Assessing Cardiovascular Risk

1. Assessing Cardiovascular Risk Helen Williams Consultant Pharmacist for Cardiovascular Disease South London Cardiac and Stroke Networks

2. Objectives To highlight key aspects of the NHS Health Checks programme To run through a case study to consider how different risk factors affects CV risk To utilise both Framingham and Qrisk and consider the differences To present the possible treatment options / interventions that need to be in place To highlight key issues in service delivery

3. Putting prevention first People between the ages of 40 and 74 will be offered vascular checks: risk assessment and management

4. The Vascular Checks Programme Vascular checks for all UK adults between the ages of 40-74 years � 5 year rolling programme; systematic approach Promote a healthy lifestyle focusing on reducing incidence of CVD, stroke and TIA,PAD, CKD, DM Identify CV risk factors present for an individual Use a recognised risk calculator to assess an individuals risk of developing vascular disease Offer interventions to lower CV risk in high risk patients (>20% CVD risk over the next 10 years)

5. The Next Steps Needed more guidance

8. What's in a Risk Assessment? Lifestyle assessment and advice Diet Weight / abdominal girth Physical activity Smoking status Alcohol intake Review of CV risk factors Age Gender Ethnicity Social deprivation Family history Smoking status Blood pressure Cholesterol (TC/HDL ratio) (Blood glucose)

9. One Doughnut Too Many�..A Case Study in CV Risk Assessment Helen Williams Pharmacy Team Leader � Cardiac Services King�s College Hospital, London

10. Mr HS 44 year old man Married with 3 children Works as a technical supervisor at a nuclear plant Main Interests: TV Food Beer You might recognise him�.

12. Call and Recall Homer attends the GP surgery / pharmacy / local community centre for his �free� NHS Health Check Robust call and recall systems

13. Non-Modifiable Risk Factors What non-modifiable risk factors does Mr HS display?

14. Non-Modifiable Risk Factors What non-modifiable risk factors does Mr HS display? Male gender Age Family history (ethnicity)

15. Modifiable Risk Factors What modifiable risk factors does Mr HS display?

16. Modifiable Risk Factors What modifiable risk factors does Mr HS display? Lifestyle Alcohol Diet Exercise Central obesity ?lipids ?blood pressure ?impending diabetes

17. And the Good News.......?

18. And the Good News.......? He�s not a smoker!

19. Risk Factors Non-modifiable Male gender Age Family history (ethnicity) Modifiable Lifestyle Alcohol Diet Exercise Central obesity ?lipids ?blood pressure ?impending diabetes

20. What happens next?

21. What Issues need to be addressed? Full CV risk assessment If CV risk > 20% over 10 years then:

22. What Issues need to be addressed? Full CV risk assessment If CV risk > 20% over 10 years then: Lifestyle advice Primary Prevention strategies Blood pressure, cholesterol, blood glucose NB. If CVD risk < 20% lifestyle advice should still be given!

23. Calculating CV risk What data do you need?

24. Calculating CV risk What data do you need? Gender Age BP (systolic) TC / HDL cholesterol ratio

25. Calculating CV risk Joint British Societies Risk Prediction Charts in the back of the BNF Online tools: JBS2 / Framingham QRisk Ensure any CV risk assessment tool is: Validated Endorsed by BHF

26. HS Risk Factors Male 48 years old BP = 159/98mmHg Total cholesterol = 6.2 / HDL = 0.8 Check the CV risk on the JBS-2 charts.... Assess risk using CVRA online tool.....

27. Risk Prediction Charts

32. Lifestyle Issues Weight loss Diet Physical activity Alcohol intake Smoking cessation

33. Other monitoring BMI - if >30kg/m2: needs diabetes filter BP � as >140/90mmHg: needs diabetes filter ECG - check for LVH Urinalysis - check for proteinuria and glucosuria Bloods renal function (Creatinine, eGFR, urea, potassium) Thyroid function (TFTs) Fasting glucose Fasting lipid profile FBC

34. Interventions Lifestyle Weight management Dietary modification Exercise on prescription Alcohol moderation Brief motivational interviewing Goal setting Drug Therapy Blood pressure management if hypertension confirmed Cholesterol-lowering with a statin Check for and manage diabetes Check for and manage CKD

35. NHS Health ChecksCommissioning Considerations......?

36. VRA � The Challenges Service capacity Patient engagement Delivering lifestyle interventions Making appropriate medical interventions Resources - where are the vascular millions?

37. Commissioning Issues Call and recall Premises Staffing Near Patient Testing Integration Governance Education and training Competence Funding

38. Call and Recall Systematic, 5 year rolling programme Registered or resident population? Age based or focussed on priority groups? Centralised or practice based? Engagement? Unregistered patients Men BME groups High risk populations

39. Premises Confidential consultation room with a sink with handwashing facilities Sufficient internet enabled IT equipment should be available to allow use of CV risk scoring tools, and to support signposting to other services sufficient space to safely store and operate patient testing equipment, handle blood samples and any resultant clinical waste

40. Staffing Who takes overall responsibility for the Health Check GP, Nurse, Pharmacist Other healthcare staff will need to be involved in vascular checks for the service to be delivered effectively delivered Only staff who are trained and competent to carry out VRAs should provide the service Consistency in service provision, opening hours, accessibility Training for other HCPs / support staff

41. Near Patient Testing Equipment BP, cholesterol. Glucose, weight, height Quality Assurance - calibration Training and competency assessment Infection control Premises Clinical waste removal

42. Integration Mobility Unregistered and out of area patients Joint working across organisations (ie GP � Pharmacy) to ensure robust and efficient referral processes that meets local needs Secure transfer of information Integration into call and recall systems Signposting patients to other services Use of agreed risk assessment calculators

43. Governance Record keeping Documentation � handling, transmission and storage Confidentiality Transfer of information electronically To speed up referral processes and administrative burden Secure IT links Non-NHS net email is not appropriate for transferring patient specific data. Use of secure web based systems � Tempus-1 Standard Operating Procedures Professional indemnity insurance Data monitoring and audit

44. Education & Training / Competence Commissioners will need to ensure HCPs offering the VRA service have completed appropriate education and training All staff involved in VRA process Backfill training costs Assessment of competence On going CPD opportunties relelvant to the service Formal courses � free, funded by DOH Primary care training centre � Bradford Education for Health

45. Key competencies Key areas in which practitioners should be required to demonstrate competence include: Demonstrating the correct technique for blood pressure (BP) measurement, being able to explain what can go wrong during BP measurement and knowing how to resolve these problems Being able to explain to patients the relevance of the BP level measured and give appropriate advice and recommendations on follow up Understanding how to identify cardiovascular risk factors and explain their relevance to patients Being able to formally quantify CV risk using an approved risk assessment tool Giving appropriate lifestyle advice to address cardiovascular risk including advice on diet, physical activity, alcohol, salt intake and smoking cessation and signpost additional relevant services in the locality Identifying patients appropriate for referral for to a GP (or other HCP) for follow up and ensure appropriate communication regarding this with both GP and patient

46. Questions��.. ???