Challenges of CVD Prevention in Primary Care

Transcription

1 Challenges of CVD Prevention in Primary Care Tim Stokes Department of General Practice & Rural Health Dunedin School of Medicine Overview Will current NZ guideline recommendations (2012) change? MoH 2017 Cardiovascular disease risk assessment consensus statement (ongoing) New NZ CVD risk equations (PREDICT) Three current international trends How might they impact on any new guidance? 1

2 New NZ CVD Risk Equations Current NZ guidance uses Framingham New PREDICT equation uses NZ data will the new equations change the way five-year combined cardiovascular event risk is stratified? current stratification will likely remain the same old equation overestimates risk BUT old treatment thresholds higher than other national international guidance 2

3 New NZ CVD Risk Equations Current NZ guidance uses Framingham New PREDICT equation uses NZ data Will the whole population need to be reassessed? No! (phew.) Current risk assessments are still valid those at high risk are likely to remain at high risk current recommended treatment thresholds are also relatively conservative. Current international trends 3

4 Trend 1: CVD risk treatment threshold: how low do you go! NICE UK 2008 and 2014 Statin threshold for PRIMARY PREVENTION dropped from 20% to 10% 10 year risk of CVD Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD. [new 2014] Trend 1: CVD risk treatment threshold: how low do you go! NICE UK 2008 and 2014 Statin threshold for PRIMARY PREVENTION dropped from 20% to 10% 10 year risk of CVD Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD. [new 2014] USPSTF 2016» moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater 4

5 Trend 2: Changing the way we measure a key risk factor: BP Clinic BP measuring (manual/automated) Subject to considerable error and variation BUT: used to calculate absolute CVD risk Trend 2: Changing the way we measure a key risk factor: BP Clinic BP measuring (manual/automated) Subject to considerable error and variation BUT: used to calculate CVD risk Increasing use of 24-hour ABPM and HBPM: For both assessment/diagnosis AND monitoring if on treatment Australian HF HT guideline (2016) If clinic BP is >= 140/90 or HT is suspected, use ABPM and/or HBPM to confirm diagnosis 5

6 Trend 3: reframing success in the primary prevention of CVD Communicating CVD risk to patients Shared Decision Making What counts as a success? Is it: % of patients in your practice on a statin if 10 / 5 year CVD risk greater than 20% 10%.? UK QOF

7 Trend 3: reframing success in the primary prevention of CVD Communicating CVD risk to patients Shared Decision Making What counts as a success? Is it: % of patients in your practice on a statin if 10 / 5year CVD risk greater than 20%.10%. OR IS IT: % of patients in your practice with a 10 / 5 year CVD risk greater than 20% 10% who have participated in shared decision making about whether or not to take a statin? Trend 3: reframing success in the primary prevention of CVD Communicating CVD risk to patients Shared Decision Making What counts as a success? Communicating risk of statin side effects My best friend had terrible aching with them Is my leg pain due to my statins doc? 7

8 Shared decision making in 15 minutes? UK NICE approach Offer people information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that: presents individualised risk and benefit scenarios and presents the absolute risk of events numerically and uses appropriate diagrams and text 8

9 UK NICE approach BUT. Offer people information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. How exactly do you do this in the consultation? Guideline does not help here US approach 9

10 Online Decision Aid Mayo Clinic -aids-for-chronic-disease/cardiovascularprevention/ Benefits (prevention of CVD in future) Harms (e.g., myalgia) Burdens (e.g., daily tablet; out of pocket expenses) 10

11 Concluding thoughts Wouldn t it be great. To have a NZ clinical decision aid to use in your GP surgery with patients Which would be embedded in, and populated with data from, the Patient Management System (e.g., MedTech) Thank you! 11