Preventive Cardiology Scientific evidence

Transcription

1 Preventive Cardiology Scientific evidence Professor David A Wood Garfield Weston Professor of Cardiovascular Medicine International Centre for Circulatory Health Imperial College London

2 Primary prevention Traditional medical paradigm Hypertension Hyperlipidaemia Hyperglycaemia

3 Usual systolic blood pressure and risk of cardiovascular death in Asia and Australasia Asia Pacific Cohort Studies Collaboration. J Hypertension 2003; 21:

4 Usual cholesterol level and risk of CHD Asia Pacific Cohort Studies Collaboration. Int J Epidemiology 2003;32:

5 Usual fasting glucose and risk of CVD Asia Pacific Cohort Studies Collaboration. Diabetes Care 2004; 27:

6 Primary prevention New medical paradigm Total cardiovascular risk

7 Total risk factor approach to primary prevention

8 Impact of combinations of risk factors on 10 year risk of CVD death SEX AGE CHOL BP SMOKE RISK % F NO F YES M NO M YES

9 Impact of combinations of risk factors on 10 year risk of CVD death SEX AGE CHOL BP SMOKE RISK % F NO 2 F YES 5 M NO 8 M YES 21

10 Total risk factor approach to primary prevention

11 From SCORE to Same risk factors Same end-points Same colours The electronic interactive version of SCORE: developed by the Research Centre for Prevention and Health, Glostrup University, Denmark

12 Primary prevention New medical paradigm Reduce total cardiovascular risk

13 Relative risk estimates of CHD events and stroke for a blood pressure reduction of 10 mm Hg systolic and 5 mm Hg diastolic in the blood pressure difference trials and in epidemiological cohort studies Law MR et al. BMJ 2009; 338; b1665

14 Statins and primary prevention of CVD All cause mortality Brugts J J, et al BMJ 2009; 338:b2376

15 Cholesterol Trialists Collaboration 5-year absolute benefits in participants without CVD

16 Cancer

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18 Statins may cause loss of memory and depression Cholesterol-lowering pills taken by millions of Britons may cause memory loss and depression, researchers warn. They say not enough is known about the level of harm posed by statins, prescribed to prevent heart disease and strokes Daily Mail January 11 th 2011

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21 Potential hazards of statins have been highlighted in small studies and some, such as increased risk of cancer, can be discounted by the evidence from trials. However, even the more recent trials have not assessed potentially important side effects (e.g. possible cognitive impairments suggested by a small trial: Muldoon 2000)

22 Statins may cause loss of memory and depression Cholesterol-lowering pills taken by millions of Britons may cause memory loss and depression, researchers warn. They say not enough is known about the level of harm posed by statins, prescribed to prevent heart disease and strokes Daily Mail January 11 th 2011

23 Statins diabetes and major vascular events

24 Statins and elderly all cause mortality

25 Management Initiation of statin Up-titration of dose to achieve total and LDL-cholesterol target Adherence with therapy over the long term

26 LDL-C reduction and risk of AMI or revascularisation

27 Adherence to statin therapy Rasmussen J N JAMA 2007; 371:

28 Combination therapy (statin + fenofibrate) in type 2 diabetes ACCORD Study Group March 14th 2010 NEJM.org

29 Probability of events of non-fatal myocardial infarction with intensive glucose-lowering versus standard treatment Ray K et al. Lancet 2009; 373:

30 Aspirin and primary prevention Antithrombotic Trialists Collaboration Lancet 2009; 373:

31 Healthy lifestyle score in high risk patients and risk of CHD Chiuve S E, et al Circulation 2006; 114:

32 Healthy lifestyle score in high risk patients and risk of CHD Medication users Chiuve S E, et al Circulation 2006; 114:

33 Healthy lifestyle score, medication and risk of CHD Chiuve S E, et al Circulation 2006; 114:

34 Total Risk Management Lifestyle (diet, physical activity) all risk factors (blood pressure, lipids and glucose) and cardioprotective drug therapies.

35 Multifactorial intervention in type 2 diabetes The Steno 2 study 8 years of follow up Composite endpoint CV-death, MI or stroke, CABG or PCI, limb amputation or vascular surgery Gaede et al New Engl Med 2003; 348:383

36 Multifactorial intervention in type 2 diabetes The Steno 2 study 8 years of follow up Composite endpoint CV-death, MI or stroke, CABG or PCI, limb amputation or vascular surgery Impact of intensive therapy on OR 95% CI Cardiovascular disease Nephropathy Retinopathy Autonomic neuropathy Gaede et al New Engl Med 2003; 348:383

37 Modern Preventive Cardiology programme Lifestyle (smoking cessation, diet, physical activity) intervention Psycho-social factors Managing other risk factors (blood pressure, lipids and glucose) to target Adherence with cardioprotective drug therapies for life.

38 MSc Preventive Cardiology Imperial College London