Understanding new international guidelines to tackle CV Risk: A practical model John Deanfield, MD UCL, London United Kingdom s

Transcription

1 Understanding new international guidelines to tackle CV Risk: A practical model John Deanfield, MD UCL, London United Kingdom s Ho Chi Minh City, Vietnam August 7, 2014

2 JBS 2 Risk Guidelines (2005) Based on Short term (10yr) Absolute Risk Treat risk not risk factors Focus on highest 10 year risk But things have changed!

3 Recent CV Guidelines USA: November 2013 UK: February 2014

4 November 2013 ACC/AHA Guidelines Treat risk not Risk factors No lipid targets Only consider RCT evidence Target 4 groups - Established CVD - Diabetes - FH -10 yr CV risk > 7.5%

5 Moderate-Intensity Statin Therapy Elderly black man 79yr of age Total cholesterol HDL cholesterol Recommended 150 mg/dl 40 mg/dl 120 mmhg Systolic blood pressure Not taking antihypertensive medication Not diabetic Nonsmoker Calculated 10-yr risk of CHD or stroke 13.7% Comment: Patient qualifies because he has a 10-yr risk of >7.5% but is >75 yr of age. Kearney NEJM 2014; 370:

6 New Cholesterol Guidelines to a Population-Based Sample 56 million people Pencina NEJM 2014; 370:

7 ESC CV Prevention Guidelines 2012 European Heart Journal 2012; 33: Disenfranchises the young, especially women!

8 Statin Therapy Not Recommended White woman with hyperlipidemia and hypertension 46yr of age Total cholesterol 230 mg/dl HDL cholesterol 55 mg/dl Systolic blood pressure 150 mmhg Taking antihypertensive medication Not diabetic Nonsmoker Calculated 10-yr risk of CHD or stroke 2.0% Comment: Total cholesterol is high and blood pressure is not controlled, but patient has no other risk factors. Kearney NEJM 2014; 370:

9 Short Term v. Lifetime Risk in USA Non-smoking men <45yrs All women <65yrs <10% 10yr CHD Risk Marma Circ 2009;120: % of US adults (87,000,000) have low (<10%) 10yr and high lifetime ( 39%) risk Marma Circ Cardiothoracic Qual Outcomes 2010;3:8-14

10 Young Man comes to your Clinic at 25 years 25 yrs 40yrs 58yrs TC Waiting 310 for mg/dl dyslipidemic 310 mg/dl 310 mg/dl HDL 50 mg/dl 50 mg/dl 50 mg/dl TG 400 mg/dl 400 mg/dl 400 mg/dl LDL before starting 180 mg/dl 180 therapy mg/dl 180 is mg/dl a FH of CVD BMI 25 kg/m 2 25 kg/m 2 25 kg/m 2 patients to reach middle age failure of prevention Hazen yr risk 3.1% 7.5%

11 Joint British Societies (JBS)3: March 26th 2014 Early intervention pays long term dividends Investing in Your Arteries!

12 JBS3 : What s different? Investing in Your Arteries Personalised, lifetime approach to CVD prevention New CVD risk calculator with understandable risk metrics linked to interventions.demonstrate the potential for benefit on a person s risk over their Empower lifetime. individuals to take control of their Provides CV risk management guidance for the CVD health by promoting lifestyle changes, whole range of not people. just drugs Heart March 2014 and

13 JBS3 CVD Risk Approach Established CVD or Familial Hypercholesterolaemia Diabetes age >40 years Chronic Kidney Disease Use JBS3 risk calculator NO YES Lifestyle and drug therapy as recommended in JBS3 10 year CVD risk score BELOW current NICE threshold* Examine JBS3 lifetime metrics Heart age Projected CVD risk To inform discussion on risk modification by: Lifestyle changes Drug therapy when indicated ABOVE current NICE threshold*: Lifestyle + Drug therapy *Current NICE Guidance Ongoing research on implementation and impact of JBS3 recommendations and risk calculator

14 JBS3 CVD Risk Calculator 35 year old female: adverse risk factors Heart March 2014 and

15 Heart March 2014 and

16 JBS3 : Start of a new Process Changes interactions in primary care Personalised approach Empowers lifestyle Not just a statin conversation! Implementation and Evaluation challenges!

17 JBS3: Patient Pull Patient friendly app Send programme with individual data

18 Next Steps: Formal Evaluation in Primary care Health Checks JBS3 Understanding Behaviour Risk factors CV events

19 Lifetime CVD Risk Management JBS3 platform applicable to other NCDs such as dementia which share risk factors

20 BP ( ) Gottesman JAMA Neurol 2014; 1646: E1-10

21 CV disease is preventable Life-long Rx likely to be cost-effective and often cost saving Circulation 2011;124:

22 Joint British Societies (JBS)3: March 26th 2014 Management of High short term Risk Strategy to communicate CV risk to rest of us as well as opportunities for lifetime benefit