 

34. Level of sociability: 
§ I have few but very good friends and I spend time with them 
§ I have quite a few friends and I spend time with them 
§ I spend time with people, but I don't consider them my friends 
§ I have no friends 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 
Figure 19: Spanish midday nap habit test 

 
Dietary habits amongst the Spanish population are known to be similar to MedDiet patterns 

(262). However, this part of the survey tends to investigate food consumption patterns in 

terms of macronutrient and micronutrient intake based on age and gender (Figure 20).  

 
 

 

 

 

 

 

 

Figure 20: Dietary habits of Spanish population 
 
The final part of the questionnaire assesses the level of social connections and relationships 

of the individuals across the wider society (Figure 21).  

 

 
 
 
 
 

Figure 21: Social interaction assessment  

 
 
1.2 Vascular age calculator and interpretation of the results for patients  
 
In order to calculate the VA, the SCORE (Systemic Coronary Risk Estimation) risk assessment 

equation adapted to the Spanish population published in 2010 was used (185). This is a form 



 78 

of a multivariable modelling equation based on patient’s age, gender, smoking status, lipid 

profile including TC and HDL-C as well as SBP. In the questionnaire embedded inside the 

website, these parameters are mandatory and marked with * for VA calculation. In the case 

where one of the mandatory sections is not filled, VA results cannot be displayed and the 

sentence “please complete this section” will appear to promote rectification of the problem. 

After completion of the questionnaire, the website will allow the service provider to store 

and print the results. This will allow the patient’s medical record and lifestyle habits to be 

available at CP’s fingertips. The printed hard copy can be used by the pharmacists to easily 

perform a PFU. Pharmacists are encouraged to fill out all questions fully and arrive to the 

patient’s VA by pressing the “enviar” option whereby the VA will be calculated and displayed 

on the next page. In any case after estimation of a VA for the patient by the CP, patients will 

be offered the service of PFU. Therefore, and based on both the VA and the information 

included in the questionnaire, the pharmacist will design an intervention plan aimed at 

reducing the CV age/risk by promoting changes in patients’ lifestyle and pharmacotherapeutic 

treatment if required. 

Research has shown that cardiovascular health is better perceived by patients when 

presented in the form of VA. To enhance patients understanding in relation to their particular 

risk factors CPs can display a patient’s VA using various models. For example, let’s say Mrs 

Gonzales who is a 55-year-old smoker with BP of 140 mmHg and TC of 220 mg/dL arrives at 

the community pharmacy. Her initial VA which is 9 years and 4 months higher than her 

chronological age will be displayed as below (Figure 22):  



 79 

 

Figure 22: Illustrate how vascular age tool can improve patient’s comprehension 
 

In this case the pharmacist will assess the risk profile of the patient. There are many possible 

means for improvement for this patient. The pharmacist will tackle each CVR individually to 

demonstrate the true impact of each risk on the patient’s VA. Initially the pharmacist can 

encourage patients to quit smoking. Pharmacists will then use the VA tool to demonstrate 

that without tobacco use Mrs Gonzales will gain six more years of potential VA as shown by 

the automated calculator below (Figure 23).  

 

Figure 23: Vascular age tool improves smoking cessation 
 

Smokin
g  

Blood pressure 140 mmHg Blood cholesterol 220 mg/dL 

Blood cholesterol 220 mg/dL Blood pressure 140 mmHg 



 80 

Another case scenario can be that pharmacists try to encourage Mrs Gonzales to have a 

healthier diet and exercise regularly. These measures can reduce parameters such as weight, 

BP, and TC. To make the patient comply with the suggested health measures, pharmacists can 

adjust her current results on the calculator to aid her visualization and understanding of the 

tremendous effect this will have on her VA. Let’s say Mrs Gonzales only succeeds in reducing 

her BP from 140 to 120 mmHg. Her VA will improve by more than 4 years as shown below 

(Figure 24).  

 

Figure 24: Blood pressure reduction by vascular age tool  
 
Furthermore, pharmacists can suggest that if Mrs Gonzales complies with a healthy diet and 

manages to reduce her TC then again, her VA will be reduced as shown in Figure 25.  

In addition, pharmacists can refer the patient to doctors in the case where prescriptions are 

required for pharmacological treatments such as anti-hypertensives or lipid-lowering 

medication, among others. In the case of existing BP or cholesterol medication, the 

pharmacist can assess Mrs Gonzales’ medication compliance and promote a better adherence 

if required.  

 

Blood pressure 120 mmHg Blood cholesterol 220 mg/dL 



 81 

 

 
Figure 25: Blood cholesterol reduction by vascular age tool  

 

Finally, the CPs can explain to Mrs Gonzales that if she quits smoking, improves her diet, 

exercise regularly, avoids salt and stress, reduces her alcohol consumption, etc. she will 

improve her VA significantly as displayed below in Figure 26.  

 

Figure 26: Improvement of patient’s comprehension by vascular age tool 
 
This method of visual aid to enhance a patient’s understanding is a milestone and the 

webpage can act as an excellent tool to assist the pharmacist in performing the best 

intervention to improve patients’ lives.  

 

 

Blood cholesterol 180 mg/dL 

Blood cholesterol 180 mg/dL Blood pressure 120 mmHg 

Blood pressure 120 mmHg 



 82 

1.3 Study protocol  
 
A clear protocol was designed to make uniform the interventional services delivered by 

pharmacists. The study protocol is exhibited in the “Metodología Estudio” section of the 

webpage and is also shown in Figure 27.  

 
Figure 27: Methodology of the study 



 83 

1.4 Study design  
 
The VA study will use intervention control before and after the CP’s intervention 

methodology. A simple design methodology in which many patients from a multicentre are 

recruited and subjected to intervention might seem appealing. The problem with simple 

design methodology is that it has less precision in estimation. Due to the enrolment of a 

heterogeneous sample of patients with less control over the service provider's training and 

standardisation of the intervention, bias in results is inevitable. Therefore, intervention 

control before and after study design is preferred.  

Another issue involved in the design of the study is masking the treatment to reduce bias in 

the outcome. However, in interventional studies such as a weight loss program, the 

researcher cannot hide the intervention from the participants. However, in the case where 

the primary outcome of the pharmacist’s intervention is objective measures (weight loss, 

reduction in BP or TC), it is not essential to mask. The individual perception of the treatment 

is less likely to influence objective outcome measures such as biochemical blood results.  

As is demonstrated above, initially pharmacists will identify potential volunteers to 

participate in the interventional program. The patients will be recruited if they fall into the 

inclusion criteria. The inclusion and exclusion criteria are described below.  

1.5 Inclusion criteria  
 
Participants must be between 34 and 75, men or women living in Spain, and with at least 

one of the following criteria based on ACC/AHA 2019 Guideline on the Primary Prevention 

of Cardiovascular Disease: 

• Patients who are regular smokers (individuals who have more than one cigarette a 

day during the last month).   

• Overweight (BMI 25-29.9 kg/m2) or obese individuals (BMI 30-40 kg/m2). 



 84 

• Patients who drink more than 14 units of alcohol per week.  

• Patients with hypertension (SBP ≥ 140 mm Hg or DBP ≥ 90mmHg) as well as individuals 

under antihypertensive treatments.  

• Patients with dyslipidaemia or familial hypercholesterolemia (full lipid profile 

including TC, HDL-C, LDL-C, and TG concentrations should be considered). 

• Individuals with a family history of premature CHD (defined as MI or sudden death 

before 55 years of age in a male first degree relative, or before 65 years of age in a 

female first degree relative).  

1.6 Exclusion criteria  
 
Patients with the following criteria are not eligible to take part in the study:  
 

• Individuals with a history of previous CVD such as acute myocardial infarction (AMI), 

atrial fibrillation (AF), angina, CHD, heart failure, stroke (ischemic, haemorrhagic, or 

transient ischemic attack), or peripheral artery diseases or any other known 

cardiovascular comorbidities.  

• Patients with chronic inflammatory disease (e.g., HIV).  

• Individuals with cognitive disabilities with difficulties in communication or 

understanding pharmacists’ advice in relation to possible intervention.  

• Individuals with a history of previous CKD which has been classified as stage 3, 4 or 5.   

• Patients who are either pregnant or breastfeeding.  

1.7 Patient recruitment  

All patients aged between 35-74 who comply with the inclusion criteria, do not fall into 

exclusion categories, and express interest in participation in the VA study, can be recruited 

by the CPs to participate in the study. Pharmacists are encouraged to provide these 

interventional services for patients whose calculated VA is higher than their chronological age 



 85 

or have one or more CVR factors. This approach, also known as the high-risk interventional 

approach, has been explained in the section 1.4.3 of this thesis. Patient recruitment can be 

performed directly by pharmacy staff via oral invitation or through a poster presentation in 

the pharmacy premises. A request for a copy of the poster to be sent to a pharmacy can be 

made directly via email to the principal investigators; those details can be found below in the 

home section of the webpage, as shown in Figure 28.  

 

Figure 28: Principal investigator contact details in webpage home section  
 

Pharmacists are responsible for giving correct and sufficient information about this 

cardiovascular health campaign before signing an agreement with the participants. The 

following factors should be discussed, and patients should be given time to understand the 

study and process what it involves in terms of the follow-up. All patients' doubts should be 

clarified before initiating the study. 

1. Voluntary participation: the pharmacist must explain to the patients that they are 

invited to take part in the study to estimate their VA and to improve their CVRs. 

Emphasis must be placed on the voluntary nature of the study. It should be explained 

to the patients that they have the right to withdraw consent at any time, without 

altering the relationship with their pharmacist. However, the data collected previously 

from the patients cannot be retrieved due to the anonymous nature of the data 

collection techniques.  



 86 

2. The objective should be explained clearly to the patients. It should be emphasized the 

aim of this study, which is to calculate the patient's VA. Based on risk factors 

personalised intervention will be designed to try to reduce the patient's risk. The 

patient's progress will be evaluated during a maximum period of 12 months. Patients 

must agree to visit the pharmacy once a month.  

3. The pharmacist must explain the implication of the FarmaFit protocol in detail for 

patients. They must include what patients' participation will involve:  

• Providing the pharmacist with the necessary information to calculate VA including, i) 

anthropometric parameters (weight, height, waist circumference and percentage of 

fat mass), (ii) BP, iii) fasting plasma determinations (TC, HDL-C, LDL-C, TG, glycaemia 

and HbA1c). This data may be determined by the pharmacist or provided by the 

patients from a recent analysis within the last month.  

• Provide the pharmacist with information on their personal health habits (diet, 

exercise, alcohol consumption or tobacco use, level of social interactions, stress, etc.). 

• Answering questions in relation to the patient's adherence to the pharmacological 

treatments. 

• Pharmacists must notify smokers that their participation in the study will involve 

answering a questionnaire to evaluate the degree of dependency on and motivation 

to stop smoking. 

• Patients will be given a monthly prior appointment as well as a 6 and 12 month visit 

under which patients personal progress will be monitored based on their personalised 

plan.  

• Possible risks involved in participation in the study must be discussed by pharmacists 

with patients.  



 87 

• The time determined to fill out the questionnaire has been estimated to be no more 

than 10-15 minutes for each of the planned visits.  

• Pharmacists must clarify that participating in this study means compliance with the 

monthly visits as indicated by the pharmacists and agreeing to take part in the study 

activities as clearly explained above.  

• It should be explained to the patients that participation is voluntary, and they will not 

receive any financial return. The benefit of the involvement in this study will be to 

improve the CVR profile and quality of life of the patients on a long-term basis. 

• Patients must be assured that their personal data is fully protected. The researcher is 

committed to fully complying with the requirements of the Protection of Personal 

Data and guarantee of digital rights Organic Law 3/2018, of December 5. Pharmacists 

must further explain to the patients that their identity will not be disclosed to any 

person except in the case of a medical emergency to the doctor via a referral form or 

legal requirement. Study subjects will be identified only by a code, traceable only by 

the pharmacist responsible for follow-up purposes.   

• Finally, contact details of principle investigators and pharmacists in charge should be 

provided to the patients in case of questions. The above information can be found in 

section ‘3. Hoja de información al paciente" of the "Documentación" as in Figure 29.  

Patients who agree to participate in the study should sign a copy of the patient's consent 

form, which will be kept by the participating pharmacies during the survey. The patient's 

consent form will be collected by the researcher after the data collection period (12 months) 

and kept by the university for five years after the study. The patient's consent form can be 

found in the "Documentación" section under sub-category "4. Consentimiento informado" 



 88 

as shown in Figure 29. The detailed copy of the patient's consent form is demonstrated in 

Figure 30.  

 

Figure 29: Webpage snapshot on study documents  
 
1.8 Sample size 
 
It has been estimated that the VA study requires 385 participants to produce statistically valid 

results. The Cochrane equation was employed:  

N = 45	(7)!
)!  

N is the minimum sample size for a statistically significant result. P is the proportion in the 

population possessing the characteristic of interest (risk of CVD), Q is 1-P, Z is a type I error 

equal to 1.96 found on the Z table. In statistical hypothesis testing, a type I error is the 

rejection of a true null hypothesis. E is the margin of error of 5%. To estimate the effect of 

CP’s intervention on patients' VA reduction in Spain; maximum variability of half of the 

population in Spain with CVD has been assumed; therefore, (p = 0.5). A 95% confidence 

intervals was used. This gives us Z values of 1.96 on the Z table, ((1.96)2 (0.5) (0.5)) / (0.05)2 

= 385, therefore a random sample of 385 patients across Spain should provide the confidence 

levels required for a statistically significant result.  

 



 89 

 
Figure 30: Patient’s consent form 

 

1.9 Standard Operating Procedure (SOP) for patient’s consultation 
 
After recruiting of the patients as explained above inviting them for a private consultation in 

the community pharmacy; pharmacist and patients will sit in the consultation room while 



 90 

complying with all infection control procedures. The pharmacist must wash their hands using 

the seven-step technique. 

Table 2: Initiating consultation by using I2C6 technique 
 

Initiating consultation using I2C6 technique  

Patient’s identity must be confirmed  Pharmacist must introduce themselves to the patients 

and ask for their full name and date of birth. 

Explain the study process Pharmacist can briefly explain to patients that the 

vascular age study involves taking patients through 

medical history, medication history, family history as 

well as lifestyle. Finally, the must explain what kind of 

biochemical test will be taken from patients in case 

they did not test their blood parameters have not been 

tested recently.  

Gain patient consent  Patients must sign a copy of the consent form 

presented in Figure 21. This consent form must be kept 

in the pharmacy until the end of the study period (5 

year). 

Confidentiality  Pharmacist must explain to the patients that all 

information obtained from them will remain 

confidential and anonymous.  

Patient’s carer  Pharmacist can ask patients if they wish to be 

accompanied by another person whilst being 

interviewed by pharmacist.  

Patient comfort and privacy   Pharmacist must take all steps possible to ensure 

patient comfort and protect their privacy during 

vascular age study.  

 

Subsequently the pharmacist will sign into an allocated computer to access the VA 

questionnaire. Pharmacists can follow the universal I2C6 consultation technique for the 

initiation of the interview. Table 3 demonstrates a template of I2C6 and suggests this uniform 

initiation of a conversation with patients for all service providers. The procedure checklist is 



 91 

intended as an aide memoire to proficient CPs performance. It can also standardise the 

interviews across multiple community pharmacy centres.  

After completion of the consent form and initiation of the consultation with the patient using 

the I2C6 technique, the pharmacist can start by monitoring and recording patient’s 

anthropometric (height, weight, BMI, waist circumferences and biochemical data (TC, TG, 

HDL-C, LDL-C, FBG, HbA1c and BP) as shown in the protocol in Figure 27. The pharmacist then 

uses the collected data to complete the VA questionnaire explained in detail below and 

generate a chronological VA by using calculator embedded inside the website. The pharmacist 

should develop a personalized care plan depending on the patient’s calculated VA and 

biochemical parameters.  

After pharmacists enter the mandatory information marked with * in the questionnaire on 

the website the VAC will display a chronological VA result. According to this result pharmacists 

can generate a personalised care plan for patient intervention according to their risk factor 

profile. The full timetable for patient’s follow-up can be observed in a table presented in 

Figure 31 as below. This table can also be found in the “Metodología Estudio” section of the 

webpage under the study protocol.  

 

Figure 31: Study follow-up schedule 
 



 92 

As explained in Figure 31, patients will visit the pharmacy once a month. During these monthly 

visits the anthropometric values such as weight, height (from which BMI will be calculated) 

waist circumference and BP will be measured. Patients will visit the pharmacy on month 3,6,9, 

and 12 after initiation of the study to monitor the biochemical values such as TC, TG, HDL-C, 

LDL-C, FBG and HbA1c.  On the other hand, patient’s VA will only be monitored every six 

months.  

Also, pharmacists will fill out the ADHFARM questionnaire as shown in Figure 32 below, as an 

integral part of the intervention. In the ADHFARM questionnaire the first section examines 

the patient adherence to the pharmacist’s intervention offered to them on their initial visit 

(e.g., diet and alcohol intake, physical activity, and patient’s mental health such as stress 

level). The second part of the ADHFARM questionnaire provides suggested advice for 

pharmacists depending on the patient’s respond to the pharmacist’s questions in section one. 

The last section is a visual display and an evaluation table of the patient’s risk profile as well 

as the VA results taken every six months.    

 

Figure 32: ADHFARM questionnaire for patient follow-up 



 93 

 

Before the pharmacists initiate the intervention process, a certain framework is to be 

followed with the aim of achieving coherent provision of intervention through community 

pharmacies. This is to advocate the advancement of community pharmacy services from 

conventional dispensing towards providing advice and assisting patients closely in improving 

their cardiovascular health. The following conditions must be met by pharmacists to support 

and promote behaviour change in patients as part of the VA study.  

1.10 Premises requirements for pharmacies and pharmacist  
 
The criteria to be met by the pharmacies to be able to participate in this cardiovascular health 

campaign is defined on the website. This can be found under the sub-category "1. Criterios 

para las farmacias participantes" in the "Documentación" section of the webpage, as 

demonstrated in Figure 29. The actual document is presented in Figure 33.   

 
 

Figure 33: Criteria for pharmacies that participate in the cardiovascular health campaign 



 94 

 
 

As shown in Figure 33, the eligible pharmacy must have an allocated consultation area marked 

clearly as private in which the interviewing pharmacist and patients can sit together. In Spain 

this area is normally marked as “Zona de atención personalizada”. Pharmacists are 

responsible for complying with sanitary requirements suggested by the WHO. The 

consultation area must be a place in which both parties can talk at average speaking volumes 

without being overheard by others on the premises. Finally, pharmacists are advised to place 

a computer in the consultation area for ease of access to the questionnaire or VAC.  

The pharmacist must fulfil certain conditions for VA service provision. Firstly, to consolidate 

the advice to be given to patients, participating pharmacists should attend a training day at 

the Universidad Complutense de Madrid presented by the "Grupo para el Estudio de la Salud 

Cardiometabólica” group for cardiometabolic health studies" (GESCAMET) before the 

beginning of the service. In this session, the GESCAMET group will address medication 

reconciliation techniques, specific healthy living advice on diet, alcohol consumption, physical 

activity, stress avoidance and smoking cessation. Pharmacies that complete this training will 

be granted a certificate issued by the GESCAMET.  Secondly, all participating pharmacists are 

obligated to keep the patient's data safe to avoid a possible data breach.  If they fulfil these 

two conditions pharmacists can participate in the service provision for which they need to 

sign a contract. This is a written agreement between the provider of the intervention and the 

researcher team. The contract can be accessed by pharmacists from the "Documentación" 

section under the sub-category "2. Contrato con las farmacias participantes" as 

demonstrated in Figure 29. A copy of the signed contract must be sent to the researcher via 

post or by email. The research group will keep this copy for the duration of the study and five 



 95 

years after to meet the national legal requirements. Figure 34 shows the contract for the CPs 

who are eligible to participate in the study.   

DATOS DE LA FARMACIA  

Nombre de la farmacia   

Dirección de la farmacia   

Dirección de correspondencia (si es diferente de la anterior)  

Dirección de correo electrónico del farmacéutico   

Número de teléfono del farmacéutico  

 

ACEPTACIÓN DE PARTICIPACIÓN EN EL ESTUDIO 

v Adjunto una copia del certificado de formación en promoción de la salud cardiovascular para el farmacéutico 

que realiza la actividad. 

v He comprendido mi papel en el estudio y acepto participar en el mismo.  

En Madrid, a _____ de ___________ de 2020. 

Firma del farmacéutico      Firma del responsable del proyecto 

Figure 34: Pharmacists' contract for participation location 
 
1.11 Telepharmacy   
 
The beginning of the global pandemic has influenced our medical practice in such a way that 

patients are encouraged to visit the medical practices including pharmacists only if essential. 

That has prompted the researcher to think of alternative means for data collection and 

delivery of CPs’ service and the form of interventions. Initially, CP must sign a written consent 

with the patient to have their data, in this case, the mobile phone or any communication 

address with the patient. This requirement is to comply with the Data Protection Service of 

the Pharmacy Office10 law in Spain. Therefore, participating pharmacists can perform the 

intervention and patients interview via telephone or a video call. The strength and 

weaknesses of this technique will be further explored in the discussion section of this thesis. 

Participating pharmacists need to give a prior appointment to the patients to avoid time 

 
10 Reglamento 2016/679/UE 



 96 

overlapping with their other daily tasks. The interview over the phone should also be 

performed in the consultation area to maintain the patient's confidentiality. 

1.12 Record management  
 
The patient information data obtained from the questionnaire on the website must meet 

the following requirements 

1. Authenticity: The medical data created in the system is anonymous and only 

accessible for the CPs’ follow-up purposes. Furthermore, each pharmacy staff 

member using the system to enter patient data is advised to have a designated 

username and password.  

2. Reliability: The information in the record is full and accurate. It is going to be entered 

by the trained healthcare professionals. Biochemical parameters are going to be either 

measured by HCPs at the patient interview or are being extracted from patients' own 

statements.  

3. High integrity: The VA and the patient's data cannot be modified afterwards on the 

database. 

4. Operational: Data can be kept in the printable format for future follow-up purposes.  

1.13 Data collection process  
 
CPs are recruited randomly from a cohort of pharmacists specialised in pharmaceutical care. 

Participating pharmacists are required to follow six initial steps before starting the data 

collection from the patients as part of the VA online assessment questionnaire. These steps 

are:  

1. Complete the pharmacist contract demonstrated in Figure 34 and return it to the 

GESCAMET research group.  



 97 

2. They will be given a webpage address and pharmacy specific ID to use as username 

and password to enter the webpage, upon receipt of the contract by the GESCAMET 

research administrator. The welcome page of the webpage is displayed in Figure 35 

below.  

 

Figure 35: Pharmacists access to the Vascular age calculator 
 

 
Pharmacists must initially register their username and password by clicking the icon "Check-

in" on the "Access Form" of the home page. This form is shown in Figure 36. After this point 

the user can utilize the same data for re-entering the VA questionnaire.  

                     

Figure 36: initial registration of the pharmacy in the database 

3. Confirm a person to act as Data Collection Officer. This pharmacist will be appointed 

by the Technical Director of the Pharmacy Office after approval of the project. This 



 98 

person will be the only person with access to the webpage and will be responsible for 

keeping patient information data confidential, interviewing the patients, and 

recording the data correctly on the webpage. The same person will later be 

responsible for dealing with any conflicts that might arise during the study and 

communication with study group.  

4. Pharmacists must ensure that personal emails are not used in transferring patient 

information.   

5. It is obligatory for pharmacy contractors to select one of the staff to take responsibility 

for protecting the confidentiality of patients and making sure that pharmacy premises 

meet all the requirements in the service specification. Also, the data collected from 

the patients is only used for the purpose of pharmacist’s interventions dealing with 

the VA study and follow-up.   

6. All staff involved in the VA study must attend training before the initiation of the 

study. The research group encourage the pharmacists to hold a briefing with other 

pharmacy staff and explain the purpose and procedures involve in the VA research. 

Furthermore, pharmacists can delegate some of their daily tasks to the staff to help 

reduce the pressure on them whilst performing the study.    

1.14 Referral to the Doctor  
 
CPs are providing many interventional services in Spain. They have the potential to detect and 

manage NCDs at an early stage. However, to achieve continuity of care a multidisciplinary 

approach is required. Continuity of care means that pharmacists should work collaboratively 

with other HCPs to provide ongoing and consistent care. There is a great need in Spain for a 

joint electronic database  



 99 

which all healthcare professionals, including CPs involved in the care of patients, have access 

to. This eHealth record can allow HCPs to be aware about any changes in patient's medication 

or state of health immediately. Transferring the data by digital means is not yet possible in 

Spain. According to the study protocol, it is essential for pharmacists to contact the patient's 

doctor by letter if any of the below issues arise during the VA study. A template for this 

communication letter is presented in Figure 37. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Farmacia ………………….. 
Ldo. ………………. 
Nº Colegiado: …… 

 

Estimado Dr. ……………….:  

Me pongo en contacto con usted porque el …….(FECHA)…………… detectamos la aparición de 

un problema relacionado con la medicación de su paciente, D/Dña. ………………..  

Dicho paciente se encuentra actualmente en tratamiento con 

……………………………………………………………………………………………………………………………………………

………………………… y desde hace unos días refiere 

……………………………………………………………………….., lo cual considero que puede estar 

relacionado con dicho tratamiento, tras haber descartado otras posibles causas que 

pudieran justificar dichos síntomas.  

Lo dejo en sus manos para que tome las medidas que usted estime oportunas.  

En cualquier caso, quedo a su entera disposición si necesita de mi colaboración.  

Un cordial saludo, 

 

En Madrid, a … de ……………. de 2020  

Fdo. Ldo. ………….  

Datos analíticos recientes (si es necesario): …………………………………………………. 

Figure 37: Doctor referral form 



 100 

This document can be accessed in the "Documentación" section under sub-category “6. 

Formulario para derivar al medico” as shown in Figure 29.  

The inclusion criteria for referral to the doctors are:  

1. Raised BP 140/80 in three consecutive reading and patient on no BP medication.  

2. Those with a family history of premature ASCVD (males, age < 55 years and females 

age < 65 years), Primary hypercholesterolemia (LDL-C, 160–189 mg/dL (4.1–4.8 

mmol/L); non–HDL-C 190–219 mg/dL (4.9–5.6 mmol/L)* with no medications such as 

statins. For initiation of primary prevention in patients age over 75, please refer to 

the introduction section.  

3. Those with metabolic syndrome which can be detected by the presence of three of 

the following symptoms (increased waist circumference by ethnically appropriate 

cutpoints, elevated TG (>150 mg/dL, nonfasting), elevated BP, elevated glucose, and 

low HDL-C <40mg/dl in men and <50 mg/dl in women; should be referred to a doctor 

for further cardiovascular health screening and preventative medicines such as 

statins, antithrombotic agents like Aspirin®.  

4. VA more than ten years above chronological age with raised BP or TC and patient with 

no preventative medicines.  

5. Patient request for varenicline (Champix) or bupropion. This can be obtained by 

prescription from the pharmacy for smoking cessation services. 

6. Client request for prescription-only medicines (benzodiazepine) to alleviate their 

stress.   

7. Individual with BMI of more than 30. 

8. Patients who drink more than 14 units of alcohol per week on a continual basis.  



 101 

9. Patient who has reported noncompliance due to a drug-related problem such as side 

effects to a specific medicine.  

1.14.1 Red flag symptoms in referral to a doctor  
 
The pharmacist should be aware of symptoms that may indicate more serious medical 

conditions requiring urgent referral to the doctor. They must encourage patients to seek 

immediate medical advice if they encounter any of these symptoms whilst interviewing the 

patients during VA study. A broad range of symptoms may suggest the onset of cardiovascular 

abnormalities. Red flag symptoms include: 

§ Clammy, unwell patient. 

§ Sudden onset of chest pain with increased intensity over 5-10 min may suggest MI. 

§ Heavy, tight, pressure on the chest is typical for ischaemia. 

§ Pain radiating to left arm, right shoulder or both arms may suggest MI. Radiation from 

the back, abdomen or legs may suggest aortic dissection. Furthermore, exacerbated 

pain relieved by rest may suggest angina. 

§ Breathlessness, nausea or vomiting with one or more of the above symptoms could 

suggest MI. 

CPs must take into consideration the onset, site, character, radiation, severity, exacerbating 

and relieving factors as well as duration and associated symptoms of red flags on a case-to-

case basis before referral. Red flag symptoms where there is a known history of coronary 

artery disease or a family history of premature coronary artery disease in an immediate family 

member or of the male sex may suggest acute coronary syndromes and needs immediate 

referral to the relevant doctor or emergency unit.   

 



 102 

1.15 Detailed pharmacist intervention protocol  
 
Consultation can be defined as a discussion or advice given by the pharmacist to the patient. 

This is the opportunity for the pharmacist to make a difference in the patient’s life. 

Traditionally, HCPs made decisions during consultation with little or no input from the 

patients. This paternalistic approach has been replaced by shared decision-making between 

patient and HCP; based on the patient’s beliefs, evidence-based information and advice given 

by HCP. Pharmacists are advised to take a holistic approach towards a patient’s cardiovascular 

health. They must consider social, physical, psychological, and behavioural aspects of a 

patients’ life that may impact on their health.  Therefore, during their consultation, the CP 

should:  

1. Explore the patient’s agenda (get to know your patients to help them better by more 

personalised advice). 

2. Consider patient views and beliefs about CVD and medications.  

3. Involve patients as a true partner in the discussion. Patients must be at the centre of 

their own healthcare and take an active part in decision making.  

1.15.1 Management of patients with obesity  
 
Pharmacist advice on weight management is available on the “Protocolos de Intervención” 

section under sub-category “obesidad” as shown in Figure 38.  

The pharmacist can use the WHO scale shown in Table 4 to identify the degree of overweight 

or obesity in patients.  

 



 103 

 

Figure 38: Webpage snapshot of pharmacist’s intervention guide for obesity control 
 
 

Table 3: WHO classification for BMI (kg/m2) measures in white Caucasian adult 
 

Classification  BMI (kg/m2) white Caucasian adult 

Underweight  18.5 or less 

Healthy weight  18.5-24.9 

Overweight  25-29.9  

Obesity I  30-34.9 

Obesity II 35-39.9  

Obesity III 40 or more (morbid obesity) 40 or more  

 
BMI measures an individual’s total weight (Kg) relative to their height (m). It determines the 

degree of overweight or obesity in patients. However, BMI is non-specificity for body fat. 

Athlete individuals have above average muscle mass and weigh more, therefore their BMI 

results should be interpreted with caution.   

Waist circumference indicates the distribution of body fat known as central adiposity. 

Patients with greater central obesity have higher risk of developing CVD and diabetes. 

Pharmacists should practice their clinical judgment when considering patients from diverse 

ethnic backgrounds.  

 



 104 

 

Table 4: Classification of patient’s risk based on waist circumference in cm  
 

Classification  waist circumference cm 
Low waist circumference  Men – less than 94 cm 

Women- less than 80 cm 
High waist circumference Men- 94-102 cm 

Women- 80-88 cm 
Very High waist circumference Men- more than 102 cm 

Women more than 88 cm 
 

Pharmacist can use the risk classification suggested by the NICE clinical guideline 189 on 

obesity management (263). Table 7 shows appropriate types of intervention based on a 

patient’s CVR factors.  

Table 5: Classification of patient’s risk by BMI, waist circumference & comorbidities  
 

BMI (kg/m2) Waist circumference (cm) Patient with 

comorbidities  

 Low  Hight  Very high   

Overweight  1 2 2 3 

Obesity (Class I) 2 2 2 3 

Obesity (Class II) 3 3 3 4 

Obesity (Class III) 4 4 4 4 

 

Table 6: The choice of intervention adequate for patient’s risk  
 

 
Risk level according to BMI, 
waist circumference and 
comorbidities 
 

 

1 General advice on healthy weight and 
lifestyle 

2 Diet and physical activity 
3 Diet and physical activity; consider referral 
4 Diet and physical activity; consider referral 



 105 

The pharmacist must agree with the patient about the choice of intervention most adequate 

according to their preferences and lifestyle. Realistic goals and a plan to achieve this must be 

drawn up by taking into consideration the patient’s opinion. The pharmacist must provide 

support and regular follow-up for the patients.  

General advice provided in the intervention section of the website that can be given to the 

patients are  

1. Healthy weight loss is no more than 0.5 - 1kg/week. 

2. Recommended caloric intake for women is 1200-1500 Kcal per day and for men is 

1500-1800 Kcal per day. 

3. The pharmacist must come to an agreement with the patient to try to achieve a weight 

loss of between 5-10% of the initial weight or until a BMI of 20-25kg/m2 is reached.  

The pharmacist can give the following diet advice focused on weight loss to their patients: 

1. Eating five servings of fruit and vegetables a day. 

2. Daily consumption of legumes, nuts (small amounts) and whole grains. 

3. Three portions of fish per week.   

4. Avoid eating fast food, foods high in saturated fat. 

5. Reducing salt intake.  

6. Limit the intake of red and processed meat. 

7. Reduce the intake of carbonated and sweetened drinks. 

8. Use extra virgin olive oil preferably for cooking. 

9. Preferably grilled, steamed, or baked food. 

Furthermore, pharmacists can provide personalised advice for patients based on the 

information obtained as part of the VA questionnaire and the patient’s ability to maintain an 

active lifestyle. Pharmacists should provide personalized advice that consists of 



 106 

recommended frequency, intensity, time (duration), and type of exercise for each individual. 

CPs must advice against sedentary behaviours. Physical activity counselling in line with the 

ACC/AHA Guideline on the Primary Prevention of CVD is as follows:  

1. At least 150 minutes per week of accumulated moderate-intensity aerobic physical 

activity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an 

equivalent combination of moderate and vigorous activity) to minimize the patient’s 

specific CVR.  

2. Longer duration of exercise of ≥10-minute is beneficial to reduce CVRs.  

Moreover, a patient information leaflet (PIL) was designed by the researcher for visual 

displays. The best interventional procedures are the ones where verbal information is 

backed up with written information. This PIL can be printed from the webpage in the 

“Consejos” section under sub-category “obesidad” as shown in Figure 39. The actual 

leaflet is displayed in Figure 40.  

 

Figure 39: Webpage snapshot of PIL on obesity prevention 
 

 



 107 

 

 

Figure 40: Patient information leaflet on obesity 
 
This PIL can be used as an aid for clinical discussion and to facilitate a person's understanding 

of the importance of lifestyle modification and risk factor reduction. Photos are used to reach 

out more to the patient and convince them of the importance of change. It also can assist 

Consejos nutricionales 
enfocados a la pérdida de peso 
1. Ingesta de cinco porciones de
frutas o verduras al día
2. Consumo diario de legumbres,
frutos secos (pequeñas cantidades)
o cereales integrales
3. Tres porciones de pescado a la
semana.
4. Evitar la ingesta de comida
rápida, snacks y alimentos con alto
contenido en grasas saturadas
5. Reducir la ingesta de sal
6. Cocinar preferentemente a la
plancha, vapor o al horno
7. Evitar el consumo de bollería y
dulces

Déjenos ayudarle a 
perder peso

Consulte a su 
farmacéutico

8. Utilizar aceite de oliva virgen 
extra prefentemente para cocinar
9. Limitar la ingesta de carne roja 
y procesada
10. Reducir la ingesta de bebidas 
gaseosas y edulcoradas 

• Pédida de peso saludable (no
más de 0.5 - 1kg/semana)

• Ingesta calórica recomendada:
mujeres (1200-1500 Kcal/día);
hombres (1500-1800 Kcal/día)

• Recomendamos a realización
de ejercicio físico moderado al
menos 5 días/semana durante
30’ minutos donde su corazón
late más rápido .

Características del plan 
de pérdida de peso

¿Para quién está dirigido este
servicio?
Adultos (18 años o más) que
desean ayuda y apoyo para su
control de peso y que estén
dispuestos a acudir a citas
regulares cada 3 meses de
seguimiento.

El objetivo es perder entre el 5 y
el 10% de su peso corporal
actual, hasta alcanzar el objetivo
final de reducir su IMC por
debajo de 25kg/m2 y/o su
perímetro de cintura por debajo
de los siguientes valores:
• < 94 cm en hombres
• < 80 cm en mujeres

.

El Servicio de Control de Peso
para Adultos ofrece apoyo y
asesoramiento a las personas que
desean perder peso de una
manera controlada y saludable.
Podemos ayudarle a mejorar su
salud y bienestar, así como
apoyarle para mantener el peso
que pierde. Al bajar de peso
puedes mejorar tu salud,
bienestar emocional y disminuir el
riesgo de diabetes y de
enfermedades cardiovasculares.

Servicio de Control de 
Peso para Adultos



 108 

patients in remembering the pharmacist’s advice after an intervention session in “Protocolos 

de Intervención” section.  

1.15.2 Management of patients with Dyslipidaemia 
 
One of the major risk factors associated with CVD is high blood TC. Pharmacist advice on 

cholesterol management is available in the “Protocolos de Intervención” section on the 

designed web page; under sub-category “Dislipemia” as shown in Figure 41.  

 

Figure 41: Webpage snapshot of pharmacist’s intervention guide for lipid measurement and control 
 
Furthermore, a PIL was created by the researcher to improve a visual display for the patient. 

Also, the webpage gives the pharmacist the ability to print a PIL from the “Consejos” section 

under sub-category “Dislipemia” as shown in Figure 42. The actual PIL is presented in Figure 

43.  

 

Figure 42: Webpage snapshot of patient information leaflet for lipid measurement 



 109 

 

 

Figure 43: Patient’s information leaflet in relation to hypercholesteremia 



 110 

The pharmacist should offer cholesterol monitoring and management to patients without 

regard to their age categories. Effective primary CVD prevention requires attention to ASCVD 

risk factors such as dyslipidemia at any stage of the life cycle. The pharmacist can measure 

the patient’s cholesterol in a community pharmacy setting with the following consultation 

skills. 

Before pharmacist conduct any clinical assessment procedures they must:  

• Check the expiry dates on all equipment before conducting the measurement. Please 

note that it is suggested that Percentage of fat mass be measured using a lipocaliber 

bioimpedance (Tanita Innerscan Dual RD-953) device and TC, HDL-C, LDL-C and TG 

should be determined by Cobas B-101 (Roche Diagnostics, Barcelona, Spain) to 

ensure uniformity of data across all service providers.   

• Wash hands and sterilize with alcohol gel.  

• The pharmacist must introduce themselves, explain their role and confirm patient 

identity.  

• Full explanation of the clinical assessment and procedure involved in measuring the 

lipid profile. 

• Gain verbal consent from the person for the pharmacist to perform the TC 

measurement.  

• Ask if the patient has any question or concern.   

• Consider whether the patient likes to have a chaperone with them during the clinical 

assessment.  

After the clinical assessment procedures, the pharmacist should:  

• Advise the patient that the cholesterol check is finished and thank them for 

participating in the study. 



 111 

• Document the test results obtained. 

• Clean up the test site by alcohol and sterilized cotton wool, if appropriate. 

• Dispose of the needle used safely in the yellow needle box. 

• The pharmacist must wash their hands and sterilize the room for the next patient 

appointment. All the chemical waste should be disposed in line with the legislation of 

the Official College of Pharmacists of Madrid with an agreement signed with SRCL 

Consenur company. The waste management form for CP in Madrid can be found in 

the Annex V.  

• Check with patients if they have any question. 

The pharmacist can place the patient’s risk into categories of normal, high and very high risk 

by considering the patient’s clinical metric and age with special emphasis on abnormal LDL-C 

level in accordance with the 2019 ACC/AHA Guideline on the Primary Prevention of CVD and 

2020 ESC/EAS Guidelines for the management of dyslipidaemias (46, 264) . According to the 

patient’s risk, the pharmacist can decide on the appropriate course of action. Figure 44 states 

the TC, LDL-C, HDL-C, and TG level which indicates the patient’s risk stratification. And Figure 

45 plans out an appropriated course of action.  

 

 
 
 
 
 

 
 
 
 
 
 
 
 
 Figure 44:TC, LDL-C, HDL-C and triglyceride level and related risk of CV 



 112 

 
 

Figure 45: Pharmacist course of action depends on patient’s LDL-C, total cholesterol,  
HDL-C, triglyceride level and other comorbidities 



 113 

The pharmacist can give the following dietary advice focused on cholesterol control to their 

patients: 

• Recommend an intake of at least 2 portions of fish a week, including a portion of oily 

fish (such as herrings, sardines, mackerel, or salmon). A portion is measured to be 

about 140 g (a fillet of fresh fish or a small tin).  

• Eating at least 5 portions of fruit and vegetables a day. A portion is about 80 g (for 

example, an apple or 3 heaped tablespoons of peas).  

•  Avoid products containing saturated fat (for example, fatty meat, whole fat dairy such 

as margarine and cheese). Substitute these with mono-unsaturated fats (such as olive 

oil) and polyunsaturated fats (e.g., corn oil and sunflower oil).  

• Avoid consumption of sweetened products, processed foods.   

• Recommend the patient prepares the meals in the oven or grill instead of frying them. 

Also suggest they use healthy ways of cooking by adding flavour using spices, herbs, 

and lemon juice instead of using buttery, cheesy or creamy sauces, which tend to be 

high in fat. 

• Suggest patients use wholegrain food including wholegrain rice and pasta. 

• Promote the use of at least 4 to 5 portions of unsalted nuts, seeds, and legumes (such 

as peas and beans) a week.  

1.15.2.1 Referral to doctor  
 
Patients with two or more elevated TC parameters (see below) and existing ASCVD risk, 

should be referred to the doctor (letter is presented in Figure 37).  

Þ Patient with TC>240 mg/dl. 

Þ Patient with LDL-C> 160 mg/dl. 



 114 

Þ Men with HDL-C < 35 mg/dl and women with HDL-C < 40 mg/dl whose lifestyle did not 

elevate the HDL-C parameter. 

Þ Patient with TG level of > 150 mg/dl. 

1.15.3 Management of patients with diabetes  
 
Pharmacist advice on diabetes management is shown in the “Protocolos de Intervención” 

section under sub-category “Diabetes” as shown in Figure 46. 

 

Figure 46: Webpage snapshot of pharmacist’s intervention guide for diabetes management and control 
 
Printable PIL to provide the patient a visual display on diabetes control is also available on the 

webpage. The PIL is available from the “Consejos” section under sub-category “Diabetes” as 

shown in figure 47. The actual PIL is also presented in Figure 48. 

 
Figure 47: Webpage snapshot of patient information leaflet for diabetes intervention 



 115 

 

 

Figure 48: Patient’s information leaflet in relation to diabetes management and control 



 116 

Although this interventional service is focused on improving CVR factors, diabetes is highly 

linked with increasing of CVD in the general population as a separate risk factor or in 

combination with other comorbidities such as CKD. Therefore, CPs can offer a personalized 

intervention to patients with elevated blood glucose highlighted by the VA intervention. 

The WHO has divided diabetes into four categories. Our intervention is going to be focused 

on T2DM and patients with diabetes due to the use of other medicines (glucocorticoids, 

thiazides, beta-blockers, nicotinic acid, ciclosporin, tacrolimus, atypical antipsychotics, and 

protease inhibitors) or comorbidities (pancreatitis, neoplasia and cystic fibrosis 

hyperthyroidism and genetic syndromes such as Cushing’s syndrome). The pharmacist should 

carry out an appropriate screening in individuals in one of the categories below to aid early 

diabetes detection and time management. The categories of people in whom it may be 

beneficial to screen for diabetes include the following: 

1. Patients with a family history of diabetes in first degree relatives.  

2. Patients in ethnical groups with a higher prevalence of diabetes. 

3. Overweight (BMI>25 kg/m2) or obese (BMI>30 kg/m2) patients. 

4. Patients with abdominal obesity (waist circumference >80 cm in women and >94 cm 

in men). 

5. Patients over 40 years of age. 

All diabetic and pre-diabetic individuals should exercise regularly, stop smoking and improve 

their diet as shown in Figure 49.  

 

 

 

 



 117 

 

 

 

 

 

Diabetes 
control   

• Adopt a diet rich in fruit and vegetables at least 5 portions a day. 
• Suggest patient cuts down on saturated and trans fats (butter, margarine, cheese) 

and chooses unsaturated & monounsaturated fats or oils (olive oil), more than 2 
portions of oily fish a week and low-fat dairy products. 

• Advice on reduction of salt intake to less than 6g per day. 
• Limit sugar and sugary foods. Avoid soft drinks with added sugars. 
• Restrict the consumption of fruit with a high glycaemic index: grapes.  
• Advice on starchy carbohydrate with each meal; lower glycaemic index foods are 

preferable, including pasta, basmati rice, grainy breads, porridge oats.  

• Advice on daily activity. Total 
of 150 minutes of moderate-
intensity activity, or 75 
minutes of vigorous activity, in 
bouts of 10 minutes or more 
over a week.  

• Encourage patient to lose 5% 
to 10% of their weight. 

Low Risk Drinking Guidelines 
• Advice on no more than 14 units 

a week on a regular basis.  
• Advice on spreading drinking 

evenly over 3 or > days 
• Encourage patient to have drink-

free days  
 

• Suggest BMI <25kg/m2 
• a waist size of <80 cm in 

women and <94 cm in men 
to prevent abdominal 
obesity  

Figure 49 : Diabetes control protocol 



 118 

1.15.3.1 Referral to doctor  
 
The following group of patients with two or more elevated glucose parameters and existing 

symptoms should be referred to the doctor.  

Þ Patients with FBG ≥7.0 mmol/L (126 mg/dL). 

Þ Patients with HbA1c ≥6.5% (48 mmol/mol). 

Þ Patients presenting excessive osmotic diuresis (polyuria), extreme thirst (polydipsia), 

tingling hands, visual disturbances, or recurrent genital thrush due to candidiasis.  

Þ Diabetic patients who report recurrent candidiasis, bacterial urinary tract infections, 

foot ulceration due to lack of sensation in the toes, feet, legs (peripheral neuropathy), 

erectile dysfunction or change in vision, should be investigated for medication 

compliance, given information on lifestyle, and then referred to the doctor. 

Þ The pharmacist should note that referral in suspected diabetes individuals is crucial. 

Confirmation of the diagnosis should be based on plasma glucose samples measured 

by the laboratory as it is more accurate than the capillary samples.  

Þ The pharmacist should provide information and advice on lifestyle to patients with 

FBG of 6.1 mmol/L – 6.9 mmol/L (110 – 125 mg/dl) and monitor them frequently. Pre-

diabetes is a state of increased risk of progressing to diabetes. It increases patient’s 

risk of developing CVD and CKD. There are two categories, impaired glucose tolerance 

and impaired fasting glucose. Pre-diabetes should also be referred to the doctor to re-

affirm the diagnosis and provide early management.  



 119 

1.15.4 Smoking cessation services  
 
Pharmacist advice on quitting smoking is shown in the “Protocolos de Intervención” section 

under sub-category “Deshabituación Tabáquica” as shown in Figure 50.  

 

Figure 50: Webpage snapshot of pharmacist’s intervention on smoking cessation 
 
A printable PIL to improve the visual display on smoking cessation for patients is also available 

on the webpage. The PIL is available from the “Consejos” section under sub-category 

“Deshabituación Tabáquica” as shown in Figure 51.  

 

Figure 51: Webpage snapshot of patient information leaflet on smoking cessation 
 



 120 

The actual PIL is also presented in Figure 52. 

 

 

Figure 52: Patient information leaflet in relation to diabetes management and control 



 121 

1.15.4.1 Pre-quit smoking  
 
Smoking is influenced by the patient’s environment and social habits therefore smoking 

cessation services should be offered as part of a community-based program which is more 

accessible for patients. 30 seconds of CP time can save a patient’s life and transform someone 

‘s future for the better by preventing premature death caused by lung cancer or CVD. The 

power and effectiveness of the three simple steps of Ask, Advice and Act campaign was first 

stablished by the SNS in the United Kingdom has been proved in clinical practice.  

Pharmacists initially need to establish if the patients are active smokers. It can be difficult to 

build a rapport with patients and not make them feel not judged. However, CPs are an active 

part of the community and patients who are smokers trust them. Therefore, building on that 

relationship and reaching out to smokers to provide services can be easier. The pharmacist 

can then record the smoking status of the patients on their system. It is essential to explain 

the health benefits of quitting smoking for the patients. Clarify that research has shown that 

the best method to quit smoking is to receive a combination of support and pharmaceutical 

treatment (e.g. nicotine replacement therapy). Discuss further that the choice is theirs, but 

they can always receive personalized smoking cessation services and support free of charge 

from the community pharmacy.  Finally ask if that is something that interests them, and if 

they would like to book an appointment. In the case where the patient shown interest, set a 

date for them to quit smoking. Take note of the date, patient name and their telephone 

number in a confidential manner. The pharmacist is to give the patient a call one day prior to 

the appointment to ensure their attendance. On the initial visit explain to the patients that 

weekly contact of the pharmacist with patients is extremely important. They will have six 

support sessions over six weeks, once before quitting, once on the day they quit, and then 



 122 

once a week for four weeks after that date. Figure 53 demonstrates the suggested protocol 

for smoking cessation services. 

 

Figure 53: protocol for smoking cessation services 
 
Behavioral support requires creating an understanding in patients about the 

pathophysiological nature of nicotine dependency in simple words. Correct understanding of 

nicotine dependency can further support patient in quitting. It will create a realistic 

expectation of what an attempt to give up will involve. On the initial visit it is advised that CPs 

establish the patient pack history, in Spanish “Historia de fumador”. In order to support the 

patient fully the pharmacist is required to understand the patient’s past and current history 

of smoking and their previous attempts to stop smoking. The CPs can ask the following 

questions:  

1. When did you first start smoking? 

2. How many cigarettes a day do you usually smoke? 

Initial visit

•Preparation visit. Establish a pack history, meaasure
motivation level by Richmond test, dependency level
by Fagerström Test, CO2 level by carbon monoxide
breath test , determine anthropometric values and BP.
agree with patients on a date to stop smoking. Explain
treatment options and advice patients on craving
symptoms.

Second 
appointment 

•Patient quits smoking on this day. 
Advice on pharmaceutical treatment 
available (e.g. nicotine patch) 

Supportive 
sessions  

• 3 – 8 days after the initial visit
•15 days after the initial visit
•30 days after the initial visit

Follow up  
visits 

•6 months after the initial quitting date
•1 year after the initial date they 
stopped smoking



 123 

3. What do you smoke and where do you buy them? 

4. How many times have you tried to quit smoking before?  

In the case whose patients who have had a previous attempt to quit smoking, it is essential 

to establish if they have tried any specific medication and their experience related to using 

that medication (e.g., rash with nicotine patch). This will allow the pharmacist to evaluate 

whether the smoker has used medication correctly in the past, and what expectations they 

have of the medication.  The pharmacist can ask:  

1. What medication have you used to stop smoking and how was it? 

In some cases, patients have failed attempts to stop smoking. The CPs must ensure the 

patients with previous failed attempts demonstrate their commitment to quit smoking and it 

will increase the chance of quitting smoking this time. Finally, the CPs must consider that the 

attempt to stop smoking and behavioral support of the patients may be influenced by the 

patient’s comorbidities such as a history of depression. In patients with a history of mental 

health disorders, general health advice and support should be paired with referral to a doctor 

in the case of worsening of mental health symptoms. Thereafter, complete a short 

questionnaire to measure the patients’ levels of motivation and cigarette dependency, using 

the brief Richmond motivational questionnaire shown in Figure 54 as on the website. 

Research has shown the higher the score of the patient’s Richmond test, the greater the 

chances of success. 

 



 124 

 

Figure 54: Richmond test 
 
Thereafter, the CP must assess patients’ nicotine addiction level. The Fagerström Test for 

Nicotine Dependence (FTND) can be used as a tool to establish the level of patients’ 

dependency. This test can be seen as presented on the website in Figure 55. This test includes 

questions such as:  

1. How many cigarettes per day do you smoke? 

2. How soon after waking do you have your first cigarette of the day? 

3. Do you wake up in the middle of the night to smoke?  



 125 

 

Figure 55: Fagerström Test for Nicotine Dependence (FTND) 

 
1.15.4.2 Carbon monoxide breath test 
 
To increase the patient’s level of motivation and assess their success in their attempt to stop 

smoking, the carbon monoxide breath test at every visit is scientifically proven to be highly 

motivational. Carbon monoxide (CO) has a short half-life and is usually undetectable 

around 24 hours after the last cigarette. Smokers may underreport their smoking habits; 

therefore, a quick exhaled air test can confirm this. The CP must follow the following 

procedure when using the carbon monoxide device:  

• The patient must be instructed to inhale deeply, hold their breath for 15 seconds, then 

exhale slowly aiming to completely empty the lung. 

• The results are instantly available on monitor screen. The CO measuring kit gives a CO 

reading in parts per million (ppm). 9 ppm2 is generally considered to be the highest 



 126 

acceptable level of CO in the exhaled breath of an individual who reported not 

smoking. NICE recommends that success in stopping smoking should be validated by 

a CO monitor reading of less than 10 ppm2 at the four-week point after the quit date. 

A patient with the following may demonstrate a higher CO result despite absence of 

smoking:  

1. Chronic obstructive pulmonary disease levels up to 11 ppm2. 

2. Exposure to CO fumes from a faulty gas boiler or car exhaust. 

3. Lactose intolerance where the high reading is a consequence of consuming 

dairy products.  

4.  Passive smoking. 

5. Unusually high ambient CO concentrations due to air pollution. 

• The CP must sterilize the device after each patient and use a fresh mouthpiece. 

The device must be calibrated initially and monthly thereafter unless it is a device that 

does not require a calibration. Figure 56 demonstrates the flow chart on the website on 

CO carboxyhaemoglobin (CO-Hb) exhaled in 15 seconds and its relationship with cigarette 

consumption. 

 

Figure 56: Direct relation between carbon monoxide (CO) carboxyhemoglobin (CO-Hb) exhaled in 15 second 
and smoking 

 



 127 

The CP should then measure the patients’ anthropometric values including BP, HbA1c and 

record the result in a confidential manner for the follow-up visit. The quitting date should be 

agreed with patients. The pharmacist should explain to the patients that they might 

experience depression, irritability, restlessness, difficulty concentrating, increased appetite, 

cough, constipation, weight gain, and in some cases mouth ulcers. Most of these symptoms 

can be resolved by using drugs such as NRT, bupropion or varenicline, though they might also 

completely disappear after a few weeks. However, increased appetite may last longer. Advice 

on healthy diet should also be offered as well as an information leaflet. 

The hydrocarbon agents in cigarette smoke stimulates a liver enzyme responsible for 

metabolizing drugs such as antipsychotics, antidepressants, and anxiolytics. Therefore, the 

pharmacist should refer the patient on this medication who quits smoking to a doctor to 

adjust the dose of their medication to achieve the same drug level and therapeutic effect. 

This process is explained clearly on the website as demonstrated in Figure 57. 

            
 

Figure 57: Demonstrate the smoking cession protocol for initial visit 



 128 

Possible first line therapeutical options for patients could be:  
 

• Varenicline (Champix®) 

• Nicotine replacement therapy (NRT) 

• Transdermal Patches  

• Gum  

• Lozenges  

• Sublingual 

• Inhaler  

• Bupropion  

Þ It is important to note that patients who require a medical prescription for varenicline 

or bupropion should be referred to the doctor. One or a combination of these 

treatments can be used for smoking cessation purposes. The treatment choice 

depends on patient’s preference but mainly on the level of dependence (e.g., night 

crave) shown in Figure 58 and Table 8 on the website. 

 

Figure 58: Patient treatment options according to their level of dependency 
 
  

 

 



 129 

Table 7: Suggested regimen for therapeutical treatment protocol 

 

In addition, pharmacists are encouraged to reinforce the positive health outcome of the 

smoking cessation to the patients to increase motivation in quitting smoking and improve their 

adherence to medication. To do so, the following advantages of stopping smoking might be 

useful (Figure 59).  

 

Figure 59: Exhibit the advantages of stopping smoking  
 
During the follow-up visits it is suggested that the pharmacist follow the protocol shown in 

Figure 60.  



 130 

                                 
Figure 60: Smoking cessation protocol for the community pharmacist 

 
After a month of abstinence from smoking, it is advised that the pharmacist ask patients to 

visit the pharmacy after six months and a year. This is intended to assess how effective the 

community pharmacy services are as well as measure patients’ success in quitting smoking. 

Figure 61 shows the guideline to follow on the 6 month and one-year follow-up visit.  

 

Figure 61: Protocol for follow up on STOPPING smoking services at 6 months and one year  
 
 

Measure CO level, weight, BP, HbA1c in diabetic 
patients

Advise patients on risk of relapse and suggest 
possible ways to avoid it.  

Reinforce the positive impact stopping smoking has 
on their health. (CO measure to motivate patients)

Discuss difficult situation that arises (relapse or 
attempts) 

Evaluate patient medication adherence (possible 
side effect)

Confirm patient abstinence 

Draw positive conclusion by using vascular age calculator and 
demonstrating how one year stopping smoking improve the vascular 

age by 10 years. 

Do not blame patients if they had a relapse offer help and advice again 

Ask patients if they have any relapse or temptation to smoke

Reinforce the positive impact this had on patient. 

Confirm abstinence from smoking (use CO measure and patients’ self-report)  



 131 

1.15.4.3 Remote consultation for smoking cessation  
 
Although as part of the essential services provided by CPs, the pharmacy team have been in 

direct contact with patients, the current state of the pandemic in Spain demands the 

reduction of pharmacist and patients’ face-to-face interactions. CPs must continue to provide 

education and support via healthy lifestyle intervention to patients to reduce CVD. Smoking 

has been identified as one of the significant risk factors for COVID-19. Therefore, patients may 

need smoking cessation services more than before. Therefore, pharmacists must continue to 

provide this service to patients by phone or pre-arranged video-based communication.  

1.15.5 Medication reconciliation  
 
One of the main reasons for patients’ uncontrolled BP, TC or worsening diabetes can be lack 

of medication compliance. CP can play a huge part in improving patients’ adherence to their 

medication, detecting unwanted side effects, and referring the patients to the doctor for 

alternative treatment options. Pharmacist advice on medication adherence is shown on the 

“Protocolos de Intervención” section of the website under sub-category “Adherencia al 

tratamiento” as in Figure 62.  

 

Figure 62: Webpage snapshot of pharmacist’s intervention on medication adherence 
 



 132 

The different types of medication review that can be performed by the CP are the following: 

1. Providing information to the patient on their medication including indications, correct 

use, side effects. 

2. Refer the patients to the doctors to obtain an alternative medicine due to unwanted 

side effects, ineffectiveness of medication or polypharmacy.  

3. Notification to the pharmacovigilance system any safety incidents such as a life-

threatening or serious side effects.  

4. Medication optimization by ensuring medicines provide the greatest possible benefit 

to the patient by medication review. 

It is suggested the pharmacist performs a structured medication review by taking a 

patient- centred approach. A tool such as the Morisky-Green test provided on the website 

(Figure 63) can be used to establish the level of a patient’s medication compliance.  

 

Figure 63: Morisky-Green test 
 



 133 

Morisky Green test consists of four item tests. The patient who answers yes to the first two 

questions and no to the following two are compliant with their treatments.   

This test can be accessed from the “Protocolos de Intervención” section as shown in Figure 

64 under “Descargar test de Morisky-Green”. 

 

 

Figure 64: Adopted Morisky Green test for assessing patients’ medication compliance 
 

Another available and valid test such as the Brief Medication Questionnaire (BMQ) may also 

be used to access patients’ compliance, but it may take longer. CPs continually face lack of 

time to perform patient-centred intervention, therefore this project has adopted a short 

version of the Morisky Green test to facilitate the pharmacist service delivery.   

1.15.6 Hypertension control  
 
Hypertension is a silent cause of cardiovascular morbidity and mortality among patients. The 

protocol for CPs’ intervention on hypertension is presented in the “Protocolos de 

Intervención” section of the website under sub-category “Hipertensión” as in Figure 65.  



 134 

 

 

Figure 65: Webpage snapshot of pharmacist’s intervention on hypertension  
 
 

In this section pharmacists are advised to target SBP below 120 mmHg and DBP below 80 

mmHg in the patients. Furthermore, the following advice are included in this section to assist 

patients in maintaining optimal BP:  

1. The pharmacist can advise patients to maintain the DASH diet which is known to lower 

BP. This includes intake of five portion of fruit and vegetables daily. A diet rich in whole 

grains is also recommended as is consumption of lean meats (chicken, turkey), fish 

and pulses instead of red meat. Reduction in daily salt intake to <6g daily and 

reduction in daily sugars and saturated fat intake are recommended.  Pharmacists 

must advice the patient to avoid alcohol or reduce their consumption to less than 14 

units per week. Furthermore, advise patients to avoid salty snacks and processed 

foods. Daily intake of at least 2L of water can improve their kidney function and in turn 

reduce their BP. Research has shown that keeping a daily food diary by patients means 



 135 

pharmacists can provide continuous and personalised support to improve the 

patients’ diet and reduce patient’s BP greatly.  

2. Pharmacists must advise the patient to maintain an active lifestyle by performing at 

least 150 minutes per week of accumulated moderate-intensity aerobic physical 

activity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an 

equivalent combination of moderate and vigorous activity) to minimize CVR.  Exercise 

of ≥10-minutes can reduce CVRs. 

Exercise in geriatrics must be personalised according to their age, exercise experience, 

functional capacity, safety, co-morbidities, and lifestyle habits. According to the European 

guidelines on sport cardiology, the elderly population are advised to perform aerobic, 

strength or flexibility and balance exercises as in Table 9 below.  

 
Table 8: Exercise protocol in the elderly 
 

Type of exercise   Frequency  Intensity  Duration  
Aerobic  Þ Moderate exercise (e.g., 

walking or riding a bicycle on 
ground level) for 5 days per week 
Þ  Vigorous exercise (e.g., 
jogging or running, swimming 
fast) for 3 days per week  

• 5-6 points from 
10-point Borg scale 
• 7-8 points Borg 
scale 
 

30 minutes per day 
for moderate or at 
least 20 minutes for 
continuous exercise 

Strength training 
(all major muscle 
groups) 
 

At least twice a week 8-10 exercise  10-15 repetitions  

Flexibility and 
balance  
 

Twice a week    

 
 

3. The pharmacist can advise patients to stop smoking. 

4. Patients diagnosed with BP who age on medications for uncontrolled hypertension, 

can benefit from medication optimization and review to increase adherence to 



 136 

treatment. This is an opportunity for pharmacists to identify any unwanted ADRs and 

increase patients’ understanding about the state of their health. 

5. The pharmacist can demonstrate the benefit of the above healthy lifestyle in patients 

by performing monthly BP monitoring. 

6. Pharmacists must refer the patients to a doctor if SBP ≥ 140 mmHg, DBP ≥ 90 mmHg 

by considering the patient’s age and other contributing factors (in at least 3 

consecutive measurements). 

The pharmacist can provide the PIL to patients to increase their understanding of their state 

of health and encourage habitual changes. This PIL designed by the researcher (Figure 67) can 

be found in the “Consejos” section under sub-category “Hipertensión” as shown in Figure 66. 

 

 

 Figure 66: Webpage snapshot of patient information leaflet about hypertension  



 137 

 

 

Figure 67: Patient information leaflet in relation to hypertension management 



 138 

1.15.7 Advice on reduction of alcohol consumption  
 
Excessive alcohol intake over a long term can result in poor cardiovascular health outcomes 

such as an increase of heart rate, high BP, weakened heart muscles causing heart failure, 

irregular heartbeat, and stroke in addition to alcohol-related accidents and hospital 

admission. The community pharmacy is part of the primary care umbrella, with high 

accessibility to patients due to its unique location, based in the heart of the community. 

Intervention on reduction of alcohol consumption is presented in the “Protocolos de 

Intervención” section of the website under sub-category “Consumo de alcohol” as in Figure 

68.  

 

Figure 68: Webpage glimpse of pharmacist’s intervention on reduction in alcohol use 
 
One unit of alcohol can be defined as: 
 

                                                                                                   
 
  
 

25 ml of spirit  ½ pint of beer   ½ glass of wine   



 139 

 
Figure 69: Guide to unit of alcohol definition  

 
The pharmacist must take every opportunity to talk to the patient about safe drinking habits. 

Pharmacists can display posters or patient information leaflets in the pharmacy to encourage 

patients to have a short conversation about this major public health issue. Pharmacists must 

use the evidence-based preprepared conversation to discuss alcohol consumption with 

patients. Pharmacists can start by explaining the negative impact that drinking of alcohol 

drinking has on health as shown in Figure 70.  

They can use three simple questions to give a score to patients’ alcohol consumption as in 

Table 10 to motivate and support the individual to think about changing their drinking 

behaviour. CPs should provide advice to the patient with a score higher than 5 using the PIL 

available in the “Consejos” section of the website under sub-category “Consumo de alcohol” 

as in Figure 71 and Figure 72.  Furthermore, patients with a score higher than 10 should be 

referred to the addiction center or medical doctors.   

 

 

 



 140 

 

 

     

 
Figure 70: Alcohol misuse health implications   

 

 

 

 
 Figure 71: Webpage snapshot on patient information leaflet about alcohol consumption 

 
  

 

 

 

 

 

  

 

Heart 
disease  

High blood 
pressure   

Liver 
Cirrhosis & 
liver cancer 
& 
Pancreatitis  

Reduced 
fertility  

Stroke & 
depression    

Harm to 
the fetus  

Breast 
cance
r   

Cancer of 
mouth & 
throat, 
oesophagus
& larynx   



 141 

 

 Never Monthly 
or less 

2-4 times 
per month 

2-3 times 
per month 

More than 4 
times per week 

How often do you 
have a drink 
containing alcohol?  

0 1 2 3 4 

 0-2* 3-4* 5-6* 7-8* 10+* 
How many units do 
you drink on a 
typical day when 
you are drinking?  

0 1 2 3 4 

 Never  Less than 
monthly  

Monthly  Weekly Weekly Daily or 
almost daily  

How often have you 
had 6 or more units 
if female, or 8 or 
more if male, on a 
single occasion in 
the last year?   

0 1 2 3 4 

  
*Score 0-4 is associated with low risk 
*Score 5-10 is associated with medium CVD risk give patient advice and PIL 
*Score above 10 is associated with high risk provide support and advice, refer patient to doctor 
 
 

Table 9: Scoring system to quantify the patients’ risk based on their weekly alcohol consumption 
 



 142 

 
  

 
 

Figure 72: Alcohol consumption Patient information leaflet 
 

1.15.8 Other CVD intervention  
 

The material provided for pharmacists on the website and the eHealth interactive tool in 

relation to risk factors for CVD development is an endless list and pharmacists do not have 

the time or adequate tools to possibly provide advice on all. However, some other risk factors 

such as mental state and stress level (Figure 73), woman’s health (Figure 74) and healthy aging 

(Figure 75) are also covered on the website in the form of educational material for the patient. 

Pharmacists can provide advice and support on these matters to the patients to improve their 

cardiovascular health.    



 143 

 

 
Figure 73: Stress and mental state patient information guide  



 144 

 
Figure 74: Women & cardiovascular health patient information guide   



 145 

 

 
Figure 75: Aging and cardiovascular health patient information guide  

 
 



 146 

1.16 Website validation by the community pharmacist  
 
A total of 24 pharmacists from Madrid were included in the pilot study, of whom 54% were 

female as shown in Figure 76.  

 
Figure 76: Gender distribution for vascular age pilot participants.  
Data are expressed in percentage of the total number of participants. 

 
 

Most participants were in the 20-29 (50%) age group (Figure 77). 

 
Figure 77: Age distribution for vascular age pilot in community pharmacies. 
Data are expressed in percentage of the total number of participants. 
 
The gender distribution of the participants according to their age group is shown in Table 11.  

Table 10: Age and gender distribution for vascular age pilot participants  
 

Age categories (years) Men n (%) women n (%) 

20-29  8(33%) 4(16%) 

30-39  1(4%) 3(12%) 

40-49 1(4%) 3(12%) 

50-59 1(4%) 2(8%) 

60-69 0 1(4%) 

Total  11(45%) 13(54%) 

Data are expressed in frequency and percentage (in brackets) of the total number of participants. 



 147 

  66% of the participants had prior training or been accredited for the provision of PCS (Figure 

78).  

 

Figure 78: Ratio of community pharmacists accredited for the provision of pharmaceutical care.  
Data are expressed in percentage of the total number of participants. 

 
Among the 24 participants, only six (25%) have claimed to be actively involved in providing 

PCS, of whom 16 (66%) were formally accredited in addition to their pharmacy degree for 

provision of pharmaceutical care and 9 (37%) were trained in motivational interviews with 

some overlap between these two groups. Eleven pharmacists with training in the 

pharmaceutical care plan did not participate in the provision of interventional services. Six 

pharmacists with training in motivational interviews did not provide services to the patients. 

The relation between CPs training in pharmaceutical care or motivational interviewing and 

their true participation on a daily basis in provision of PCS can be seen in Table 12.  

Table 11: Stratification of pharmacists according to the age group, level of training and provision of 
pharmaceutical care  

 
 
Age  

 
Provision of pharmaceutical care (n) 

 
Trained in 
pharmaceutical care* 

 
Trained in motivational 
interviews * 

20-29 3 7 4 
30-39 2 4 3 
40-49 1 4 2 
50-59 0 1 0 
60-69 0 0 0 

* 9 pharmacists were trained in both pharmaceutical services and motivational training. Data are expressed in 
frequency. 
 



 148 

Training bodies used by CPs varied, 28% of them received pharmaceutical care training in the 

form of an internship. The distribution of the various accreditation is shown in Figure 79.  

 

Figure 79: Community pharmacist’s various form of accreditation for providing pharmaceutical care.  
Data are expressed in percentage of the total number of participants.  
 

The majority of these courses are provided by accredited universities across Spain (57%) or 

by the Official Associations of Pharmacists in Spain (14%) as demonstrated in Figure 80. 

 

Figure 80: Accreditation bodies for pharmaceutical care across Spain.  
Data are expressed in percentage of the total number of participants. 
 
In response to the open questions (Appendices I), most of the CP claimed that it is 

straightforward to use (95%). They all also reported the design and protocols to be easy to 

follow and use (75% strongly agree, 25% somewhat agree). Notably, all 6 pharmacists who 

provide pharmaceutical care for patients strongly agreed the website is easy to use and 

simple to understand.  70% strongly agreed and 29% somewhat agree that the patient 

information designed is appropriate in terms of language and content.  



 149 

In terms of protocols used to control the various risk factors in improving VA, on a scale of 1 

to 5, 54% gave the score of 5 (all providers of PCS and 37% gave the score of 4, which reveals 

the appropriate use of up-to-date protocols. Nevertheless, the participants were given the 

opportunity to express their view in the last section of the survey.   

In terms of the VA questions, 62% of pharmacists, all in the PCS provider group, strongly 

agreed that the time to fill out the VA questionnaire is reasonable. On a scale of 1-5, 62% gave 

the score of 5 and 29 % gave the score of 4 for the clarity and adequacy of responses to the 

VA survey. It is noteworthy that 87% strongly agreed and 12 % somewhat agreed to 

recommend the VA tool to their colleagues to improve a patient’s vascular health. 

Interestingly all regular provider of PCS (n=6) claimed that they recommend the website to 

their colleagues.  

We also explored the barriers pharmacists face in providing such services to the patient and 

their perception towards providing pharmaceutical services. The majority of the respondents 

claimed that providing pharmaceutical services to obtain VA has the potential to improve 

their sense of job satisfaction (62% said it will significantly improve 33% it will slightly 

improve). Furthermore, 83% believed that their professional image with patients will improve 

significantly and 12% said slightly. On the other hand, a large number of participants thought 

that the VA tool may improve the pharmacist’s relation with medical doctors, 37% said 

significantly, 37% claimed slightly although some alleged that it will not make any differences 

(20).  Very interestingly 79% claimed that VAC will improve pharmaceutical care delivery. The 

details of the community pharmacies responses in relation to a patient’s visiting time at the 

CP in relation to VAC can be found in Figure 81.  

 

 



 150 

 

Figure 81: Patient’s visiting time from community pharmacy with vascular age services.  
Data are expressed in percentage of the total number of participants. 
 
It is noteworthy most of the participants claimed that VA will improve the quality of the 

cardiovascular care significantly (75%). However, a majority of the pharmacists were 

concerned that VA interventional services may increase the community pharmacy workload 

as shown in Figure 82. 

 

Figure 82: Relation between community pharmacists’ increase in workload and vascular age intervention.  
Data are expressed in percentage of the total number of participants. 
 

In the final section of the questionnaire, 79% of the pharmacists believed that the VA tool will 

help significantly to improve the patient’s cardiovascular health and 20% said slightly. Also, 

66% responded that collaboration between pharmacists and doctors will help reduce the 

health care costs for both the patient and the health care system significantly and 33% said 

slightly. In conclusion 79% of the CPs who participated in the VA study strongly believed that 

this tool can be a key component in cardiovascular health promotion services.  

 

 



 151 

1.17 Reflexive thematic analysis results:  
 
An open-ended final question gave the participants the possibility to express their opinion to 

obtain an in-depth insight. The question was “Do you have any possible suggestions regarding 

the questionnaire or parameters to be included as part of this CP's intervention?” or in 

Spanish “¿Tiene alguna posible sugerencia en relación con el cuestionario o los parámetros 

que se incluirán como parte de la intervención de este farmacéutico comunitario?”. Fifteen 

participants expressed their opinion in detail and others said there is nothing extra they would 

like to add. The reflective thematic analysis with the NVivo qualitative data analysis software; 

QSR International Pty Ltd. Version 12 was used for evaluating the open-ended question. 

Initially common words were used for coding. Thereafter, what is known as a “fully realised” 

coding was used. That involves using a shared meaning underpinned by a central concept 

from which various themes will emerge (Figure 83).  

               

Figure 83: Reflective thematic analysis for qualitative research  
 

The word cloud generated from the pharmacists’ responses is illustrated in Figure 84. 

Familarizati
on

•Responces were read
•Codes were developed according the the literature review or close 
ended questions used in the qualitative section (Q1-Q25).  

Meaning 
• Domains and sentences were summerised.  

Code
•Open codes (common words) were merged into categories. 

Themes
•The categories was then used to create themes. 



 152 

 

Figure 84: Vascular age pilot from community pharmacist’s viewpoint world cloud 
 



 153 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                     DISCUSSION   
 



 154 

Discussion  
 
CVD with a 28% prevalence, is one of the top NCDs and causes of mortality in Spain (7). 

Obesity, smoking and high BP are among the most common risk factors in this Mediterranean 

country  (36). The INTERHEART study stated that 80% of the premature death due to CVD are 

preventable by the adoption of a healthier lifestyle and risk factor prevention (265). One of 

the key problems with engaging patients in CVD prevention programmes is the lack of a clear 

perception about true CVR factors. Patients are often found to underestimate their risk and 

have difficulty understanding absolute risk percentage (266). In response to this challenge the 

VA concept was introduced. VA was proven effective in communicating a patient’s true risk 

and better comprehended by patients.  It is widely used by healthcare providers to inform 

patients and motivate them to participate in adopting a healthier lifestyle (174, 267). A 

greater comprehension of risk and protective factors by which they may influence the 

development of CVD is a first step to prevention. The conventional VAC normally uses the 

population specific risk score along with patient’s age, gender, ethnicity, BP, TC, comorbidities 

such as AF, CKD, rheumatoid arthritis, diabetes, etc., smoking status, BMI, family history and 

medication history to provide an estimation for the VA of the patients (153). However, more 

in-depth assessment of the literature provides evidence of other possible CVR factors which 

were not explored by the Spanish scientists in cluster form before.  

The explicit objective of this thesis was to create a patient-centred tool to be used by CPs to 

estimate the patient’s VA and in turn analyse risk factors in patients. The current existing VA 

tools across the world does not incorporate all risk factors that lead to developing CVD, 

neither do they consider the protective factors that slow down vascular ageing. However, the 

questionnaire created for this thesis tried to incorporate the risk factors that can be targeted 

by the CP services. Although this list may not be inclusive and future scientific advancement 



 155 

may shed light on additional factors the author believes that they should not be dismissed in 

the risk calculation process. Pharmacists and other HCPs are responsible for the health 

information they provide to patients and therefore an incomplete risk calculation might result 

in over or underestimation of the results.  

Furthermore, this research aims to facilitate the CP’s service delivery in Spain by providing a 

common training framework for the CPs and patients in Spain. Clear standard operating 

procedures, a safe, confidential, and reliable platform to record patient data and a clear 

follow-up procedure based on patient medication history and biochemical results was 

created. The author admits that previously in Spain some methods such as Dáder or Pharmafit 

existed, but this thesis and research is hoping to put all the tools and more together, so 

pharmacists can benefit from them on a national level. To meet the first objective of this 

thesis, an accessible tool in form of a website has been created to be used by CPs to develop 

a better understanding of patient’s CVR factors. Regarding the VA tool, in the first section, 

demographic data was explored. The British version of the heart age calculator considered 

inequalities presented by a patient’s unequal economic, environmental conditions 

(employment status, education level) and geographical location that subject the individuals 

to a different political and economic climate (urban and rural living location). The Public 

Health service in England made this data widely available in the form of a “Health Inequalities 

Dashboard” map. This Dashboard can be used to dictate an efficient use of health resources 

including pharmacists as viable health workers. It can further help in future planning of CVD 

preventative programmes in poor economic areas (268). The unique Spanish healthcare 

model with 17 distinct states and various legislative powers in relation to the operation of 

community pharmacies and the CVD preventative health policy arises health inequalities 

throughout Spain which makes it worth exploring to detect areas with greater needs.  



 156 

A pool analysis was identified that accessed 11 studies conducted in the first decade of the 

21st century, in Spain. They identified that CVD prevalence is greater in the Islas Canarias, 

Extremadura, and Andalucía. However, this pool analysis which was performed in 2011 did 

not link this high rate of CVD with the socioeconomical status in these regions which may 

initiate future planning of health measures (269). Therefore, new data is required in respect 

of CVD prevalence specially post COVID-19, at different local levels in Spain. To fill the gap in 

the existing knowledge, the demographic section of the questionnaire explored the patient’s 

education level and their location. The author was hoping to link this data with variable VA in 

the Spanish cohort to assist future planning of community pharmacy interventional services.  

Another limitation found in the existing VAC across the world is that it is normally performed 

without considering disparities in sexual orientation. This method of risk estimation is biased 

since it overlooks the additional risks that a homosexual individual may have by taking 

hormonal therapy. New investigation revealed that gay and bisexual men had significant 

elevations in DPB, and pulse rate. Also, lesbians and bisexual women had more risk factors 

for CVD including smoking, heavy alcohol consumption, and higher BMI (270). Therefore, a 

gender-stratified VA questionnaire was developed. However, some individuals might hesitate 

to share their sexual orientation with the HCPs due to fear of discrimination, embarrassment, 

breaches in confidentiality and more factors beyond scope of this discussion (271, 272). 

Expert advice HCPs to provide this opportunity for the patients to disclose information about 

sexual orientation using an open and accepting language. Further, provision of services in a 

consultation area where patient’s voice cannot be overheard by others can facilitate this 

moment of disclosure (271).   

Prior work has suggested that the anthropometric and biochemical values, smoking history, 

exercise, alcohol intake, family history of CVD, comorbidities, medication use and finally diet 



 157 

can negatively influence VA (153, 174) . These aspects were included in our VA questionnaire. 

In addition, there is growing evidence on the benefits of maternal health on CVD outcome. 

New scientific advancement has revealed that the short-term beneficial effect of 

breastfeeding for more than six months in women leads to improvements in metabolic health, 

lipid & glucose homeostasis, and insulin sensitivity (273, 274). On the other hand, breast 

feeding is associated with a lower risk of diabetes, hypertension, obesity, and metabolic 

syndrome and (275-277). Similarly, evidence showed that breastfeeding ≥5 months in at least 

one pregnancy seemed to decrease the risk of coronary artery disease in later life (277).These 

protective aspects were incorporated in the VA questionnaire but a longitudinal study over a 

large period of time can shed light on the number of years these factors add to the VA. One 

of the other elements observed in Spanish society is a midday nap. Evidence suggests that a 

habitual long siesta (> 60 min/day) increases the risk of CVD and metabolic disorders and the 

risk of mortality compared to the daily short  and infrequent siesta, which was considered by 

the authors (278). Further, chronic stress has been linked to higher prevalence of CVD (279). 

This factor has also been included in the questionnaire since the CPs can provide counselling 

to patients on OTC medicines for stress or refer the patients to the appropriate HCPs for stress 

management (280). Another key determinant of vascular health which is often missed out is 

individual level of social interaction. Studies have found that social interaction protects 

individuals from all-cause and CVD-specific mortality and reduces the risk of CVD incidence 

(281). In conclusion, one cannot attempt to solve and eradicate CVD unless by clearly defining 

the problem from the original, although the author does not claim that the VA questionnaire 

is inclusive of all causes. However, it can be a steppingstone and a sound theoretical 

framework for future advancements.  



 158 

The feasibility of the provision of VA services was assessed by looking through existing 

literature. A systematic review showed that pharmacist interventions in CVR reduction can 

significantly improve the cardiovascular health in patients by improving medication 

adherence, reducing BP, TC, glucose level and weight management. More research studies 

are needed to explore the community pharmacy interventional services on smoking cessation 

and alcohol consumption. Furthermore, identified intervention varied in data collection and 

methodology. Therefore, uniform protocols can assist in drawing a better conclusion on the 

impact of CP intervention on improving cardiovascular health in Spain. The systematic review 

of the literature also revealed that, in the past few years the traditional model of community 

pharmacy practice has shifted from dispensing only towards delivering a more 

comprehensive services to improve population health. This historical shift can be a 

steppingstone for future changes in the pharmaceutical care delivery model throughout 

Spain. The creation of a tool such as the VA webpage can unify the pharmaceutical care 

provision. Further research should explore the impact of delivering VA services on the 

pharmacist’s workload. Additionally, the research team must plan adequate training11 for the 

service providers. Another issue is that the pharmacist cannot provide adequate 

pharmaceutical care unless they have access to patient’s full medication history. Future 

health policies in Spain should consider pharmacies as an integral part of the healthcare 

setting rather than a commercial entity.   

1.1 Provoking factors for vascular aging in the Spanish population  
 
Despite the high prevalence of risk factors in the Spanish cohort, there is an unexpectedly low 

incidence of CVD observed in the countries of the Mediterranean area of southern Europe in 

 
11 Training day with official accreditation  



 159 

comparison to the rest of the world. This may be explained by the protective effect of 

“southern European paradox”. Three possible theories have been proposed to support the 

low incidence of CHD observed in the Spanish cohort (282). One is underestimation of the 

mortality rate, another is national delay in the consumption of fatty food which delayed the 

appearance of raised serum TC concentrations in Southern Europe and thirdly, the MedDiet 

and lifestyle. The second theory is contradictory with no significant changes in CHD rate 

despite the high population exposure to an animal fat diet within the last 40 years (283).  The 

high content of olive oil (rich in oleic acid (55%-80% of total fat), monounsaturated fatty acid 

and linoleic acid (5%-20% of total fat), polyunsaturated omega-6 fatty acid, and several 

antioxidants such as polyphenols) in the MedDiet could explain the cardiovascular benefits 

associated with its consumption. The level of HDL-C and vitamin D has also been found high 

in Spanish individuals (284). Although Spaniards live the longest in the EU, many report CVD 

in old age. The WHO European health policy framework endorsed by the 53 member states 

of the WHO European Region in 2012 (9), and places particular focus on reducing health 

inequalities and strengthening health systems using a people-centered approach (10).  

1.2 Interpretation of findings of the vascular age questionnaire  
 
A cross-sectional observational method was performed with CPs to study inaccuracy of the 

VA tool. It further aimed to explore the CP's perception about the feasibility of measuring VA 

and added value of webpage, assessing the CVR profile and identifying possible barriers faced 

in using VA tool. The online survey was selected as a preferred mode of data collection due 

to being cost-effective, convenient for participants due to automation, not time-consuming, 

broader geographical accessibility, design flexibility and responder's anonymity 12 (285).   

 
12 Respondents may be more willing to share information 



 160 

Confidentiality of the VA webpage limited the number of respondents. The survey consisted 

of 32-items with a mixture of open and close-ended questions presented in the form of cloud-

based Google Forms. The result of the survey showed that half of respondents were aged 

between 21-29 years with a slightly higher percentage of female (54% vs 46% of men). All the 

participants were based in Madrid. A plausible explanation for this high portion of young 

respondents based in Madrid can be the snowball convenience sampling technique within 

the researcher's social network via email for the study. The author suggests the use of 

randomizing sampling techniques to overcome this shortcoming and increase the external 

validity of the results for future research. The stratification of the respondents by 

accreditation and age demonstrated that a large proportion of trained pharmacists were 

younger than 50 years. Most of those who were accredited in pharmaceutical care were also 

trained in motivational interviewing.  These data may suggest the shift of the community 

pharmacy role from dispensing to clinical care and diagnostic. Nevertheless, these results 

must be interpreted with caution and further studies with a larger sample size is required. 

But shift from traditional role of CP in dispensing medicines only into provision of more 

pharmaceutical services, has also been observed among other EU countries and England. For 

instance, the process of the "Hub and Spoke dispensing model" in community pharmacies is 

being used in some EU countries13. As part of this model, prescriptions are collected from a 

"spoke" pharmacy, medication is prepared centrally in a "hub" with centralized dispensing 

and then delivered back to the "spoke" pharmacy, which provides it to the patient (286). 

Therefore, the CPs have more time to provide pharmaceutical care for the patients. On the 

other hand, the General Pharmaceutical Council (GPhC), which is the independent regulator 

 
13 Belgium, Germany, Sweden, Finland and Netherland  



 161 

for pharmacists in Great Britain, decided that in future, all graduate pharmacists will be 

independent prescribers at the end of five years Master of Pharmacy course (287). This may 

indicate that the advancement in technology and automation will demand a more clinical role 

of the CP in the near future.  

The next section of the questionnaire explored the perception and experiences of the 

pharmacist from the VA interface. There is a wide range of online health information available 

to HCPs. However, credibility and up to datedness of online resources plays a fundamental 

role. Performing a pilot among the service users was a crucial step in this thesis. It created an 

opportunity for pharmacists to interact with the information available on the website. That 

allowed the author to understand the functionality and practicality of the webpage design as 

well as health promotional protocols on the community level. The questionnaire considered 

other aspects beyond the visual display of the website. Subsequently, pharmacist's views can 

assist the research group to improve the webpage. This section of the survey explored the 

ease of navigation and accomplishment of the pharmacist goal in health promotion. It 

appears that the majority of pharmacist found the website straightforward to navigate. The 

next section assessed visual display (colour, framework, and layout) and information 

architecture (visual organization of information) of the interface. Seventy-five per cent found 

the design inspiring and protocols adequate. Seventy per cent strongly agreed, and twenty-

nine per cent slightly agreed that the PIL designed are appropriate in terms of language and 

contents. However, improvement in quality of care is only possible if patient's perceptions 

are also considered for contextual quality of PIL or method of service delivery. 

Miscommunication and information gap will negatively impact the patient's adaptation to a 

healthy lifestyle (288). Further studies are required to give a patient a voice by exploring the 

patient’s views.  



 162 

Pharmacist stratification according to their accreditation status14 indicated that all six trained 

pharmacists could navigate through the website easily. The next part of the survey assessed 

the pharmacist's views on the credibility of the contents of the interface. In terms of 

protocols, the majority15 indicates the trust they had in the quality of information being 

shared. Noteworthy individuals who trusted in the information of the interface were all 

trained in PCS. However, further qualitative measures such as open-ended question or 

interview with participants are needed to gain insight and more in-depth knowledge in 

protocols improvements. 

Thereafter, the pilot explored the user experience in a real-world situation. Sixty-two per cent 

responded that the time to fill out the VA questionnaire is reasonable. Previous studies 

indicated that if service provision is time-consuming, HCPs will not participate in the service 

(289). Therefore, a key consideration for designing and deploying the VA questionnaire was 

to identify if the tool is optimal layout to prevent time constraints in practice.  

Regarding health information sharing habits among CPs, our results indicated that 

recommending an eHealth tool to a professional network is common practice among the 

participants. Eighty-seven per cent of the respondents strongly agreed that they would 

recommend the VAC to their colleagues to adopt in their daily pharmaceutical care. The 

author noted that skilled pharmaceutical care providers (n=6) were more likely to share and 

recommend health promotion tools to their colleagues.  

The barriers and facilitators pharmacists faced in using the VA questionnaire was then 

assessed. Most of the respondents claimed that providing pharmaceutical services in the form 

of VA has the potential to improve their sense of job satisfaction. A recent systematic review 

 
14 Pharmaceutical care or motivational training 
15 A 54% gave the score of 5, and 37% gave the score of 4 



 163 

which examined satisfaction in the pharmacist workforce stated that factors such as amount 

of work, stress level, development opportunities, job security, independence, equality in the 

workplace, colleagues and boss attitude and job atmosphere are determinant factors in 

pharmacists' job satisfaction (290). However, some of the respondents claimed that vascular 

health promotion in pharmacy in the form of VA might increase their workload. Nevertheless, 

it appears that factors such as better attributes of professional image enhanced pharmacist's 

relation with medical doctors and improve pharmaceutical care delivery, which in turn can 

lead to the development of new opportunities for pharmacists, can increase pharmacists' 

work satisfactions. Most significantly, respondents claimed that a VA webpage could improve 

the quality of cardiovascular care. This is because the VA website is made for a CP to monitor 

patient's CVR factors, improve their lifestyle by patient-centred care and continual education, 

improve adherence to pharmacotherapy by surveillance and motivate them to increase their 

physical activity, eat healthily and quit smoking and reduce their alcohol intake. In the last 

question of the survey, fifteen pharmacists expressed their opinion in detail about the VA 

tool. The reflective thematic analysis with the NVivo software was used for evaluating the 

open-ended question. The summary of this analysis can be accessed in the Annex. In relation 

to the visual display of the tool, many positive themes were mentioned by the pharmacists 

(complete, good, innovative, attractive, important tool, comprehensive, etc.). In terms of 

information architecture, two of the repliers asked for the breakdown of the survey into 

different pages. However, the research group believes that a one-page display may be less 

time consuming for completion. This result must be interpreted with caution due to the small 

sample size, and further study is required to explore the practicality of this display mode.  

Some of the responses suggested adding additional components to the VA questionnaire, 

such as alanine aminotransferase (ALT) and aspartate transaminase (AST) values, indicators 



 164 

of chronic liver disease. Because the liver is responsible for the production of lipoproteins 

(HDL-C and LDL-C), that are directly related with atherosclerosis and CVD (291). This is a valid 

comment that the research group will implement in the revised version of the questionnaire.  

Other suggested adding QR code to the website to facilitate the intervention process during 

the pandemic. This suggestion was also implemented in the study protocol. Other 

respondents proposed to add other drugs that influence the plasma TC and TG concentration, 

such as antivirals and isotretinoin. This suggestion will also be implemented in the 

questionnaire. These detailed and additional suggestions are a clear indication of the high-

level clinical knowledge and expertise of the CPs, which is not being utilized by the healthcare 

system.  

This remarkable tool can be employed by the CP throughout Spain to assess, support, and 

educate patients on their personal risk of developing CVDs.  

1.3 Implication of the eHealth vascular age tool on pharmacy 
practice in Spain 
 
Although, the Spanish SNS provides free access to healthcare for the general population, 

health spending in Spain is lower than the EU average (36). Another pressing issue is a high 

percentage of an older population in Spain, as older population will suffer more from CVD. 

Careful allocation of health resources is a critical step in disease prevention. Continuous 

assessment of risk factors and vascular status in form of VA may decrease the burden of CVD 

and reduce related health costs and slowing declining quality of a patient’s life. The concern 

for lack of pharmacist time to implement pharmaceutical care and promote healthy lifestyle 

as well as lack of time and eHealth user difficulties within pharmacists was address by the 

research pilot. Although the finding should be interpreted with caution and larger scale 

webpage audit is still required. These problems can be also addressed with proper 



 165 

pharmacists training and service reorganization. The strategic locations of the pharmacies 

with extended opening hours, and ease of public accessibility and the pharmacists’ 

undeniable expertise in pharmaceutical care, make these centres strategic places for 

implementing interventional services.  

1.4 Limitation  
 
One of the greatest limitations in this research was the COVID-19 pandemic. The original plan 

of the author was to pilot the VA tool among the general public, but risk of contamination 

had stopped the large-scale data collection. The research group is hoping that with time and 

the help of vaccination, COVID-19 will be controlled which will allow the investigation to be 

carried out. The plan will be to initially launch the webpage as a pilot to include the patient’s 

voice (participation) and later to assess the VA of the patient. 

This future plan itself stopped the investigator from piloting the webpage on a larger scale. 

The pilot was performed among a small network of pharmacists with a convenient sampling, 

which may limit generalization to other jurisdictions. Moreover, the pilot was performed 

anonymously to increase the reliability of the results.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



 166 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CONCLUSION  
 
 
 
 
 
Conclusions 
 
• The vascular age calculator constitutes a novel tool to improve the patients understanding 

and consciousness about their cardiovascular risk and might contribute to improve the 

patient’s attitude and implication in their self-care. 



 167 

 

• The vascular age webpage is inclusive, easy to use and provides the appropriate 

intervention protocols and advises for patients. It can be a useful tool for community 

pharmacists to facilitate the follow-up and management of the patient’s cardiovascular 

risk, thus contributing to improve their cardiovascular outcomes.  

 

• The vascular age website might favor the communication and coordination among 

different healthcare professionals involved in the integral patient care, such as 

pharmacists, doctors, nurses, nutritionists, etc. 

 

• The assessment of the vascular age website in the general population would be required 

to properly validate it, so that its use might be generalized in pharmacotherapeutic follow-

up services provided by community pharmacists. 

 

• Once validated, the vascular age tool might contribute to improve the community 

pharmacist’s recognition as an integral part of the healthcare system rather than a 

commercial entity in Spain. 

 

 

 

 

 
 



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APPENDICES  

Appendix I: The questionnaire used in the vascular age website pilot 
 

1. Edad  
2. Sexo  

§ Mujer  
§ Hombre  
§ otro 

3. Ubicación 
4. ¿Ha participado en algún programa de seguimiento farmacoterapéutico e 

intervención farmacéutica en pacientes con alto riesgo cardiovascular o 
pacientes con enfermedad cardiovascular? 

§ Si 
§ No 

5. ¿Ha recibido alguna vez formación previa o ha sido acreditado para la 
prestación de Servicios de Atención Farmacéutica? 

§ Si 
§ No  

6. ¿Ha recibido alguna vez formación previa o ha sido acreditado para la 
realización de entrevistas motivacionales en el pasado? 

§ Si 
§ No  

7. Seleccione el tipo de formación recibida: 
§ Cursos de formación continuada on-line 
§ Cursos de formación continuada presenciales 
§ Máster Universitario en Atención Farmacéutica 
§ Realización de prácticas en un Servicio de Atención Farmacéutica 
§ Otro 

8. Indique el organismo que le proporcionó dicha formación: 
§ Universidades 
§ Consejo General de Colegios Oficiales de Farmacéuticos 
§ Colegio Oficial de Farmacéuticos 
§ Farmacia particular 
§ Otro 

Descripción de la página web 
Por favor, entre en nuestra página web https://edad-vascular.ucm.es/ y después de 
familiarizarse con la herramienta web proporcionada, responda a las siguientes preguntas.  
Para responder dispone de una puntuación del 1 al 5 de gradiente ascendente conforme el 
grado de acuerdo es mayor. Por tanto, el 1 representa el total desacuerdo y el 5 el total 
acuerdo 

9. El manejo de la web es sencillo 
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 



 187 

10. Encontré lo que necesitaba fácilmente 
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 

11. Los documentos de información al paciente son apropiados  
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 

12. Los protocolos de actuación recomendados son apropiados  
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 

13. El tiempo que se emplea en rellenar el Cuestionario es razonable 
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 

14. Las opciones que se ofrecen como respuestas al cuestionario son adecuadas 
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 

15. Recomendaría la web a mis compañeros 
§ 1 
§ 2 
§ 3 
§ 4 
§ 5 

Impacto de la web en la práctica farmacéutica   
Por favor, tómese su tiempo para responder a las siguientes preguntas. 
 

16. Su sensación de satisfacción laboral 
§ Mejorará notablemente 
§ Mejorará ligeramente 
§ No cambiará 
§ Empeorará ligeramente 
§ Empeorará notablemente 

17. Su imagen profesional de cara al paciente  
§ Mejorará notablemente 



 188 

§ Mejorará ligeramente 
§ No cambiará 
§ Empeorará ligeramente 
§ Empeorará notablemente 

18. Su relación con los médicos 
§ Mejorará notablemente 
§ Mejorará ligeramente 
§ No cambiará 
§ Empeorará ligeramente 
§ Empeorará notablemente 

19. Esta intervención mejorará sus servicios de atención farmacéutica 
§ Mejorará notablemente 
§ Mejorará ligeramente 
§ No cambiará 
§ Empeorará ligeramente 
§ Empeorará notablemente 

20. El tiempo de las visitas de los pacientes 
§ Aumentará notablemente 
§ Aumentará ligeramente 
§ No variará 
§ Se reducirá ligeramente 
§ Se reducirá notablemente 

21. La calidad de la atención al paciente 
§ Aumentará notablemente 
§ Aumentará ligeramente 
§ No variará 
§ Se reducirá ligeramente 
§ Se reducirá notablemente 

22. Su carga de trabajo  
§ Aumentará notablemente 
§ Aumentará ligeramente 
§ No variará 
§ Se reducirá ligeramente 
§ Se reducirá notablemente 

Impacto socioeconómico de la herramienta de la edad vascular 
Por favor, tómese su tiempo para responder a las siguientes preguntas. 

23. La herramienta para calcular la edad vascular contribuirá a mejorar la salud del 
paciente 

§ Totalmente de acuerdo 
§ Ligeramente de acuerdo 
§ Ligeramente en desacuerdo 
§ Absolutamente en desacuerdo 

24. La colaboración entre farmacéuticos y médicos contribuirá a reducir el gasto 
sanitario tanto para el paciente como para el sistema de salud 

§ Totalmente de acuerdo 
§ Ligeramente de acuerdo 
§ Ligeramente en desacuerdo 



 189 

§ Absolutamente en desacuerdo 
25. Esta herramienta es otro componente clave para sus servicios continuos de 

promoción de la salud cardiovascular 
§ Totalmente de acuerdo 
§ Ligeramente de acuerdo 
§ Ligeramente en desacuerdo 
§ Absolutamente en desacuerdo 

26. ¿Tiene alguna posible sugerencia en relación con el cuestionario o los 
parámetros que se incluirán como parte de la intervención de este 
farmacéutico comunitario? 

 

 

 

 

 

  



 190 

Appendix II: Community pharmacist responses in Spanish for 
question 26 of the pilot.  
 
1. El cuestionario es bastante completo. Sí que trabajaría en los protocolos de intervención. Como están 
ahora, son una serie de recomendaciones generales, que se pueden dar incluso a la población general, 
lo cual está bien, pero me parece insuficiente para el paciente diabético o hipertenso, por ejemplo. Los 
trabajaría para acompañar al paciente en el cambio de hábitos de vida, elaborando una herramienta 
que nos permita marcar objetivos realistas para cada paciente en función de su situación actual y el 
objetivo que queremos alcanzar. Como ejemplo, en el protocolo de adherencia terapéutica, al margen 
de hacer el test de Morisky-Green, estudiaría ofrecer servicios de seguimiento farmacoterapéutico 
protocolarizado y en caso necesario elaborar SPDs para el paciente. También estudiaría la posibilidad 
de facilitar en la sección de documentación, una carta de presentación del proyecto para entregar al 
médico/s de atención primaria de la zona, para intentar establecer una comunicación fluida entre 
médico y farmacéutico. 
2. Creo que se incluyen todos los parámetros, pero añadiría otra pregunta donde señalar el tipo 
patología en antecedente familiar como (ictus, IAM, hipercolesterolemia, diabetes, etc.) detallar algo 
más la patología del familiar. 
3. Hay algún campo que revisar en el formulario, pero me parece una web, una herramienta y un 
proyecto bastante importante y significativo para la salud de los pacientes y poder contribuir desde la 
farmacia comunitaria en este aspecto. 
4. En mi opinión sería interesante la vinculación a entidades como el COFM, el Consejo, SEFAC, CENTROS 
DE SALUD, etc. de esta campaña del cálculo de la edad vascular para aumentar la difusión en beneficio 
del paciente y reducción del gasto sanitario. 
5. Simplemente como comentario: es necesario hacer hincapié en la confidencialidad de los datos, cara 
al paciente. Figura en el aviso legal, pero creo que debe quedarle más claro, quizás encabezando el texto 
de información. 
6. Valorar la posibilidad de incluir los valores de ALT y AST con relación al colesterol y el riesgo 
cardiovascular. 
7. La posibilidad de añadir en el algoritmo de trabajo un pequeño seguimiento, en lugar de excluir al 
paciente completamente del estudio. Así, si el ve que su edad cardiovascular va empeorando, quizás se 
anima. 
8. Dividir el formulario en diversos apartados que se vayan completando por fases (datos personales, 
antecedentes familiares, datos analíticos, hábitos alimentarios y de estilo de vida, etc. 
9. La cumplimentación del formulario podría agruparse en bloques: datos personales; hábitos 
higiénicos-salud (fumar, ejercicio, comida), parámetros analíticos (bioquímica), antecedentes 
personales (enfermedades, tratamientos...). 
10. Página web muy intuitiva y visualmente atractiva. 
11. No, está bastante bien. 
12.Tratar de implicar al mayor número posible de oficinas de farmacia en el proyecto. 
13. Integrating with QR code 
14. Yo pondría referencias para los protocolos 
15. Incluir otros fármacos que influyen en el colesterol y los triglicéridos plasmáticos, como isotretinoína 
(tratamiento del acné) y antirretrovirales. 



 191 

Appendix III: The themes that merged from the pharmacist’s responses coding  
 

Respondents Questions  Protocols  Benefits for 
pharmacy sector 

Benefit to the 
patients  

Other 
benefits  

How to improve 
the protocols or 
questions 

Other tool or protocols 
which can be added to the 
services  

1 Complete  -Can be improved  
-Cover generalize 
cardiovascular 
advice.  
-It is good 
-Insufficient for 
patients with 
diabetes and 
hypertension.  

- - - Personalize 
patient 
intervention plan 
is needed to 
support patient 
change their 
lifestyle habits.   
 

- Tool to set realistic targets 
for each patient based on 
their current situation and 
the goal. 
- Assessment test to 
identify patient’s 
compliance such as 
Morisky-Green* or 
Therapeutic drug 
monitoring (TDM). 
- Clear documentation  
-Pre-designed referral letter 
to communicate with the 
doctor.  

2  -Inclusive -must include an option for 
patient to specify the family history for 
CVD in detail (e.g., Stroke, diabetes, 
hypercholesteremia)  

- - - - - - 

3 - Some part of the questionnaire 
needs revising.  
-Important tool and significant project  
  

- Involves 
community 
pharmacists’ in 
reducing the CVD 
risks.  

Improves 
cardiovascular 
health among 
patients 
significantly. 

- - - 

4  - - - Improves 
cardiovascular 
health in patients 
significantly.  

Reduce the 
cost in 
healthcare 
system. 

- Collaborative work with 
COFM, the Council, SEFAC, 
HEALTH CENTRES  

5      Clarify that 
patient 
information is 
secure.  

 



 192 

6       This participant asked the 
research group to include 
ALT and AST values in 
relation to cholesterol and 
cardiovascular risk. 

7       Adding control group to the 
study for patients who 
don’t want to participate 
but can use vascular age 
tool.  

8 Divide the form into different sections       
9 Divide the form into different sections       

10  Webpage is very innovative and 
attractive  

      

11 Good website       

12       Involve many pharmacists.  

13       Use QR code for webpage 

14       Add more references 

15       other drugs that 
influence plasma 
cholesterol and 
triglycerides, such 
as isotretinoin 
(acne treatment) 
and anti-
retroviral. 

 



 193 

Appendix IV: NVivo analysis of the vascular age website pilot word 
repetition  
 

Word Cou
nt 

Weighte
d 
Percenta
ge 

Percenta
ge  

communication 2 3,57% 0.5% 

divide 2 3,57% 0.5% 

form 2 3,57% 0.5% 

health 2 3,57% 0.5% 

adherence 1 1,79% 0.2% 

algorithm 1 1,79% 0.2% 

alt 1 1,79% 0.2% 

ast 1 1,79% 0.2% 

attractive 1 1,79% 0.2% 

benefit 1 1,79% 0.2% 

campaign 1 1,79% 0.2% 

centres 1 1,79% 0.2% 

changing 1 1,79% 0.2% 

cholesterol 1 1,79% 0.2% 

cofm 1 1,79% 0.2% 

comprehensive 1 1,79% 0.2% 

confidentiality 1 1,79% 0.2% 

contribute 1 1,79% 0.2% 

council 1 1,79% 0.2% 

cvd 1 1,79% 0.2% 

drugs 1 1,79% 0.2% 

encourage 1 1,79% 0.2% 

family 1 1,79% 0.2% 

follow 1 1,79% 0.2% 

good 1 1,79% 0.2% 

habits 1 1,79% 0.2% 

history 1 1,79% 0.2% 

important 1 1,79% 0.2% 

inclusive 1 1,79% 0.2% 

innovation 1 1,79% 0.2% 

insufficient 1 1,79% 0.2% 

intuitive 1 1,79% 0.2% 

legal 1 1,79% 0.2% 

lifestyle 1 1,79% 0.2% 

monitoring 1 1,79% 0.2% 

multidisciplinary 1 1,79% 0.2% 

notice 1 1,79% 0.2% 

objectives 1 1,79% 0.2% 

opportunity 1 1,79% 0.2% 

personalize 1 1,79% 0.2% 

pharmacotherap
eutic 

1 1,79% 0.2% 

protocol 1 1,79% 0.2% 

realistic 1 1,79% 0.2% 

reduce 1 1,79% 0.2% 

sefac 1 1,79% 0.2% 

services 1 1,79% 0.2% 

significant 1 1,79% 0.2% 

spending 1 1,79% 0.2% 

therapeutic 1 1,79% 0.2% 

treatment 1 1,79% 0.2% 

visually 1 1,79% 0.2% 



 194 

Appendix V: Application for the provision of waste management 
services, SRCL Consenur company form. 
 

 
  


	Tesis Marjan Manouchehri
	PORTADA
	TABLE OF CONTENTS
	LIST OF FIGURES
	LIST OF TABLES
	LIST OF ABBREVIATIONS
	ABSTRACT
	RESUMEN
	INTRODUCTION
	HYPOTHESIS AND OBJECTIVES
	MATERIALS AND METHODS
	RESULTS
	DISCUSSION
	CONCLUSION
	REFERENCE
	APPENDICES