Prof. Jaakko Tuomilehto Department of Public Health University of Helsinki,

1. Prof. Jaakko Tuomilehto Department of Public Health University of Helsinki, Department of Epidemiology and Health Promotion National Public Health Institute Helsinki, Finland; Donau-Universität Krems, Krems, Austria; Chair, Working Group on Epidemiology and Prevention European Society of Cardiology

2. DEVELOPED COUNTRIES Deaths in 2001 attributable to 15 leading causes 98% of all deaths attributable to 15 leading causes Source: WHR 2002 Number of deaths (000s)

3. DEVELOPED COUNTRIES Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s)

4. CVD PREVENTION WORKS Start of the North Karelia Project Nationwide activity Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35-64 years from 1969 to 2001 Mortality per 100 000 population

6. CVD PREVENTION WORKS • Japan: reduction of salt intake resulting in lower blood pressure levels and drastically reduced stroke mortality. • Singapore:national programme associated with decline in NCD trends. • Mauritius: changing cooking oil from palm to soy bean oil resulted in a 15% decrease in serum cholesterol in the population. • Poland:sudden change in dietary fats, related to political changes - resulted in a 20% decline in heart disease mortality.

7. Serum cholesterol Men 30-59 years mmol/l mmol/l

8. Diastolic Blood PressureWomen 30-59 Years mmHg

9. Smoking PrevalenceMen 30-59 Years %

10. Body-Mass IndexMen 30-59 Years Kg/m2

11. Prevalence of HYPERGLYCEMIA in European people aged 30 - 92 years - DECODE • Previously known diabetes: 4.9% • Isolated fasting hyperglycemia: 2.1% • Isolated post-challenge hyperglycemia: 1.7% • Combined hyperglycemia: 1.6% • Impaired glucose tolerance (IGT) 11.9% • TOTAL HYPERGLYCEMIA 22.2% DECODE Study Group. Lancet 1999;354:617–621

13. 1994 FirstJoint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention 1995-96EUROASPIRE I 1998 Second Joint Task Force Recommendations 1999-2000 EUROASPIRE II 2000 Joint European Societies CVD Prevention Committee 2003 Third Joint Task Force Guidelines

14. European Guidelines on Cardiovascular Disease Prevention in Clinical PracticeThe Third Joint Task Force European International European European Association Diabetes Society of Society of for the Study Federation General Hypertension Diabetes Europe Practice/Family Medicine International European European European Society of Society of Heart Society of Behavioural Atherosclerosis Network Cardiology Medicine

15. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice What is new in these guidelines? • From CHD to CVD prevention • A new risk estimation model: SCORE • Update / adaptations of • Priorities • Goals • Management aspects

16. Task force risk chart Based on Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83(1):356-62

17. Problems with the existing chart • Based on the Framingham function which overpredicts in European populations with low or medium levels of disease incidence Thomsen et al. Int J Epidemiology, 2002, In press

18. Problems with the existing chart • Derived from a relatively small data set; few or no events in some risk factor combinations • Difficult to accommodate other risk factors such as as HDL-cholesterol • Uses end points which cannot be reproduced from other data sets; therefore hard to validate • Probably underestimates the importance of diabetes

19. SCORE The SCORE ProjectThe Systematic COronary Risk Evaluation Project Started in 1998under the auspices of The European Society of Cardiology Conducted and supported by: • Royal College of Surgeons in Ireland • EU BIOMED II programme Contract BMH4-98-3186 • National funding agencies of the component studies

20. SCORE SCORE objectives To assemble databases representative of typical European populations to assess the accuracy of the existing European risk system. To prepare a risk score system or systems which are optimised for coronary prevention in European clinical practice.

21. SCORE The SCORE database 12 European cohort studies • Mainly population studies • Some with multiple component cohorts In round figures: • A quarter of a million persons • 3 million person-years of observation • Over 7,000 fatal cardiovascular events

22. SCORE Key differences • Total fatal cardiovascular risk rather than just CHD • Fatal events rather than total events • Charts for cholesterol and cholesterol:HDL ratio • New chart shows more detail in 50-65 age range • No charts for those with established disease or diabetes

25. Current prediction CHD Includes nonfatal events Uses idiosyncratic definition Not possible to break down risk into angina and MI Over-predicts in low/medium-risk regions ”One size fits all” SCORE prediction CVD (but can do CHD) Restricted to fatal events Uses common definition Component risks can be calculated Separate prediction for low risk regions Can be customised using national mortality statistics SCORE Better than current chart – or simply different?

26. Priorities of Cardiovascular Disease Prevention in Clinical Practice • Patients with established coronary heart disease, peripheral • artery disease and cerebrovascular atherosclerotic disease • Asymptomatic individuals who are at high risk of developing • atherosclerotic cardiovascular disease because of: • Multiple risk factors resulting in a 10 year risk of > 5% now (or if extrapolated to age 60) for developing a fatal cardiovascular event. • Markedly raised levels of single risk factors: cholesterol > 8 mmol/l (320 mg/dl), LDL chol > 6 mmol/l (240 mg/dl), blood pressure > 180/110 mmHg • Diabetes Type 2 and diabetes Type 1 with microalbuminuria • Close relatives (first degree relatives) of • Patients with early-onset atherosclerotic cardiovascular disease • Asymptomatic individuals at particularly high risk • Other individuals met in connection with ordinary clinical practice

27. Using the cardiovascular risk chart

28. Using the cardiovascular risk chart Qualifiers Note that total CVD risk may be higher than indicated in the chart: -    as the person approaches the next age category. -    in asymptomatic subjects with pre-clinical evidence of atherosclerosis (e.g. CT scan, ultrasonography) -    in subjects with a strong family history of premature CVD -    in subjects with low HDL cholesterol levels, with raised triglyceride levels, with impaired glucose tolerance, and with raised levels of C-reactive protein, fibrinogen, homocysteine, apolipoprotein B or Lp(a). -    in obese and sedentary subjects

29. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice Management of risk in clinical practice • Behavioural changes • Dietary changes • Smoking cessation • Physical activity • Control of arterial hypertension • Management of dyslipidemias • Management of diabetes • Prevention in subjects with the metabolic syndrome • Prophylactic drug therapy

30. How to achieve intensive lifestyle change in patients withdisease and in high riskpeople? Strategies to make behavioural counselling more effective include: • Develop a therapeutic alliance with the patient • Gain commitments from the patient to achieve lifestyle change • Ensure the patient understands the relationship between lifestyle and disease • Help the patient overcome barriers to lifestyle change • Involve the patient in identifying the risk factor(s) to change • Design a lifestyle modification plan • Use strategies to reinforce the patient’s own capacity to change • Monitor progress of lifestyle change through follow-up contacts • Involve other health care staff wherever possible.

31. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice Management of risk in clinical practice • Behavioural changes • Dietary changes • Smoking cessation • Physical activity • Control of arterial hypertension • Management of dyslipidemias • Management of diabetes • Prevention in subjects with the metabolic syndrome • Prophylactic drug therapy

32. Goals: < 140/90 mmHg in all high risk subjects < 130/80 mmHg in patients with diabetes

34. Goals for CVD prevention in patients with type 2 diabetes

35. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice Where to find more? • Executive summary Eur Heart J 2003;24:1601-1610 Eur J Cardiovasc Prevention & Rehab 2003; 10(4):S1-S11 • Pocket version • Full document soon on the ESC web published later in 2003 EJCPR