cardiovascular disease risk - northallerton...

CARDIOVASCULAR DISEASE RISK

ALISTAIR INGRAM

SEPTEMBER 2011

CARDIOVASCULAR DISEASE

Why bother ?

Mortality & morbidity

Multiple interventions

ePortfolio 5. Healthy People: promoting health and

preventing disease

15.1 Cardiovascular Problems

QOF

NHS Health Checks


Basic epidemiology

Risk factors

Management of risk factors

Case scenarios

NHS Health Checks


Cardiovascular disease (CVD) is currently

the main cause of death in the UK

CVD includes coronary heart disease,

cerebrovascular disease, peripheral

vascular disease


36% all deaths

170,000 per year in England

Responsible for 1/5th all hospital

admissions

Largest single cause of long term ill health

and disability

Risk Factors

People who already have CHD, cerebrovascular disease, peripheral artery disease

Diabetes (Type 1 and 2)

Ethnicity (ancestry from India, Pakistan, Bangladesh, or Sri Lanka)

Increasing age

Male gender

Lifetime smoking habit

High ratio of total cholesterol to HDL cholesterol

High systolic BP

Overweight or obesity

Sedentary lifestyle

Risk Factors

Alcohol abuse

Socioeconomic deprivation

Familial hypercholesterolaemia, familial mixed dyslipidaemia, or other inherited dyslipidaemias

Family history of premature CVD

Impaired glucose regulation

High triglycerides

Renal dysfunction

Left ventricular hypertrophy

Major Modifiable Risk Factors

Smoking

Obesity

Hypertension

Hypercholesterolaemia

Major Risk Factors

Greenland P et al. JAMA 2003;290:891–7 • In 3 large cohort studies, 87 –100% of patients who

died of CHD had exposure to at least 1 clinically elevated major risk factor

• This challenges claims that CHD events commonly occur in people without risk factors.

Khot UN et al. JAMA 2003;290:898–904 • 14 large RCTs conducted in the 1990s

• At least 1 of the conventional risk factors was present in 84.6% of the women and 80.6% of the men.

Lifestyle Advice

Don’t smoke

Maintain a normal body weight for adults (BMI

18.5 to 24.9 kg/m2

Engage in regular physical activity of moderate

intensity for at least 30 minutes per day, most

days of the week

Limit daily alcohol consumption

Lifestyle Advice

Eat a healthy balanced diet

Plenty of fruit and vegetables (at least 5 portions/day), nuts, fish

and fibre (approx 18g/day)

Limited dairy products and meat

Avoid saturated fat – mono-unsaturated vegetable oils are

preferable

At least 2 portions of oily fish per week

Limited salt intake (max 6 g/day)

Avoid processed foods

Losing weight is associated with a reduction in:

•Mortality (all cause, cancer, CVD and diabetes-related)

•The risk of developing type 2 diabetes

•Hypertension

•Cholesterol

“Move a little more, eat a little less”

90% of obesity in the USA could be abolished by:

walking an extra 2000 steps a day (about a mile)

and

reducing dietary intake by 0.418MJ (~100kcal)* per day

* 100 kcal = a ‘pat’ of butter or 2 Jaffa cakes or 5 Rolos or 1 small Kit Kat

or ½ a Lion bar

www.americaonthemove.org

Effect for lifestyle interventions

Intervention Average

red’n in

SBP & DBP

% with

10mmHg red’n

in SBP

(<1 year)

Other comments

(from NICE guideline 2006)

Diet

(healthy, low-calorie)

5-6mmHg ~40% Average weight changes were from

2-9 Kg

Exercise

(Aerobic 30-60 min, 3-5x wk)

2-3mmHg ~30%

Relaxation therapy

(structured)

3-4mmHg ~33% Cost in primary care unknown.

Availability?

Multiple interventions 4-5mmHg ~25% Education alone unlikely to be

effective

Alcohol reduction

(structured)

3-4mmHg ~30% <21 units/wk men, 14 units/wk

women raised BP, poorer health

Salt reduction

(<6g/day)

2-3mmHg ~25% Effects diminish over time (2-3 years)

Other: Caffeine ( 5 cups coffee) increase BP by ~2/1 mmHg; Smoking (per se) has no effect on BP; Mineral

supplements — no robust evidence

Lifestyle Advice - Summary

We have good observational and some RCT evidence that improving lifestyle improves health or protects against disease

So following a healthy lifestyle — not smoking, eating a balanced diet, limiting alcohol intake and exercising regularly — would seem to be sensible

It may help to Reduce the risks of becoming ill

Modify risk factors

Control disease

Reduce mortality

Avoid the need for drug treatment and the associated risks

On a population basis small changes are likely to have the biggest benefits

Although the evidence for multiple interventions is limited small changes in several areas may improve health outcomes further

It’s never too late to adopt a healthy lifestyle

Background

High Blood Pressure:

Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.

Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state.

Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:

– 7% from heart disease – 10% from stroke

Epidemiology

Hypertension is common in the UK population.

Prevalence influenced by age and lifestyle factors.

25% of the adult population in the UK have hypertension.

50% of those over 60 years have hypertension.

With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.

Standardise the environment and provide a relaxed, temperate setting with the person quiet and seated.

When using an automated device:

palpate the radial or brachial pulse before measuring blood pressure. If pulse if irregular measure blood pressure manually

ensure that the device is validated* and an appropriate cuff size for the person’s arm is used.

Measuring blood pressure:

updated recommendations

* See notes

Definitions

Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmHg or

higher and ABPM or HBPM average is 135/85 mmHg or higher.

Stage 2 hypertension: Clinic BP 160/100 mmHg is or higher and ABPM or HBPM daytime average is 150/95 mmHg

or higher.

Severe hypertension: Clinic BP is 180 mmHg or higher or Clinic diastolic BP is 110 mmHg or higher.

If the clinic blood pressure is 140/90 mmHg or

higher, offer ambulatory blood pressure

monitoring (ABPM) to confirm the diagnosis of

hypertension.

Diagnosis (1)

When using the following to confirm diagnosis, ensure:

ABPM:

–at least two measurements per hour during the person’s

usual waking hours, average of at least 14 measurements

to confirm diagnosis

HBPM:

–two consecutive seated measurements, at least 1 minute

apart

–blood pressure is recorded twice a day for at least 4 days

and preferably for a week

–measurements on the first day are discarded –

average value of all remaining is used.

Diagnosis (2)

Offer antihypertensive drug treatment to people:

who have stage 1 hypertension, are aged under

80 and meet identified criteria

who have stage 2 hypertension at any age.

Initiating drug treatment

Initiating Drug Treatment

If aged under 40 with stage 1 hypertension

and without evidence of target organ damage,

cardiovascular disease, renal disease or

diabetes, consider:

specialist evaluation of secondary causes of

hypertension

further assessment of potential target organ

damage.

Use clinic blood pressure measurements to

monitor response to treatment. Aim for target

blood pressure below:

140/90 mmHg in people aged under 80

150/90 mmHg in people aged 80 and over

Monitoring drug treatment (1)

For people identified as having a ‘white-coat effect’ consider ABPM or

HBPM as an adjunct to clinic

blood pressure measurements to monitor response

to treatment.

Aim for ABPM/HBPM target average of:

below 135/85 mmHg in people aged under 80

below 145/85 mmHg in people aged 80 and over.

Monitoring drug treatment (2)

White-coat effect: a discrepancy of more than 20/10 mmHg between clinic

and average daytime ABPM or average HBPM blood pressure

measurements at the time of diagnosis.

Care pathway

CBPM ≥160/100 mmHg

& ABPM/HBPM

≥ 150/95 mmHg

Stage 2 hypertension

Consider specialist

referral

Offer antihypertensive

drug treatment

Offer lifestyle interventions

If younger than 40 years

If target organ damage present or

10-year cardiovascular risk > 20%

Offer annual review of care to monitor blood pressure, provide support and

discuss lifestyle, symptoms and medication

Offer patient education and interventions to support adherence to treatment

CBPM ≥140/90 mmHg

& ABPM/HBPM

≥ 135/85 mmHg


NICE guidance recommends BP treatment targets of:

≤140/90mmHg for non-diabetic patients with hypertension

≤140/80mmHg for patients with type 2 diabetes or ≤135/75mmHg if microalbuminuria or proteinuria is present

≤ 150/90mmHg for patients over 80 years of age

Treatment targets

Treatment Targets

A small reduction in BP is beneficial if targets are difficult to achieve

a 10mmHg lower BP equates to a 40% reduction in the risk of death

Aim to achieve the largest BP reduction possible given side effects, practicability, and concordance for each individual patient

Step 4

Summary of

antihypertensive

drug treatment

Aged over 55 years

or black person of

African or Caribbean

family origin of any

age

Aged under

55 years

C2

A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further

diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

Key

A – ACE inhibitor or low-cost

angiotensin II receptor

blocker (ARB)1

C – Calcium-channel

blocker (CCB)

D – Thiazide-like diuretic

See slide notes for details of

footnotes 1-5

Use a formal estimation of cardiovascular risk to discuss

prognosis and healthcare options with people with

hypertension.

For all people with hypertension offer to:

–test urine for presence of protein

–take blood to measure glucose, electrolytes, creatinine,

estimated glomerular filtration rate and cholesterol

–examine fundi for hypertensive retinopathy

–arrange a 12-lead ECG.

Assessing cardiovascular risk

and target organ damage:

Updated recommendations

Lifestyle interventions

Offer guidance and advice about:

– diet (including sodium and caffeine intake) and exercise

– alcohol consumption

– smoking.

Patient education and adherence

Provide:

– information about benefits of drugs and side effects

– details of patient organisations

– an annual review of care.

Additional recommendations

Costs and savings

for total population of England

Year Change in

diagnosis cost

(£m)

Change in

treatment cost

(£m)

Net resource

impact

(£m)

Year 1 £5.1 − £2.5 £2.6

Year 2 £5.1 − £5.8 − £0.7

Year 3 £5.1 − £9.1 − £4.0

Year 4 £5.1 −£12.4 − £7.3

Year 5 £5.1 −£15.7 −£10.5

Costs and savings of using ABPM to confirm diagnosis of hypertension

Care pathway

CBPM ≥160/100 mmHg

& ABPM/HBPM

≥ 150/95 mmHg


Consider specialist

referral

Offer antihypertensive

drug treatment

Offer lifestyle interventions

If younger than 40 years

If target organ damage present or

10-year cardiovascular risk > 20%

Offer annual review of care to monitor blood pressure, provide support and

discuss lifestyle, symptoms and medication

Offer patient education and interventions to support adherence to treatment

CBPM ≥140/90 mmHg

& ABPM/HBPM

≥ 135/85 mmHg


Formal CVS Risk Assessment

History

Examination

Investigations

Use a formal estimation of cardiovascular risk to discuss

prognosis and healthcare options with people with

hypertension.

For all people with hypertension offer to:

–test urine for presence of protein

–take blood to measure glucose, electrolytes, creatinine,

estimated glomerular filtration rate and cholesterol

–examine fundi for hypertensive retinopathy

–arrange a 12-lead ECG.

Assessing cardiovascular risk

and target organ damage:

Updated recommendations

Risk estimation methods

How can CVD risk be best estimated in the population of England

and Wales to identify people at high risk of developing CVD for

lipid modification therapy?

• Framingham: developed in a historic American population

• ASSIGN: developed using a Scottish cohort

• QRISK2: developed using data from UK general practice

databases

Use Framingham 1991 10-year risk equations

Primary prevention:

Full formal risk assessment

CVD risk = 10-year risk of

fatal and non-fatal

stroke, including

transient ischaemic

attack

10-year risk

of coronary

heart disease

(CHD)

+

Estimating CVS Risk

CVS risk = Framingham CHD 10yr x 4/3

Joint British Societies (JBS) 2

charts People are considered to be at high risk for cardiovascular disease events if they have:

a 10-year risk for CVD events greater than 20% because of multiple risk factors or a condition that is known to pose a high risk for CVD events, e.g. established coronary heart disease, stroke or transient ischaemic attack, type 1 or 2 diabetes

People who have a single risk factor that is particularly abnormal are also considered to be at high risk

e.g. people with blood pressure > 160/100 mmHg, or familial dyslipidaemia

People with 10-year CVD risk of 10–20% (orange on the JBS 2 risk charts) are considered to be at moderate risk

People with 10-year CVD risk less than 10% (green on the JBS 2 charts) are considered to be at low risk

Joint British Societies (JBS) 2

charts

Ethnicity

NICE – Multiply by factor 1.5

Family History

NICE – One first degree relative (

<55 or <65) – increase factor by 1.5 if one relative

or 2.0 if two relatives

Primary prevention:

Information Offer information about:

• absolute risk of CVD

• absolute benefits/harms of an

intervention over a 10-year period

Information should:

• present individualised risk/benefit

scenarios

• present absolute risk of events

numerically

• use appropriate diagrams and text

Management High Risk

Lifestyle Advice

Hypertension medication

Lipid medication

Offer statin therapy for adults who have a 20%

or greater 10-year risk of developing CVD

Initiate treatment with simvastatin 40 mg

If simvastatin 40 mg is contraindicated, offer a

lower dose or alternative preparation (such as

pravastatin)

A target for total or LDL cholesterol is not

recommended

Primary prevention:

Statin therapy

Monitoring statin

Measure liver function within 3 months, at

12 months then only when clinically

indicated

Advice re muscle pain, tenderness,

weakness

Drug interactions

Clinical Scenarios

Putting Prevention First

– DH April 2008

In April 2008, DH published its plan for a systematic, integrated approach to assessing risk of vascular diseases for everyone between 40 and 74, followed by the offer of personalised advice and treatment and individually tailored management to help individuals manage their risk more effectively


Nationally £250 million of new money has

been allocated

PP1 % of patients newly diagnosed with

hypertension with a risk assessment

PP2 % of people diagnosed with

hypertension after 1 April 2009 who are

offered lifestyle advice


The Department of Health has estimated

that of those who attend for assessment,

65% would be eligible for one or more of

the lifestyle interventions, and 20% would

require statins and/or anti-hypertensives in

their first round of tests


In England 3 million people per year

invited

5 year rolling programme

Assuming 75% uptake = 5 extra

appointments/week for average GP

practice

Aims of programme

To offer an NHS Health Check every 5 years to all adults aged between 40 and 74 years who do not have established cardiovascular disease (including diabetes, hypertension, CKD) in order:

to identify people who are at risk of developing vascular disease

to identify people who have previously undiagnosed related conditions (e.g. hypertension, diabetes and chronic kidney disease)

to reduce the number of premature deaths from CVD related conditions

to reduce inequalities in incidence and premature death rates of CVD related condititions

to offer appropriate lifestyle interventions and treatment as necessary in line with evidence based recommendations

Key points

Ensure the systematic recall of all eligible patients for an NHS Health

Check every 5 years

Ensure that invited patients receive an NHS Health Check leaflet along

with the standard NHS invitation letter

Use of PCT software to upload and indentify high risk groups

Use JBS2 as the cardiovascular risk assessment tool

Promote healthy lifestyle using the PCT’s Staying Healthy internet pages

as a resource.

Estimated Numbers

For every 5000 patients with an average age and gender profile for North

Yorkshire and York, 2267 will be aged 40-74 and 1551 will are estimated

to be eligible for an NHS Health Check. 310 patients will need to be

invited per year (or 78 per quarter).

If 75% patients take up the offer of an assessment, then 233 patients will

be seen per year, and an estimated 47 will be diagnosed as being at high

risk (or 58 seen per quarter with 15 at high risk).

If 33% take up the offer of an assessment, then 103 patients will be seen

per year, and an estimated 21 will be diagnosed as being at high risk (or

26 seen per quarter with 5 at high risk).

Face to face assessment

Age

Gender

Ethnicity

Smoking habit/ status

Family history of CVD including CHD and diabetes)

Measurement of height, weight and BMI

Pulse check

Blood Pressure – systolic and diastolic blood pressure measured on at least 2 occasions using the British Hypertension Society Guidelines and appropriately calibrated devices.

Random Total Cholesterol and HDL levels with HDL cholesterol ratio

HbA1C or Fasting Plasma Glucose tests for patients at high risk of diabetes (if BMI>30 OR BMI >27.5 in at risk groups)

Personalised Advice

Brief personalised evidence based lifestyle advice (see NICE references below) should be given to all

patients with lifestyle risk factors (irrespective of their CVD risk) including: smoking cessation,

increasing physical activity, healthy eating, weight management. This should be communicated using

methods appropriate to the individual, including written information leaflets, verbal advice and internet resources including the PCT’s Staying

Healthy internet pages

Classification of Risk

High risk is defined as 20% or over risk of developing cardiovascular disease in the next ten years

Medium risk is defined as 10% to < 20% risk of developing cardiovascular disease in the next ten years

Low risk is defined as <10% risk of developing cardiovascular disease in the next ten years

Questions:

•Does pt have DM, IHD, Stroke, Hypertension

(unregistered)

•Smoking

•Age

•Family Hx (Prem IHD, DM)

•Physical activity

•Ethnicity

Measurements:

•Height

•Weight

•Waist circumference

•Blood pressure (x2)

•Pulse check

Calculations:

•BMI

Blood tests:

•Random cholesterol + HDL

•Fasting Glucose or HbA1C if BMI>30 (OR

BMI >27.5 from Indian, Pakistani,

Bangledeshi, Other Asian and Chinese ethnic

groups) OR systolic BP >140mmHg OR

diastolic BP > 90mmHg

(Random glucose should be avoided unless it

is felt that this might compromise participation

in the scheme for certain individuals)

Calculation of CVD risk

High risk

All patients to receive relevant Brief

Lifestyle interventions for

•Smoking

•Physical activity

•Weight management

(see Staying Healthy web pages)

*This may be provided after the initial

information gathering appointment

Information collection

Diabetes,

Hypertension or

CKD suspected?

If confirmed – exit

Health Checks

pathway onto

appropriate other

pathways)

Assessment of CVD risk with brief personalised lifestyle advice to all

Low to

medium

risk

Recall after

5 years

Interpretation of results

no

Further

investigations if

required

Eg U/Es, OGTT

(see NHS Health

Checks Best

Practice

Guidance)

Hypertension register

Diabetes register

CKD register

No DM,

HT or

CKD

yes

Patient entered onto

‘High Risk of

developing CVD’

register

• More intensive lifestyle support (see

Staying Healthy web pages)

• Consideration of statins

• Annual review of risk factors including

•BP

•BMI

•Smoking status


Basic epidemiology

Risk factors

Management of risk factors

Case scenarios

NHS Health Checks

THE END

cardiovascular disease risk - northallerton...

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