JBS2

1. JBS2 Some highlights from the JBS2 guidelines on prevention of cardiovascular disease in clinical practice Jim McMorran GP trainer Visiting Senior Clinical Lecturer Warwick University Editor GPnotebook

2. Changes from JBS1 • Lipid targets • Total cholesterol < 4 mmol/l and LDL < 2mmol/l, or a 25% reduction in total cholesterol and a 30% reduction in LDL cholesterol, whichever gets the person to the lowest absolute value • Audit standard of total cholesterol < 5mmol/l and LDL < 3mmol/l

3. Lipid targets in JBS2 • Lipid targets • Primary prevention guidance on lipid targets from GPnotebook..click here • Secondary prevention guidance on lipid targets from GPnotebook..click here

4. Changes from JBS1 • CVD risk rather than CHD risk – 20% • Use of factor of 30% increase if raised triglyceride > 1.7 mmol/l • increased risk of CVD if impaired fasting glycaemia or impaired glucose tolerance • Three age groups < 50 years, 50-59 years, >= 60 years • Calculation of cardiovascular risk..click here

5. Changes from JBS1 • groups that are appropriate for CV risk reduction and not requiring CV risk estimation • BP> 160/100 • Hypertension and end organ damage • Cholesterol:HDL > 6 • Renal dysfunction (JBS1) • Inherited dyslipidaemia • Diabetes • Secondary prevention

6. Higher risk groups • Some relevant information links from GPnotebook • Cardiovascular risk and diabetes • Family history as a risk factor for CHD • Microalbuminuria and cardiovascular risk • Familial hypercholesterolaemia • Familial combined hyperlipidaemia

7. Plus points with JBS2 • Comprehensive – CV risk estimation, diabetes, hypertension, lipid lowering • Good educational tool – GPs, specialist nurses, GP registrars, training grades • Definitive guidance – use of statins in diabetics

8. Some other highlights from JBS2 • Use of aspirin in patients with increased cardiovascular risk • GPnotebook reference…click here • Blood pressure targets from JBS2 • GPnotebook reference…click here • Glycaemic control in diabetes • GPnotebook reference…click here

9. Problems with JBS2 • Mixture of concensus statements and evidence base • for example guidance on use of statins in diabetic patient • Lack of referencing • for example triglycerides and CV risk • Lack of information • IFG, IGT • no HDL target, no TG target

10. Problems with JBS2 • Mixture of concensus statements and evidence base • For example, lack of comprehensive evidence base for diabetics under 40years of age – the two most significant statin trials in diabetes had patients aged 40 years or older recruited to the trial • CARDS link • HPS link • But…guidance is definitive concerning statin treatment for diabetics 18-39 years of age given various other factors such as poor glycaemic control (however this guidance is largely based on concensus rather than evidence base)

11. Problems with JBS2 • Lack of referencing • Triglycerides and CV risk this is the first time that there has been guidance concerning additional risk related to triglyceride levels in terms of increasing cardiovascular risk. Certainly there is a theoretical basis for small, dense LDL particles (associated with raised triglycerides and low HDL) being more atherogenic. However there is no reference for the stated increase in CV risk in the JBS2 document raised triglycerides and CV risk on GPnotebook small dense LDL on GPnotebook

12. Problems with JBS2 • Lack of information • IFG – increased risk associated but not stated in the document. Increased risk associated with IGT is stated in the document • no HDL target, no TG target • There is no stated HDL target for intervention/ treatment • There is no definitive TG target although it is stated that a TG > 1.7 mmol/l increases CV risk

13. Conclusions • Comprehensive document • Useful document for guiding clinical care and as an educational aid • Lacks discrimination between statements that are based on evidence base or concensus statements • Raises profile of cardiovascular risk screening and treatment of risk factors