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Primary Prevention

Primary Prevention. Cardiovascular Study day Cheltenham Racecourse 10 th October 2006 Dr Jim Moore. What is Primary Prevention?.

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Primary Prevention

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  1. Primary Prevention Cardiovascular Study day Cheltenham Racecourse 10th October 2006 Dr Jim Moore

  2. What is Primary Prevention? • Identification of people at risk of coronary heart disease who have no clinical manifestation of the condition. • Assessment and treatment of people at risk of CHD

  3. At risk groups • Diabetes /Glucose intolerance • Hypertension • Smokers • Abnormal Lipid profile including Familial hyperlipidaemia ( FH ) • Family history of CHD • Ethnic groups-South East Asians. • Obese • Premature menopause

  4. Joint British Society Guidelines on Prevention of Cardiovascular Disease in Clinical Practice.“JBS 2” 25th September 2006 Dr Jim Moore

  5. Overall aim of JBS 2 • To promote a consistent multidisciplinary approach to the personalised management of people with established atherosclerotic CVD,diabetes and others at high risk of developing symptomatic CVD: • To emphasise a total risk approach to CVD risk assessment in the asymptomatic population • To define lifestyle and risk factor interventions with thresholds and targets which reflect a growing scientific evidence base for managing high risk people

  6. Priorities for CVD Prevention • People with any form of established atherosclerotic CVD – Secondary prevention • Asymptomatic people without established CVD - Primary Prevention • high total risk≥20% over 10 years • People with diabetes mellitus • type 1 or 2

  7. JBS 2 Guidelines 2005:Significant changes in Recommendations for Risk assessment • Based on cardiovascular risk and not coronary heart disease risk alone with different risk bands. • Type 2 Diabetes excluded from risk calculations as their overall level of risk is equivalent to someone with overt CHD • Three age bands only- under 50years; 50-59years ; and 60years and over

  8. Primary Prevention Risk assessment • CVD risk prediction chart/table • Computer risk assessment using JBS 2 CD-Rom • GP computer systems integral risk assessment software in development

  9. NON-DIABETIC MAN NON-DIABETIC WOMAN JBS 2 CVD Risk Prediction Charts Figure 1: Joint British Societies’ cardiovascular disease (CVD) risk prediction chart: non-diabetic men Figure 2: Joint British Societies’ cardiovascular disease (CVD) risk prediction chart: non-diabetic women Heart: December 2005 Vol 91 Supplement V (Inside Covers) Reproduced with permission from the BMJ Publishing Group

  10. Type 2 Diabetes excluded from risk calculations as their overall level of risk is equivalent to someone with overt CHD Based on cardiovascular risk and not coronary heart disease risk alone with different risk bands. Three age bands only- under 50years; 50-59years ; and 60years and over CVD risk assessment: - <10%;10-20% or <20% over next 10years NON-DIABETIC MAN JBS 2 Guidelines 2005:Changes in Risk assessment

  11. Coronary heart disease vs Cardiovascular disease risk A 10 year Coronary heart diseaserisk of 15% over 10years is equivalent to a 20% Cardiovascular disease risk and is the level of risk at which pharmacological interventions should be considered. ( CVD risk = CHD risk × 4/3)

  12. JBS 2 Guidelines 2005:Significant changes in Recommendations for Risk assessment“AGE BANDS” • Under 50’s will be assessed on the basis of their risk factors and an age of 49years old. • Age 50-59 will be assessed on the basis of risk factors and an age of 59years. • Over 60’s will be assessed on the basis of their risk factors and an age of 69years.

  13. Who to Screen? • All adults from 40 years onwards • No history of CVD or diabetes and who are not already on treatment for blood pressure or lipids • Opportunistic comprehensive risk assessment • Younger adults (<40 years) • Family history of premature atherosclerotic disease

  14. Data for Cardiovascular Disease Risk assessment (2004) • Age • Sex • Smoking status • Systolic blood pressure • Total cholesterol/HDL ratio

  15. Practical considerations when risk calculating !

  16. Special considerations • Family history (risk increased by1.5) • Ethnicity (South Asian risk increased by1.4) • Raised Triglyceride levels above 1.7 mmol/l (risk increased by 1.3) • Pre-existing treatment of hypertension or hyperlipidaemia (risk underestimated)

  17. Special considerations: Risk assessing Established hypertensives on treatment • If up to date BP used risk will be underestimated therefore do not use • Use pre-treatment BP and present age where possible. • If pre-treatment BP not available then use systolic BP of 160.

  18. Risk Factors for Cardiovascular disease BLOOD PRESSURE

  19. Risk Factors for Cardiovascular disease What is a NORMAL blood pressure?

  20. CVD prevention“High risk groups” • Established CVD • Diabetes mellitus • Total CVD risk ≥ 20% over 10 years In addition the following groups with significant (elevated) risk factors should be considered as high risk and do not require formal risk assessment: • Elevated BP ≥ 160 systolic or ≥ 100 diastolic or lesser degrees of blood pressure with target organ damage • Total cholesterol to HDL ratio ≥ 6.0 • Familial dyslipidaemia

  21. How many patients are estimated to have a 10year CVD risk ≥20%? 23% of men and 8% of women aged40-74years !

  22. Risk thresholds and targets for blood pressure in asymptomatic people without CVD

  23. Blood Pressure TARGETS for antihypertensivedrug treatment • For most patients a target of 140 mm Hg systolic bloodpressure and 85 mm Hg diastolic blood pressure is recommended(B). For patients with diabetes, renal impairment or establishedcardiovascular disease a lower target of 130/80 mm Hg is recommended • Whenusing ambulatory blood pressure readings, mean daytime pressuresare preferred and this value would be expected to be approximately10/5 mm Hg lower than the office blood pressure equivalent forboth thresholds and targets. Similar adjustments are recommendedfor averages of home blood pressure readings

  24. General Medical Service ContractCardiovascular Prevention Quality Indicators • Audit Standards = Minimum Standard of Care • Coronary heart disease, stroke or transient ischaemic attacks, hypertension and diabetes • Blood pressure < 150/90 mmHg (< 145/85 mmHg in diabetes) • Total cholesterol < 5.0 mmol/l • Glycated haemoglobin < 7.5 %

  25. Risk Factors for Cardiovascular disease CHOLESTEROL AND LIPIDS

  26. Lowering serum cholesterol reduces CHD mortality rate References 1-9 can be found at the end of the presentation

  27. Diet and cholesterol. • Diet low in saturated fat and cholesterol can result in a 10% reduction in LDL cholesterol though in practice only 3-6% is obtained. • 2 g of Plant stanols/sterols (benecol/ flora pro activ ) daily can reduce LDL cholesterol by 9-14% depending on age • 15% reduction in LDL cholesterol reduces the risk of CHD over a lifetime by 25%

  28. Significant changes to cholesterol management in Primary and Secondaryprevention : JBS 2 (2005) • Existing Threshold Total cholesterol level of 5mmol for initiation of treatment replaced by level of 3.5 mmol (HPS study) • New Audit and Optimal Treatment (target)standards set.

  29. Optimal and audit standard lipid targets

  30. Cholesterol metabolism • Two main sources of plasma cholesterol • Absorption of cholesterol from the intestine • Production of cholesterol in the liver 16. Shepherd J. Eur Heart J Supplements 2001;3:E2-E5.

  31. Dietary intake Liver synthesis ~300-700 mg/day Biliary excretion ~800 mg/day ~1,000 mg/day Small bowel absorption Plasma–500mg/day Faecal loss 650-850 mg/day ~700 mg/day Cholesterol balance: absorption and synthesis

  32. HDL vs LDL cholesterol • High Density (Highly desirable) Lipoprotein is inversely related to CHD risk.Average HDL value in the UK is 1.2 for men and 1.4 for women. • Low Density (Less desirable) Lipoprotein is directly related to CHD risk. • Total chol /HDL ratio greater predictive value for CHD than LDL .

  33. Cholesterol treatment triallists:Efficacy and safety of cholesterol lowering treatment Irrespective of initial pre-treatment LDL and lipid profile: • Lowering LDL by 1mmol over a 5 year period reduced major vascular event rate by 21%-translates into 48 fewer vascular events per 1000 in CHD patients and 25 per 1000 in those with no history. • 23% reduction in CHD events and 17% reduction in Stroke events per mmol LDL reduction over 5 years • Significant reduction in major vascular events by 10% per mmol reduction in LDL at 1 year • Overall there was a 12 % reduction in all cause mortality per mmol LDL reduction over 5 years • Postulated that a 1.5mmol reduction in LDL should reduce major vascular events by one third over 5 years Lancet 2005

  34. GLOS.PCCAG Primary care CHD Audit April l2005 • 92% have had a cholesterol measurement in the past 15months. (nGMS max threshold > 90%) • 78.2% have had a statin in the last 6months. • 74% have a total cholesterol 5mmol/l or less in the past 15mths. (nGMS max threshold > 60%)

  35. New drugs and multiple drug therapy !

  36. Ezetimibe - EZETROL • Novel agent: first in a new class • Ezetimibe selectively inhibits intestinal absorption of cholesterol20 • Has a unique mechanism of action, which is complementary to statins20 • Using the ezetimibe together with a statin together should have an additive effect on LDL-C lowering20 20. Shepherd J. Eur Heart J Supplements 2001;3:E2-E5.

  37. SummaryEzetimibe added to ongoing statin therapy • LDL-C decrease of -25.1% from baseline (versus -3.7% from baseline in the statin only group), p<0.001 • Near maximal cholesterol lowering was seen by week 2 .

  38. x STATINS Dietary intake Liver synthesis ~300-700 mg/day Biliary excretion ~800 mg/day ~1,000 mg/day Small bowel absorption Circulation Faecal loss 650-850 mg/day ~700 mg/day Dual inhibition x EZETIMIBE

  39. Common Lipid Treatment Options • Simvastatin 40mg used as standard for secondary prevention and diabetes: -lipid profile not to target Options : • Atorvastatin 40mg • Simvastatin /Ezetemibe combination • Rosuvastatin 10mg .

  40. JBS 2 -Summary • Consistent multidisciplinary approach • Focus equally on people with: • established CVD • people with diabetes • high risk ≥ 20% • Reduce the risk of recurrent disease and increase life expectancy • Reflect growing scientific evidence base for managing high risk patients • Lower is Better

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