European Guidelines on CVD prevention

1. European Guidelines on CVD prevention ESC Commitee für Practice Guidelines to improve the quality of clinical practice and patient care in Europe Fourth Joint European Societies´ Task Force on Cardiovascular Disease Prevention in Clinical Practice European Journal of Cardiovascular Prevention and Rehabilitation (2007), 4 (Suppl2) www.escardio.org Charité, CVK, Lipidambulanz

2. CVD cardiovascular disease comprises: CAD Coronary Artery Disease PAD Peripheral Artery Disease Stroke The conditions above are the conseqence of generalized atherosclerosis Charité, CVK, Lipidambulanz

3. European Guidelines on CVD prevention - Rationale 1.) CVD is the major cause of premature death in Europe. It is an important cause of disability and contributes substantially to the escalating costs of health care. 2.) The underlying atherosclerosis develops insidiously over many years and is usually advanced by the time syptoms occur. 3.) Death from CVD often occurs suddenly and before medical care is availiable , so that many therapeutic interventions are either inapplicable or palliative. 4.)The mass occurence of CVD relates strongly to lifestyles and to modifiable physiological and biochemical factors. 5.) Risk factor modifications have been shown to reduce CVD mortality and morbidity , particularly in high risk subjects. Charité, CVK, Lipidambulanz

4. Priorities for CVD prevention in clinical practice 1 Patients with established atherosclerotic CVD. 2 Asymptomatic individuals who are at increased risk of CVD because of: - multiple riskfactors resulting in raised total CVD risk ( 5% 10 year risk of CVD death) -Diabetes type 2 and type 1 with microalbuminuria -Markedly increased single risk factors especially if associated with end organ damage 3 Close relatives of subjects with premature atherosclerotic CVD or of those who are at particulary high risk. Charité, CVK, Lipidambulanz

5. European Guidelines on CVD prevention 1.) CVD (cardiovascular disease) 2.) Use of SCORE charts to estimate cardiovascular risk - low risk chart in Belgium*, France, Greece*, Italy, Luxembourg, Spain*, Switzerland and Portugal - high risk chart in other countries of Europe *Updated charts are now availiable for Belgium, Germany,Greece, the Netherlands, Spain, Sweden and Poland. 3.) explicitly clinical priorities 4.) Evidence of all preventive cardiology studies was included Charité, CVK, Lipidambulanz

6. Systematic Coronary Risk Evaluation The SCORE system Individuals with -known CVD, -Type 2 diabetes or type 1 with microalbuminuria -very high levels of individual risk factors are automatically at INCREASED CARDIOVASCULAR RISK and need management to all risk factors!!!! For all other people, the SCORE risk charts can be used to estimate total risk. Charité, CVK, Lipidambulanz

7. Systematic Coronary Risk Evaluation The SCORE system The SCORE system is based on big prospective european studies and perdicts all kinds of fatal atherosclerotic endpoints for a period of 10 years. Following riskfactors are included: Gender, age, smoking, systolic bloodpressure and total cholesterol or total cholesterol/HDL-C ratio. Charité, CVK, Lipidambulanz

8. SCORE system High risk region 10 year risk of fatal CVD Charité, CVK, Lipidambulanz

9. SCORE system Low risk region 10 year risk of fatal CVD Charité, CVK, Lipidambulanz

10. How to use the SCORE charts to assess CVD risk in asymptomatic persons? 1.Use the low risk chart in Belgium*, France, Greece*, Italy, Luxembourg, Spain*, Switzerland and Portugal use the high risk chart in other countries of Europe *Updated charts are now availiable for Belgium, Germany,Greece, the Netherlands, Spain, Sweden and Poland. 2.Find the cell nearest to the person´s age, cholesterol and BP values, bearing in mind that risk will be higher as the person approaches the next age, cholesterol or BP 3.Check the qualifiers. 4. Establish the total 10 year risk for fatal CVD. Charité, CVK, Lipidambulanz

11. Why do the guidelines stress the assessment of total CVD risk? Multiple risk factors usually contribute to the atherosclerosis that causes CVD. These risk factors interact, sometimes multiplicatively Thus the aim should be to reduce total risk; if a target cannot be reached with one risk factor, total risk can still be reduced by trying harder with others. Charité, CVK, Lipidambulanz

12. Qualifiers Risk maybe higher than indicated in the chart in: -Sedentary or obese subjects, esp. those with central obesity -Individuals with a strong family hx of premature CVD -The socially deprived -Subjects with diabetes => risk may be 5 fold higher in women and 3 fold higher in men compared to those without diabetes. -Those with low HDL-C or high triglycerides -Asymptomatic subjects with evidence of pre-clinical atherosclerosis, e.c. reduced ankle-brachial index or on imaging such as carotid ultrasonogrphy or CT scanning. Charité, CVK, Lipidambulanz

13. Characteristics of People who stay healthy035140530 0 No tobacco 3 Walk 3 km daily, or 30 mins any moderate activity 5 Portions of fruit and vegetables a day 140 Blood pressure less than 140 systolic 5 Total blood cholesterol<5mmmol/L 3 LDL cholesterol< 3mmol/L 0 Avoidance of overweight and diabetes Charité, CVK, Lipidambulanz

14. Aims of rigorous risk factor control in high risk patients • Blood pressure under 130/80 mmHG if feasible. 2. Total cholesterol <4.5 mmol/L(~175 mg/dl) with an option of < 4mmol/L(~155 mg/dl) if feasible. 3. LDL cholesterol <2.5 mmol/L(~100mg/dl)with an option of 2 mmol/L(~80 mg/dl) if feasible. 4. Fasting blood glucose < 6 mmol/l(~110 mg/dl) and HbA1c <6.5% if feasible. Charité, CVK, Lipidambulanz

15. Management of Riskfactors Lifestyle: • No tobacco • Healthy food choices - Physical activity Charité, CVK, Lipidambulanz

16. Management of other Riskfactors • Overweight and Obesity • Bloodpressure • Plasmalipids • Diabetes • Metabolic Syndrome Charité, CVK, Lipidambulanz

17. When to prescribe cardio-protective drugs in addition to those used to treat blood pressure, lipids and diabetes • Aspirin for virtually all with established CVD, and in persons at< 10% SCORE risk once blood pressure has been controlled. • Beta-blockers after myocardial infarction and, in carefully titrated doses, in those with heart failure. • ACE-inhibitors in those with left ventricular dysfunction and in diabetic subjects with hypertension or nephropathy. • Anti-coagulants in those at increased risk of thrombo-embolic events, particularly atrial fibrillation. Charité, CVK, Lipidambulanz

18. Lipids Generally total cholesterol < 5 mmol/L(~190 mg/dl) and LDL cholesterol < 3 mmol/L(~115mg/dl) should be achieved High risk patients: Total cholesterol<4.5 mmol/L(~175 mg/dl) with an option of< 4mmol/L(~155 mg/dl) if feasible. LDL cholesterol<2.5 mmol/L(~100mg/dl) with an option of 2 mmol/L(~80 mg/dl) if feasible. Treatment goals are not defined for HDL-C and triglycerides but HDL-C < 1,0 mmol/L(40mg/dl) for men and <1,2 mmol/L(45 mg/dl) for women and fasting triglycerides of > 1.7 mmol/L(150 mg/dl) are markers of increased cardiovascular risk. Charité, CVK, Lipidambulanz

19. Lipidmanagement in asymptomatic Individuals - Risk< 5 % - TC  190 mg/dl (5 mmol/l) Lifestyle advice to reduce TC < 190 mg/dl and LDL-C < 115 mg/dl (3 mmol/L) Regular follow-up - Risk  5% - TC  190 mg/dl (5 mmol/l) Lifestyle advice for 3 months, then reassess SCORE and fasting lipids TC > 190mg/dl + LDL-C > 115mg/dl Continue lifestyle change If Risk still remains > 5% dietary and exercise advice together with attention to all risk factors comes first. If treatment goals are still not achieved consider lipid-lowering treatment TC< 190mg/dl o. LDL-C < 115mg/dl Continue lifestyle change Regular follow-up Charité, CVK, Lipidambulanz

20. Highlights – high risk patients • Lifestyle-change advice: no tobacco, healthy food choice, physical activity • Treatment with Aspirin and Statin • Consider cardioprotective drugs Charité, CVK, Lipidambulanz

21. Highlights –patients with potentially high CVD-risk • Estimate total CVD risk with SCORE-system • Lifestyle-change advice: no tobacco, healthy food choice, physical activity • Consider treatment to lower bloodpressure, lipids and bloodglucose Charité, CVK, Lipidambulanz