Why bother about CVD in 1°care?

2. CVD prevention & management: a new approach for primary careRod JacksonSchool of Population HealthUniversity of AucklandNew Zealand

3. Why bother about CVD in 1°care? In a population of 10,000 primary care patients, every year there are about: • 10 coronary & stroke deaths • 1 diabetic death • 1 breast cancer death • 1 prostate cancer death • 1 suicide every year • 1 road traffic death • (1 cervical cancer death every 5 years) NZHIS annual mortality statistics

4. Blood pressure and CHD Law & Wald BMJ 2002;324:1570-6

5. PSC.

6. Reduction in stroke with combination BP lowering therapy in PROGRESS, regardless of baseline BP

7. There is no such thing as hypertension

8. CHD and SBP or Total cholesterol Blood pressure Cholesterol 4.0 4.0 2.0 Risk of coronary disease 2.0 “Hyperchol-esterolaemia” 1.0 “Hyper-tension” 1.0 0.5 0.5 110 120 130 140 150 160 170 4.0 5.0 6.0 7.0 8.0 Systolic blood pressure (mmHg) Total cholesterol (mmol/l)

9. Reduction in CV events with cholesterol lowering in Heart Protection Study, regardless of baseline cholesterol

10. There is no such thing as hypercholesterolaemia

11. Smoking and the risk of stroke Odds Ratio Source: Bonita, 1999

12. ‘Diabetes’ & body mass index

13. There is no such thing as obesity

14. Stroke, CHD, CVD & blood glucose Asia Pacific Cohort Studies Collaboration

15. HbA1c and microalbuminuria: Auckland, NZ excl. diagnosed diabetics Metcalf et al (unpublished)

16. There is no such thing as non-insulin dependant diabetes

17. Message Number 1:there is no such thing as hypertensionor hypercholesterolaemia or obesity or type 2 diabetes and we all have CHD

18. a new paradigm:‘risk factors’‘CVD risk factors interact’

19. Impact of multiple risk factors on CVD risk Jackson et al. Lancet 2005. 365:434-41

20. ‘The bigger the CVD risk the bigger the benefit’: trials of BP lowering & stroke Relative Effects Absolute Effects Absolute Reduction in strokes / 5 years Relative Reduction in strokes Few or no participants had a history of stroke 1.4% 34% Most or all participants had a history of stroke or TIA 25% 5.1% Treatment 0.5 1.0 1.5 0% 5% 10% 15% 20% Control Estimated 5 year stroke event rate Relative Risk and 95% CI

21. NZ threshold for CVD risk drugs 15% 5 yr risk

22. Message Number 2: Measure risk, not risk factors

23. Estimating clinical risk: • Framingham Heart Study • Sex • Age • Diabetes • Smoking • BP • TC • HDL • (LVH) Anderson et al. Am Heart J. 1991;121:293-8

24. Are lipid +/or BP-lowering drugs indicated? 60 yr old man BP 150/90 mmHg smoker TC 6.0 mmol/L HDLC 1.0 mmol/L No ‘diabetes’ 45 yr old man BP 150/90 mmHg non smoker TC 6.0 mmol/L HDLC 1.2 mmol/L new ‘diabetes’ 5 yr CVD risk ≈ 25% 5 yr CVD risk ≈ 10%

25. Clinical risk:short-term vs life-time?

26. Lifetime risk is clinically irrelevant The risk of death is 1 / person (100%) What’s clinically relevant is when it happens The lifetime CVD risk chart

27. Who should we treat? Everybody - because we all have CHD BUT the intensity of treatment should be directly proportional to the clinical risk and to the costs of treatment

28. Clinical risk treatment thresholds? $$$$$$$$$$$$$$$$$$$$$$$ At the clinical (absolute) risk that is affordable to individuals or populations Cheaper interventions should be initiated at lower risk levels

29. high risk threshold for high cost treatment risk threshold for low cost treatment Patient 1 Patient 3 Patient 2 Clinical CVD risk (% per yr) low 130 150 170 high SBP treatment threshold for equal Rx benefit

30. Treatment goals? Based on clinical risk and the ‘costs’ of lowering risk

31. high CVD risk target for treatment CVD risk threshold for drug treatment Patient 1 Patient 3 Patient 2 Clinical CVD risk (% per yr) low 115 130 135 150 155 170 high SBP target for equal Rx benefit

32. Message Number 3: Treat risk, not risk factors

33. The polypill Statin Aspirin metformin? Diuretic ± ACEI ± BB ± CCB

36. PREDICT: a clinical decision support system for CVD & diabetes risk assessment & management PREDICT is a computer programme that calculates CVD risk & provides E-B management recommendations

39. Workflow: Individual Patient Tracking (Please note – dates are not representative as this is a test case)

40. Sample Report –Group Data

41. Combining information on patients Patient populations All clinical data is made non-identifiable with encrypted NHI and sent via secure internet connection for analyses Stored anonymous CVD risk profiles Practice/PHO/DHB population needs assessment & service planning

42. Making new risk prediction charts Electronic medical record Enrolled population NHI NHI (encrypted) patient-specific outcomes: hospital admissions, deaths patient-specific CVD risk factor profiles

43. Making new prediction charts Electronic medical record Enrolled population NHI NHI (encrypted) patient-specific outcomes: hospital admissions, deaths patient-specific CVD risk factor profiles Link with encrypted NHI

44. Risk groups in first 30,878 patients from PREDICT

45. Results: estimated 5-year incidence of CVD event Mean est. 5-year incidence for Hx CVD is 28.4% (95%CI 26.3 to 30.4) For prior CVD 5-year risk is: 20 + 1.3*Framingham score

46. Results: events in risk groups in first 30,878 patients from PREDICT 47% 16% 26% 11% 63% of events occur in 21% of the people (high risk)

47. The potential magnitude of the population evidence base • One assessment per practitioner every other day for 46 weeks/year = 115 per year • A practitioner can assess all appropriate patients in less than 5 years • 1000 practitioners could assess more than 100,000 patients per year ‘one every other day is ok’

48. Message Number 4:The next revolution in medicine will be electronic, not genomic The future is already here, its just not widely distributed It will be led by primary care

50. metabolic syndrome: ‘metabollocks!’