development and implementation cardiovascular clinical practice guidelines · 2017-11-09 ·...
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Development and implementation cardiovascular
clinical practice guidelines
Professor David A WoodGarfield Weston Professor of
Cardiovascular MedicineInternational Centre for Circulatory
HealthImperial College London
UK
• Hypertension
• Hyperlipidaemia
• Hyperglycaemia
Primary preventionTraditional medical paradigm
Usual systolic blood pressure and risk of cardiovascular death in Asia and Australasia
Asia Pacific Cohort Studies Collaboration. J Hypertension 2003; 21:707-716
Primary preventionTraditional medical paradigm
Single risk factors
treated in silos
Relative risk estimates of CHD events and stroke for a blood pressure reduction of 10 mm Hg systolic and 5 mm Hg diastolic in the blood pressure difference trials and in epidemiological cohort
studies
Law MR et al. BMJ 2009; 338; b1665
Primary preventionNew medical paradigm
Total cardiovascular risk
Absolute risk (%) of having a cardiovascular event in 10 years according to age, BP and other risk
factors
Professor Rodney Jackson
Professor Ian Graham
www.escardio.org/guidelinesJoep Perk, Linnéuniversitetet, Campus Kalmar
5th Joint Europ
On behalf of:
The 5th Joint European Societies’ Task Force on Cardiovascular Disease Prevention in Clinical
Practice
SCORE: the European Risk Prediction System
1994199820033rd Joint European Societies Task Force
2004European Society of Cardiology
Score enabled HeartScore, an interactive tool
• 12 European cohort studies• wide geographic spread of
countries at different levels of cardiovascular risks
• 3-million person-years of observation
• 7,934 fatal cardiovascular events
Data from:
SCORE
Systematic coronary risk evaluation
Priorities in CVD PreventionVery high risk Documented CVD
Diabetes mellitus (type 1 or 2) with one or more CV risk
factors and/or target organ damage
Severe chronic kidney disease SCORE > 10% over 10 years
Priorities in CVD PreventionHigh risk
Markedly elevated single risk factors such as familial dyslipidaemia or
severe hypertension Diabetes mellitus (type 1 or 2) but
without other risk factors or target organ damage
Moderate CKD SCORE > 5% but < 10% over 10
years
Primary preventionNew medical paradigm
At what level of cardiovascular risk is it appropriate to intervene
with drug therapies?
Systematic coronary risk evaluation
Primary preventionNew medical paradigm
At what level of cardiovascular risk is it appropriate to intervene
with drug therapies?SCORE > 5%
Equivalent to 20% CVD risk over 10 years
Joint ACC/AHA GuidelineStatin benefit groups
• Clinical ASCVD• Primary elevations of LDL-C >
190 mg/dl• Diabetes (40-75 yrs) LDL-C 70 >
189 mg/dl
Joint ACC/AHA GuidelineNew medical paradigm Total risk assessment
Pooled Cohort Risk Assessment Equations
Joint ACC/AHA GuidelineStatin benefit groups
• Estimated CVD risk > 7.5% over 10 years with LDL-C 70-189
mg/dl
Joint ACC/AHA GuidelineEstimated CVD risk > 7.5% over
10 years with LDL-C 70-189 mg/dl
About 30 million US citizens potentially eligible for a statin
Primary preventionNew medical paradigm
SCORE > 5% Equivalent to 20% CVD risk over 10 years
ACC/AHA > 7.5% CVD risk over 10 years
NICE (UK) > 10% CVD risk over 10 years
SCORE: the European Risk Prediction System
1994199820033rd Joint European Societies Task Force
2004European Society of Cardiology
Score enabled HeartScore, an interactive tool
• 12 European cohort studies• wide geographic spread of
countries at different levels of cardiovascular risks
• 3-million person-years of observation
• 7,934 fatal cardiovascular events
Data from:
SCORE
Total risk assessment
Total Risk Assessment• Lifestyle: smoking, diet and
physical activity• Body mass index and central
adiposity• Risk factors: Blood pressure,
lipids and glucose• Family history
• Other risk markers
SCORE: the European Risk Prediction System
1994199820033rd Joint European Societies Task Force
2004European Society of Cardiology
Score enabled HeartScore, an interactive tool
• 12 European cohort studies• wide geographic spread of
countries at different levels of cardiovascular risks
• 3-million person-years of observation
• 7,934 fatal cardiovascular events
Data from:
SCORE
Total risk assessment
Total risk management
Total Risk Management
• Lifestyle: smoking cessation, diet, weight management and physical
activity• Risk factors: Blood pressure, lipid
and glucose control• Cardioprotective drug therapies
Joint ACC/AHA GuidelineCost effective for primary
prevention to identify and manage all adults with a total CVD risk >
7.5% over 10 years?
Total risk managementCost effective for primary
prevention?Screening adult population to estimate
total CVD riskFurther investigations will be required
for those at high CVD riskManaging people at high CVD risk will
require a multifactorial intervention
Joint ACC/AHA GuidelineCost effective for primary
prevention to identify and manage all adults with a total CVD risk >
7.5% over 10 years?
Primary preventionNew medical paradigm
Total cardiovascular risk
Single risk factor management
Primary preventionNew medical paradigm
Total cardiovascular risk
Single risk factor management
Established CVD orFamilial Hypercholesterolaemia
Diabetes age >40 yearsChronic Kidney Disease
Lifestyle and drug therapy as recommended in JBS3
10 year CVD risk scoreABOVE current NICE
threshold*:Lifestyle + Drug therapy
BELOW current NICE threshold*
Examine JBS3 ‘lifetime metrics’Heart age
Projected CVD riskTo inform discussion on risk
modification by:Lifestyle changes
Drug therapy when indicated
Ongoing research on implementation and impact of JBS3 recommendations and
risk calculator
*Current NICE Guidance www.nice.org.uk
NO YES
Use JBS3 risk calculator
JBS3 CVD Risk Approach
Male 37 years old
Male 37 years old
Male 37 years old
JBS3 Risk Calculatorwww.jbs3risk.com
Visit the App Store for your iPhone and iPad
Primary preventionTraditional medical paradigm
Single risk factors
treated in silos