PREVENTION OF CARDIOVASCULAR DISEASES (CVD)

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1 PREVENTION OF CARDIOVASCULAR DISEASES (CVD)

2 SIGNIFICANCE OF NON-COMMUNICABLE DISEASES Non-communicable diseases were responsible for 2/3 of all deathsglobally in 2011, up from 60% in High-income countries have the highest proportion 87% of all deaths were caused by NCDs followed by upper-middle income countries (81%). Cardiovascular diseases alone killed nearly 2 million more people in 2011 than in the year CVDsremainthemajor cause of premature death in Europe, It is estimated that >80% of all CVD mortality nowoccursin developing countries.

5 CVD causes mass disability: SIGNIFICANCE OF CVDs within the coming decades thedisability-adjusted life years (DALYs) estimate is expected to risefrom a loss of 85 million DALYs in 1990 to a loss of 150million DALYsglobally in 2020, remaining the leadingsomatic cause of loss of productivity.

Burdenof disease DALY DALYs = Disability Adjusted Life Years The sum of years of potential life lost due to prematuremortality and the years of productive life lost due to disability.

6 Burdenof disease DALY DALYs = Disability Adjusted Life Years The sum of years of potential life lost due to prematuremortality and the years of productive life lost due to disability. DALY measures: deaths at different ages disability 1DALY=one lost year of healthy life. Burdenof disease = measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability.

7 TYPES OF CVD Ischemic originated Cerebrovascular originated Peripheral vascular diseases Infectious originated diseases Heart insufficiencies Cardiomyopathies Congenital heart diseases

9 SIGNIFICANCE OF CVDs CVD is strongly connected to lifestyle, tobacco, unhealthy diet habits, physical inactivity, and psychosocialstress. The (WHO) has stated that: over three-quarters of all CVD mortality may be preventedwithadequate changes in lifestyle. CVD prevention majorchallenge for the general population, politicians, and healthcareworkers, defined as a coordinated set of actions, at public and individual level, The basesof prevention are rooted in cardiovascular epidemiology and evidence-based medicine.

10 Levelof evidence

11 Whyis preventionof CVDsneeded? Atherosclerotic CVD, especially CHD, remains the leading cause of premature death worldwide. CVD affectsboth men and women; of all deaths that occurbefore the age of 75 years in Europe, 42% are due to CVD inwomen and 38% in men. CVD mortality is changing, with declining age-standardized ratesin most European countries, which remain high in Eastern Europe. Prevention works: >50% of the reductions seen in CHD mortalityrelate to changes in risk factors, and 40% to improved treatments. Preventive efforts should be lifelong, from birth (if not before) to old age. Population and high-risk preventive strategies should be complementary;an approach limited to high-risk persons will be less effective; population education programmes are still needed. Despitegaps in our understanding, there is evidencetojustify intensive public health and individual preventive efforts. There is still substantial room for improvement in risk factorcontrol, even in individuals at very high risk.

12 Cardiovascularrisk The likelihood of a person developing an atherosclerotic cardiovascular event over a defined time period. Howtoadviseyoungerpersons at low absolute but high relative risk? Cliniciansoften ask for threshold values at which totrigger an intervention, this is problematic since risk is a continuumand there is no exact point above which, for example, a drug isautomatically indicated, nor below which lifestyle advice may notusefullybe offered. Total risk: an estimate of risk made by considering theeffect of the major factors: age, gender, smoking, BP, and lipid levels.

13 Relationship between total cholesterol/hdl cholesterol ratio and 10-year fatal CVD events in men and women aged 60 years with and without risk factors

14 Riskestimation It is recommended that risk factorscreening including the lipid profile may be considered in adultmen >40 years old and in women >50 years of age orpost-menopausal. Total risk assessment be offered during a consultation if: The person asks for it. One or more risk factors such as smoking, overweight, or hyperlipidaemia are known. There is a family history of premature CVD or of major riskfactorssuchas hyperlipidaemia. There are symptoms suggestive of CVD. The SCORE system estimates the 10-year risk of a first fatal atherosclerotic event, whether heart attack, stroke, aneurysm of the aorta, or other.

15 High CVD risk SCORE chart: 10-year risk of fatal cardiovascular disease (CVD) in countries at Low CVD risk

16 SCORE charts

18 Riskfactors Non-modifiable Age Gender Genetics Modifiable Smoking Unhealthy nutrition Lack of physical activity Overweight, obesity Alcohol Other diseases Psychosocial factors Biomarkers

19 Riskfactors Non-modifiable Genetics heritability of many cardiovascular risk factors. Familial prevalence of atherosclerotic disease or of major riskfactors (high BP, diabetes mellitus, hyperlipidaemia) should be systematically sought in the first-degree relatives of any patientaffected before 55 years in men and 65 years in women. Ageand gender biggest cause of death in women. The lower rates of CHD in women but not of stroke may be interpreted as a protective effect of endogenous oestrogens.

Riskfactors Modifiable Psychosocial factors Low socio-economic status(low educational level, low income, holding a low-status job, or living in

20 Riskfactors Modifiable Psychosocial factors Low socio-economic status(low educational level, low income, holding a low-status job, or living in a poor residential area) lack of social support, stress atwork and in family life, depression, anxiety, hostility, type D personality(distressed)

21 Riskfactors Modifiable Biomarkers Inflammatory biomarkers: high-sensitivity CRP, homocystein Thrombotic biomarkers: fibrinogen, lipoprotein-associated phospholipase(lppla2) Other diseases with increased CVD risk Chronic kidney disease(hypertension, dyslipidaemia, DM) Obstructive sleep apnoea Autoimmune diseases(psoriasis, rheumatiod arthritis, SLE) Periodontitis

22 Preventionof CVDs

Transtheoretical model of behavior change(stages of changes) CVD Prevention Evidence has confirmed cognitivebehaviouralstrategies to beessential components of interventions

23 Transtheoretical model of behavior change(stages of changes) CVD Prevention Evidence has confirmed cognitivebehaviouralstrategies to beessential components of interventions targeting lifestyle change. Individualsof lowses, of older age, or female gender may need tailored programmesin order to meet their specific needs regarding informationand emotional support.

24 Smoking cessation Minimal Intervention 5As

25 Healthy nutrition

26 Physicalactivity Intensity and volume moderate-intensity physical activity or aerobic exercisetraining from 2.5 to 5 h/week; vigorous-intensity physical activity/aerobic exercise training1 1.5 h/week not only sport-related activities, but also lifestyle-commonactivities(walking briskly, climbing stairs, doing more housework andgardening work, and engaging in active recreational pursuits).

27 Body weight

28 Body weight The WHO thresholds for waist circumference accepted in Europe: Action level 1 waist circumference 94 cm in men and 80 cm in women represents no further weight should be gained. Action level 2 waist circumference 102 cm in men and 88 cm in women represents weight reduction should be advised.

29 Highbloodpressure

30 High Blood Pressure management Source: 2003 ESH/ESC Hypertension Guidelines. Journal of Hypertension 2003, Vol 21 No 10. DASH diet (Dietary Approaches to Stop Hypertension)

31 Preventionstrategies Weight reduction in overweight and obese people is recommended as this is associated withfavourableeffects on blood pressure and dyslipidaemia, which may lead to less CVD. Healthy adults of all ages have to spend hours a week on physical activity of at leastmoderate intensity, or hours a week on vigorous intense exercise. Sedentary subjects shouldbe strongly encouraged to start light-intensity exercise programmes. Patients with previous CVDsshould undergo moderate-to-vigorous intensity aerobic exercise training 3 times a week and 30 min per session. Multimodal behaviouralinterventions, integrating health education, physical exercise andpsychological therapy for psychosocial risk factors and coping with illness, should be prescribed.

32 Managingriskfactors Lifestyle measures such as weight control, increased physical activity, alcohol moderation,sodium restriction, and increased consumption of fruits, vegetables, and low-fat dairy productsare recommended in all patients with hypertension and in individuals with high normal blood pressure. All major antihypertensive drug classes(i.e. diuretics, ACE inhibitors, calcium antagonists, angiotensinreceptor antagonists and beta-blockers) do not differ significantly in their bloodpressure-lowering efficacy and thus should be recommended for the initiation and maintenance of antihypertensive treatment. In patients with grade 1 or 2 hypertension and at moderate total cardiovascular risk, drugtreatment may be delayed for several weeks, and in grade 1 hypertensive patients without anyother risk factor, for several months while trying lifestyle measures. Drug treatment is recommended to be initiated promptly in patients with grade 3 hypertension,as well as in patients with grade 1 or 2 hypertension who are at high or very high total cardiovascular risk. Systolic blood pressure should be lowered to <140 mmhg (and diastolic blood pressure <90 mmhg) in all hypertensive patients.

33 Managingriskfactors The target HbA1c for the prevention of CVD in diabetes of <7.0% (<53 mmol/mol) is recommended. In patients at very high CVD risk, the recommended LDL cholesterol target is <1.8 mmol/l(<~70 mg/dl) or a 50% LDL-cholesterol reduction when the target level cannot be reached. In patients at high CVD risk, a LDL-cholesterol goal <2.5 mmol/l (<~100 mg/dl) is recommended. The recommended target levels are <5 mmol/l (<~190 mg/dl) for total plasma cholesterol and <3 mmol/l (<~115 mg/dl) for LDL cholesterol for subjects at low or moderate risk.

34 Secondarypreventionof CVD Blood pressure measurement Anthropometric meausrements Ankle-brachialBP index (ABI < 0.9 PAD) Ophthalmoscopy (Exercise ECG Carotid ultrasound Echocardiography Radionuclide scintigraphy)

35 Ankle/brachialindex (ABI) An ABI <0.9 indicates 50% stenosis between the aorta andthedistalleg arteries. Over 50 % stenosis: sensitivity ~90% specificity ~98% Hiatt WR. N Engl J Med. 2001;344(21):

36 Where should CVD prevention be offered? Actions to prevent CVD should be incorporated into everyone s daily lives, starting in early childhood and continuing throughout adulthood and senescence. Risk factor screening including the lipid profile may be considered in adult men 40 years oldand in women 50 years of age or postmenopausal. The physician in general practice is the key person to initiate, coordinate and provide longterm follow-up for CVD prevention. Nurse-coordinated prevention programmes should be well integrated into healthcare systems. The practisingcardiologistshould be the advisor if there is uncertainty over the use of preventive medication or when usual preventive options are difficult to apply. All patients with CVD must be discharged from hospital with clear guideline-orientated treatment recommendations to minimize adverse events. All patients requiring hospitalization or invasive intervention after an acute coronary syndromeshould participate in a cardiac rehabilitation programmeto improve prognosis by modifying lifestyle habits and increasing treatment adherence. Non-governmental organisationsare important partners to health care workers in promoting preventive cardiology.

37 PerkJ. et al.: European Guidelines on cardiovascular diseasepreventioninclinicalpractice(version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in ClinicalPractice (constituted by representatives of nine societiesand byinvitedexperts). European Heart Journal (2012) 33,

2016 EUROPEAN GUIDELINES ON CVD PREVENTION IN CLINICAL PRACTICE

2016 EUROPEAN GUIDELINES ON CVD PREVENTION IN CLINICAL PRACTICE Massimo F Piepoli, MD, PhD, FESC, Piacenza, Italy on behalf of the 6 th Joint Task Force 2 3 Guidelines still based upon the principles of