Current Issues in Cardiovascular Risk Management. Les Toop Norman Sharpe June 2014

Transcription

1 Current Issues in Cardiovascular Risk Management Les Toop Norman Sharpe June 2014

2 Risk assessment is just the beginning of a conversation Les Toop Department of General Practice, University of Otago, Christchurch & Pegasus Health NZMA CME Dunedin, August 2014

3 Numbers and age-standardised mortality rates from ischaemic heart disease, by sex, Tobacco peak 1963 Prevalence >50% Coronary peak 1968 Heart disease death rates reduced by more than two-thirds since 1968 Cardiac Care Revolution?? Sat fat >40% cals

4 Age-standardised mortality rates for the five major causes of mortality, Cancer and heart disease crossover late 1980s

5 Leading specific causes of absolute inequality between Māori and non-māori, 2006

6 EVIDENCE-BASED BEST PRACTICE GUIDELINE Cardiovascular Risk Assessment and Management Guideline December 2003

7 CV Risk Guideline 2003 What was new --- Integrated previous advice on smoking, BP, lipids and diabetes into one assessment Required bloods (lipids and fasting glucose) Recommended assessment of specific age groups Recommended all treatment decisions be based on absolute cardiovascular risk - CHD and stroke risk combined Recommended intervention for individuals with CV risk above 15% 5 year level as practical and cost effective

8 Applying an arbitrary 1 Size Fits All 15% cut off risks over and under treatment Younger adult Older Adult Smok, Diet Exerc BP,Lip,Glu end organ damage 5 0 Low 5yr AR Med 5yr AR High 5y AR 5 0 Low 5yr AR Med 5yr AR High 5y AR Unmodifiabl e

9

10 plus ça change, plus c'est la même chose

11 CV and Diabetes Risk Assessment Update 2013 Summary The intensity of the intervention should be proportional to the estimated combined CVD risk ( absolute risk ) Relative risk reduction is more or less constant across the spectrum of combined risk; the higher the combined risk the greater the absolute benefit of treatment All people are at risk consider 3 management bands: <10% 5 year risk, 10-20% 5 year risk, >20% 5 year risk Clinical judgment and informed patient preference (shared clinical decision making) important, particularly with intermediate risk Non-fasting lipids and HbA1c Monitoring according to level of risk and stability following intervention

12

13

14 Risk Calculators and Shared Decision Making: Key Questions/Messages How good are they at predicting? Why aren t they better? How to make sense of their output How to help people overlay personal beliefs desires and willingness to make trade offs An informed, shared decision is always the correct one Prescribing outcomes should never be used for Incentivised QA

15 Gary S Collins, Douglas G Altman, BMJ 2010;340:c2442

16 How many are likely to avoid an event in the next five years by taking a BP or Cholesterol lowering drugs Gary S Collins, Douglas G Altman, BMJ 2010;340:c2442

17 Why aren t they better? Because there are many other risk factors that we don t know about (yet) and some softer but important ones that experienced clinicians recognise and incorporate into their assessments and advice in an intuitive manner E.g. Biological (vs chronological) age, complexities of family history, past medical history, comorbidities, habits, stress levels etc., etc., etc.

18 Important SDM concepts Lifestyle measures (healthy diet and regular exercise leading to healthy weight together with being tobacco free) offer similar or greater benefits than drugs

19 Exercise-based cardiac rehabilitation following heart attack (MI) Reduced odds of: repeat MI by 47%, fatal MI by 37% all-cause mortality by 26% Compared with statins: repeat MI by 31% fatal MI by 43% CVD mortality by 25% all-cause mortality by 16% Lawler PR et al (2011) Am Heart J 162: e572; Ward S, et al. (2007) A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technology Assessment (Winchester, England) 11: 1-160, iii-iv.

20

21

22 Important SDM concepts Lifestyle measures (healthy diet and regular exercise leading to healthy weight together with being tobacco free) offer similar or greater benefits than drugs The absolute benefits of drug treatment of BP, lipids, glycaemia and using aspirin increase with increased combined risk

23 Figure 5 Predicted benefits of increasing LDL-C reductions with statins by baseline absolute CVD risk: vascular events avoided per 1000 treated for 5 yrs 5 year vascular risk (%) LDL-C reduction (mmol/l) CTTC. Lancet 2012; 380:581-90

24 Major cardiovascular events avoided per 1000 Predicted benefits of increasing SBP reduction with drugs by baseline absolute CVD risk: 30 CVD events avoided per 1000 treated for 5 yrs SBP reduction (mm Hg) by treatment 0-10% 10-20% 30+% 20-30% 10-year risk of major cardiovascular events BLTTC unpublished 2013

25 Important SDM concepts Lifestyle measures (healthy diet and regular exercise leading to healthy weight together with being tobacco free) offer similar or greater benefits than drugs The absolute benefits of drug treatment of BP, lipids, glycaemia and using aspirin increase with increased combined risk The harms of the same drugs depend upon, dose, comorbidities, age and polypharmacy

26 We need ways to make the complexity understandable One example from the MAYO clinic

27

28

29

30

31 We plan to develop Decision aids which can reflect variety of intervention options alone and together, both quantitatively and qualitatively That can be bolted on to any risk calculator Coupled with skills training in facilitated informed decision making

32 And we are not alone

33 JAMA February 5, 2014 Volume 311, Number 5

34 From MAYO clinic JAMA February 5, 2014 Volume 311, Number 5

35 From MAYO clinic For policy makers, the target for performance measures is not the percentage of patients with at least 7.5% CVD risk who are prescribed statins, but the proportion of eligible patients who participate in shared decision making about statin use. JAMA February 5, 2014 Volume 311, Number 5

36 AHA/ACC Guidelines Controversial! Recommended threshold for statins >7.5% 10 year CVD risk (approx 4-5% 5 year CVD risk) This includes the great majority of men over 65 years of age and women over 70 years of age No data on number needed to treat in year olds No data on cost implications of follow-up No data on side effects in low risk group

37 We are all in the gutter, but some of us are looking at the stars. Oscar Wilde, Lady Windermere's Fan