Dr Joan Leighton. Professor Gerry Devlin. 14:00-14:55 WS #106: Whats Topical in Cardiology 15:05-16:00 WS #116: Whats Topical in Cardiology (Repeated)

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Practitioner Heart Foundation Christchurch 14:00-14:55 WS #106: Whats

1 Professor Gerry Devlin Clinical Cardiologist and Interventional Cardiologist NZ Heart Foundation Hamilton Dr Joan Leighton General Practitioner Heart Foundation Christchurch 14:00-14:55 WS #106: Whats Topical in Cardiology 15:05-16:00 WS #116: Whats Topical in Cardiology (Repeated)

2 What s Hot in Cardiology 2018 Joan Leighton GP Champion Heart Foundation Gerry Devlin Medical Director Heart Foundation Cardiologist Waikato Hospital

3 Sir David Hay

4 CVDRisk Assessment and Management Recognition risk based on Framingham data become has inaccurate over estimating risk New NZ specific data on CVD Risk available from PREDICT study Acknowledgement worldwide that there is benefit of treating with medication at lower levels of risk

5 Observed event rate Observed vs Predicted risk: Framingham score 1 prevention score Predicted event rate: Framingham From Rod Jackson : PREDICT

6 2018 Consensus Statement Not a Guideline

7 PREDICT STUDY Data gathered from 400,000 patients entered by Primary Care Matched by encrypted NHI to national hospitalisation and mortality data Looked at actual 5 year rate CVD events and calculated impact variety of risk factors PREDICT TOOL developed not yet available integrated PMS but is on

9 New Risk Factors Social Deprivation - NZ Dep Index 1-5 (most deprived) CVD Medications dispensed in last 6 months Atrial fibrillation Family history premature CVD defined as a first-degree relative (parent or sibling) was hospitalised by or died from a heart attack or stroke before the age of 50 year

10 Clinical High Risk Prior cardiovascular event, e.g. angina, coronary artery bypass grafting (CABG), myocardial infarction (MI), percutaneous coronary intervention (PCI), peripheral vascular disease (PVD), stroke, transient ischaemic attack (TIA) Familial Hypercholesterolemia Diabetes with an egfr < 45 ml/min/1.73m2

11 New Clinical High Risk Congestive heart failure (CHF) Stage 4 chronic kidney disease, i.e. egfr < 30 ml/ min/1.73m2 Asymptomatic carotid or coronary disease* * Coronary artery calcium score >400 or plaque identified on CT angiography

12 Age to start assessments Population subgroup Men Women Individuals without known risk factors Maori, Pacific or South Asian peoples People with other known Cardiovascular risk factors or at high risk of developing diabetes People with diabetes From time of diagnosis From time of diagnosis People with severe mental illness 25 25

13 80% 70% 60% 50% 40% 30% 20% 10% 0% When do heart deaths occur? % of heart deaths by age < Maori Pacific Non Maori, Non Pacific 2015 data courtesy of MoH. Data requested December 2017

14 Mental Health Schizophrenia, Major Depressive Disorder Bipolar Disorder, Schizoaffective Disorder Have high incidents CVD occurring earlier and poorer treatment outcomes Combination lifestyle factors and effects of medications used to treat these conditions Recommend CVD screening from age 25

15 Benefit at Lower Risk Internationally it is generally accepted that the point at which the benefit of CVD medications outweighs the risk occurs at approximately 5 percent five-year CVD risk.

17 Risk Category New using Predict Old using Framingham Low <5% <10% Intermediate 5-15% 10-20% High >15% >20%

18 Risk Management Encourage a healthy lifestyle in everyone Assessing 5 yr risk is pivotal to guide decision-making for primary prevention. Those with the highest risk have the greatest benefit.

19 Treating lipids Statins are recommended in all patients with a fiveyear CVD risk higher than 15 percent, regardless of the LDL level Consider statins for patients with five-year CVD risk between 5 percent and 15 percent

20 STATINS Most evidence for reducing risk both primary and secondary prevention In high risk patients is preventive medication least likely to be taking especially in younger patients Side -effects historically over -estimated If side-effects reported try stopping for 2 weeks then restart lower dose and slowly building up and/or changing statin Rosuvastatin not fully subsidised but often better tolerated

21 LDL target Risk Level 5-15% LDL Target 40% reduction in LDL >15% LDL-C </= 1.8

22 Treating Blood Pressure Blood Pressure >/= 160/100 (150 home or ambulatory) >/= 140/90 and 5yr CVD risk of 5-15% >/=130/80 and 5yr CVD risk of >15 % Drug treatment recommended Drug treatment recommended Drug treatment recommended

23 BP Target Reducing salt, alcohol, weight, and increasing physical activity- effective ways to reduce BP Office 130/80 Home and ambulatory 125/75

24 BP management Consider Home Monitoring or 24 hour BP monitoring in both diagnosis and monitoring response Caution with aggressive BP targets is recommended in the elderly

25 Aspirin In patients high risk < 70 consider benefit outweigh risk in Primary Prevention BUT > 70 years balance of benefits and harms cannot be determined and not recommended In patients with a intermediate fiveyear CVD aspirin for primary prevention of CVD alone is not recommended

26 Risk Communication Patient communication and joint management decisions are critical components of the CVD risk process.. Tools for risk communication and displaying the benefits and harms of management ideally integrated within PMS Use Health Literacy principles including avoiding use percentages eg for every 100 people like you 15 will have an event in next 5 years.

27 Risk assessment intervals

28 Start of a conversation Only worthwhile if we manage the risk

29 Atrial Fibrillation Majority of patients benefit from anticoagulation Aspirin alone ineffective in prevention of thrombo- embolic events Risk factor CVD Screening over 65s effective in detection

Atrial fibrillation in New Zealand primary care Anticoagulants

9% who were at high risk CHADS2VASC of >/=2 24% 61% Atrial

factors for stroke and the management of thromboembolic risk

30 Atrial fibrillation in New Zealand primary care Anticoagulants Aspirin monotherapy Neither 15% Of the 81.9% who were at high risk CHADS2VASC of >/=2 24% 61% Atrial fibrillation in New Zealand primary care: Prevalence, risk factors for stroke and the management of thromboembolic risk Andrew M Tomlin, Hywel S Lloyd,, Murray W Tilyard, European Journal of Preventive Cardiology October

31 Life Style Modification in AF Weight reduction - even 10 % can be significant Smoking cessation Alcohol Sleep apnoea

32 Heart Failure

33 Heart Failure Reduced EF (Class II-IV)

34 Dose Matters In Heart Failure with Reduced Ejection Fraction Aim titrate ACE/ARB and B Blocker aiming maximum tolerated dose closest to target Reaching <50% of the recommended ACE-inhibitor/ARB and betablocker dose was associated with an increased risk of death and/or heart failure hospitalization. Patients reaching 50 99% of the recommended ACE-inhibitor/ARB and/or beta-blocker dose had comparable risk of death and/or heart failure hospitalization to those reaching >_100%.

35 Mineralocortisol Receptor Antagonists Historically only Spironolacatone but now Eplerenon Improve morbidity and mortality in HF reduced ejection fraction Eplerenon more specific to receptor so less side-effects eg breast pain,gynacomastia Both can cause hyperkalaemia and renal dysfunction so need ongoing monitoring

36 25mg from July 1 50mg from October 1 Eplerenon e (Inspra) Special authority (indefinite) by relevant practitioner HF with EF < 40% And either Intolerant to optimal dosing of spironolactone (judgement) Clinically significant adverse event on optimal spiro dose (discretion)

37 ENTRESTO October 2018

38 Iron Therapy in Heart Failure

39 One of the Best Devices for Monitoring Heart Failure

40 Changing Rural chest pain management Non-cardiac chest pain Stable & unstable APNon-STEMI STEMI Location for patient management Ideal Current With hstn POCT (or central lab) * ** Early discharge managed at home Managed at rural hospital Referred to cardiology at base hospital * Enhanced early discharge ** Enhanced detection if NSTEMI

41 National STEMI Pathway

42 Delays to Treatment Terkelsen C J et al. Heart 2013;99:

43 Patient Delay in Presentation Acute Coronary Syndrome Account for up to two-thirds of the overall ischaemic time before reperfusion Are most likely to arise in older individuals, women, people with pre-existing diabetes, and patients of low socioeconomic status. Discuss warning signs with all High Risk patients

44 St Johns Chest Pain Responses Heart Attack Awareness

45 The Global Resuscitation Alliance 10 Steps to improving OHCA outcomes

TAVR continues to grow the gold-standard treatment for patients with severe, symptomatic aortic stenosis at extreme surgical risk, reducing the risk of mortality by at least 30% relative to standard

47 TAVR continues to grow the gold-standard treatment for patients with severe, symptomatic aortic stenosis at extreme surgical risk, reducing the risk of mortality by at least 30% relative to standard medical therapy. In high risk, PARTNER showed that TAVR was non-inferior to surgery, while the CoreValve US Pivotal trial showed that TAVR may provide a durable survival advantage over surgery. In intermediate risk patients TAVR is at least non-inferior to SAVR in terms of survival, and it facilitates a faster recovery to an improved quality of life.

48 Depression and Heart Disease Effects approximately 1 in 3 post ACS independently associated with increased cardiovascular morbidity and mortality screening tests for depressive symptoms should be used to identify patients who may require further assessment and treatment

49 So on Monday... Code all high risk CVD patients and set annual recall Expand CVD risk assessment Younger Maori, Pacific, SE Asian and Serious Mental Illness Promote statins they need us! Let s get those BPs down Sign up for Good SAM Help us promote Heart Attack awareness Consider screening for AF when giving Flu vaccine

What s new in cardiovascular disease risk assessment and management for primary care clinicians

Cardiovascular system What s new in cardiovascular disease risk assessment and management for primary care clinicians The recently released 2018 Cardiovascular Disease Risk Assessment and Management for