Cardiovascular disease - from management to prevention

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2 Cardiovascular disease - from management to prevention Reflections originating from the Fourth Joint European Societies Task Force on Cardiovascular Disease Prevention in Clinical Practice 2007 WHAT IS NEW? Lars Rydén Karolinska Institutet Stockholm, Sweden

3 Bringing knowledge, experience and practice together Research Guidelines Surveys Education

4 A product of joint efforts Fourth Joint Task Force

5 A product of long standing traditions 1994 First Joint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention EUROASPIRE I 1998 Second Joint Task Force Recommendations EUROASPIRE II 2000 Joint European Societies CVD Prevention Committe 2003 Third Joint Task Force Recommendations Joint European Societies CVD Prevention Committe EUROASPIRE III 2007 Fourth Joint Task Force Recommendations 2008 European Summit on CVD prevention

6 Guideöiens iens for cardiovascular disease prevention The importance of availability

7 Total cardiovascular risk Treatment vs. prevention Proportion in the population Population distribution of cardiovascular risk Low Covers most of those who will fall ill High Covers few with high risk to fall ill year risk

8 Bringing knowledge, experience and practice together EUROASPIRE I - III n Age <70 years Established CAD Aspirin Beta blockers ACE/ARB Lipid lowering Smoking Obesity >30 kg/m 2 High BP Cholesterol > 5 mmol/l EUROASPIRE I - III

The fourth joint Task Force Chair Ian Graham [ESC] Dan Atar [ESC] Knut Borch-Johnson [EASD/IDF] Gudrun Boysen [EUSI] Gunilla Burrell [ISBM] Renata Cifkova [ESH] Jean Dallongeville Guy de Backer [ESC]

9 The fourth joint Task Force Chair Ian Graham [ESC] Dan Atar [ESC] Knut Borch-Johnson [EASD/IDF] Gudrun Boysen [EUSI] Gunilla Burrell [ISBM] Renata Cifkova [ESH] Jean Dallongeville Guy de Backer [ESC] Shah Ebrahim [ESC] Björn Gjelsvik [ESGP/FM/Wonca] Christoff Hermann-Lingen [ISBM] Arno W Hoes [ESGP/FM/Wonca] Steve Humpries [ESC] Mike Knapton [EHN] Joep Perk [EACPR] Sylvia G Priori [ESC] Kalevi Pyörälä [ESC] Zeljko Reiner [EAS] Luis Ruilope [ESC] Susana Sans-Mendes [ESC] Wilma Scholte Op Reimer [ESC CV Nursing] Peter Weissberg [EHN] David Wood [ESC] John Yarnell [EACPR] Jose Luis Zamarano [ESC/CPG]

10 Executive Summary Europ Heart J 2007; 28: Executive summary

11 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

12 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Cardiovascular prevention in 2007 Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

13 News in summary Increased input from GP:s and nursing Increased emphasis on lifestyle, exercise, weight, behaviour change and psychosocial factors More discussion on limitations with present evidence grading Re-defined priorities and objectives Revised approach to risk in the young More information from SCORE on total events, diabetes, HDL cholesterol, and body mass index (BMI) New sections on gender, heart rate, BMI/waist circumference, other manifestations of CVD including stroke and renal impairment

14 Four reasons for CVD-prevention in clinical practice 1 CVD major cause of premature death important cause of disability behind escalating costs 2 Atherosclerosis develops from young age already advanced when symptomatic 3 Death often sudden therapeutic interventions then inapplicable 4 Relates to modifiable factors

15 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Cardiovascular prevention in 2007 Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

16 People that stay healthy have certain characteristics 0 smoking 3 km of daily walking 5If high risk portions of fruit & vegetables/day <140/90 130/80 mm Hg blood pressure < mmol/l total cholesterol < mmol/l LDL-cholesterol 0 diabetes European phone number to health

17 Priorities for CVD prevention in clinical practice 1 Patients with established atherosclerotic CVD 2 Asymptomatic individuals at increased risk of CVD Multiple risk factors resulting in raised total CVD risk ( 5% 10-year risk of CVD death) Diabetes type 2 and type 1 with microalbuminuria Markedly increased single risk factors especially if associated with end-organ damage 3 Close relatives of subjects with premature CVD or at particularly high risk

18 What are the objectives with CVD prevention 1 To assist people at low risk of CVD to maintain this state lifelong and help those at increased risk to reduce it 2 To achieve the healthy characteristics No smoking Healthy food choices Physical activity: 30 min of moderate activity/day BMI <25 kg/m 2 + avoidance of central obesity BP <140/90 mmhg Total cholesterol <5 mmol/l LDL cholesterol <3 mmol/l Blood glucose <6mmo/L

19 What are the objectives with CVD prevention 3 To achieve rigorous risk factor control in high risk subjects, especially in known CVD or diabetes Blood pressure under 130/80 mmhg if feasible Total cholesterol <4.5 mmol/l; option <4 mmol/l LDL cholesterol <2.5 mmol/l; option <2mmol/L Fasting blood glucose <6 mmol/l and HbA1c <6.5% 4 To consider cardioprotective drug therapy in high risk subjects especially those with atherosclerotic CVD

20 Why stress assessment of total CVD risk Usually multiple risk factors behind atherosclerosis causing CVD These risk factors interact, sometimes multiplicatively The aim is to reduce total risk If a target cannot be reached with one risk factor, total risk can still be reduced by trying harder with other

21 Sex Cardiovascular prevention in 2007 Impact of combinations of risk factors on 10 year risk of CVD Age years Chol mmol/l BP mm Hg Smoking Risk F No 2 F Yes 5 M No 8 M Yes 21 %

22 10 yr risk of fatal CVD (%) Cardiovascular prevention in 2007 Impact of combinations of risk factors 10 year risk for fatal CVD according to SCORE TC/HDL ratio Men, smoking SBP 160 mm Hg Women, smoking SBP 160 mm Hg Men, non-smoking SBP 120 mm Hg Women, non-smoking SBP 120 mm Hg

23 How do I assess CVD risk quickly and easily? Those with known CVD type 2 diabetes or type 1 diabetes with microalbuminuria very high levels of individual risk factors are already already at increased at increased CVD CVD risk risk and and need management of all risk factors all For other all other people, people, the SCORE the SCORE risk charts.. risk can be used to estimate total risk critically important since many people have mildly raised levels of several risk factors that, in combination, can result in unexpectedly high levels of total CVD risk

24 Ten year risk of fatal CVD in Ten year risk of fatal CVD in high risk European regions low risk European regions

25 Risk estimation using SCORE qualifiers To be used with knowledge and judgement Risk overestimated with a falling and underestimated if rising CVD mortality Risk appears lower for women than men. This is misleading - charts show that their risk is deferred by 10 years Risk may be higher than indicated in the chart in The sedentary or obese With a strong family history The socially deprived Diabetes - risk x 4-5 in women and x 3 in men

26 Relative risk chart For younger persons who despite a low total risk may have a several times higher risk in relation to others in the same age group

27 Heart Score - webbased

28 Total risk management a key message Management of individual components of risk such as smoking, diet, exercise, blood pressure and lipids impacts on total risk Thus, if perfect control of one risk factor is difficult (ex. blood pressure control in the elderly) total CVD risk can still be reduced by improving other risk factors such as smoking or blood cholesterol

29 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

30 Managing total risk lipids Treatment goals not defined for HDL cholesterol and triglycerides They are still markers of increased risk Levels should be HDL cholesterol <1.0 mmol/l for men and <1.2 mmol/l for women and Fasting triglycerides >1.7 mmol/l

31 Managing total risk lipids Established CVD Diabetes mellitus Markedly raised lipids SCORE risk 5% SCORE risk < 5% 1. Dietary and exercise advice + attention to all risk factors 2. Reduce total cholesterol to < mmol/l LDL-cholesterol to < mmol/l Often requires statin. 3. Some recommend statins for all CVD and most diabetic patients Lifestyle advice for 3 months, then reassess SCORE and fasting lipids SCORE risk still 5% Chol <5 LDL <3 Score <5% Lifestyle advice chol <5 LDL <3 Follow up

32 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

Treatment targets for patients with diabetes Lifestyle modification Smoking cessation BP Structured education Obligatory <130/80 mm Hg Renal dysf <125/75 HbA1c (DCCT standard) 6.

33 Treatment targets for patients with diabetes Lifestyle modification Smoking cessation BP Structured education Obligatory <130/80 mm Hg Renal dysf <125/75 HbA1c (DCCT standard) 6.5% Venous plasma glucose mmol/l mg/dl Fasting < Post-prandial < Cholesterol < LDL <1.8 (2.0) 70 (<80) HDL male >1.0; female >1.2 40; 76 Triglycerides <

34 Central obesity and risk (Grundy et al. 2004, Vasudevan AR. et al. 2005)

35 The metabolic syndrome The term metabolic syndrome refers to a clustering of factors that increase CVD risk central obesity, hypertension, low HDL, raised triglycerides and increased blood glucose If one component is identified a search for and managing of the others is indicated In such patients physical activity and weight control radically reduces the risk for diabetes

36 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

especially for drugs, is hampered by under-representation of women in clinical trials Women are disadvantaged since they are less

37 CVD in women More women (55%) die of CVD than men (45%) particularly of stroke. Cf 3% breast cancer deaths in women. The lower risk in women in SCORE reflects that they develop CVD 10 years later than men Evidence base for risk factor advice, especially for drugs, is hampered by under-representation of women in clinical trials Women are disadvantaged since they are less likely to be offered risk assessment, chest pain evaluation, therapy and interventions Mortality from acute coronary syndromes and after CABG is frequently higher in women

38 1. Introduction 2. Scope of the problem 3. Prevention strategies and policies 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids Contents 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drugs 20. Implementation strategies

39 Some things that would simplify CVD prevention Simple, clear and credible guidelines Sufficient time for preventive work Helpful government policies defined prevention strategies resources, incentives including remuneration Educational policies that facilitate patient adherence to advice

W H Auden 1907-1973 Cardiovascular prevention in 2007 Some words outlining the ideal doctor Give me a doctor partridge plump, short in the leg and broad in the rump, an

40 W H Auden Cardiovascular prevention in 2007 Some words outlining the ideal doctor Give me a doctor partridge plump, short in the leg and broad in the rump, an endomorph with gentle hands, who ll never make absurd demands that I abandon all my vices, or pull a long face in a crisis, but with a twinkle in his eye, will tell me that I have to die

41 Cardiovascular disease - from management to prevention Time for question!!!

European Guidelines on CVD Prevention Fourth Joint European Societies Task Force on cardiovascular disease prevention in clinical practice

European Guidelines on CVD Prevention Fourth Joint European Societies Task Force on cardiovascular disease prevention in clinical practice September 2007 1 Recent developments in CVD prevention in Europe