CVD Risk Assessment. Michal Vrablík Charles University, Prague Czech Republic

CVD Risk Assessment Michal Vrablík Charles University, Prague Czech Republic

What is Risk? A cumulative probability of an event, usually expressed as percentage e.g.: 5 CV events in 00 pts = 5% risk This is called an absolute risk Refers to a specific time period (0 years)

Relative Risk and Lifetime Risk Relative risk (RR) is a ratio of risks e.g. % risk in hypertensives, % risk in normotensives RR = 0. / 0.0 = hypertensives have times the risk of normotensives Lifetime risk is the absolute risk of a person for an event during his/her whole remaining life From an individual point of view it is probably the most accurate expression of risk and of intervention benefits

Q: How many risk factors for cardiovascular disease have been described?. 00. 00. 500. > 000 66% 5% % %....

Risk Factors for Cardiovascular Disease Modifiable Smoking Dyslipidaemia raised LDL-C low HDL-C raised triglycerides Raised blood pressure Diabetes mellitus Obesity Dietary factors Thrombogenic factors Lack of exercise Excess alcohol consumption Non-modifiable Personal history of CHD Family history of CHD Age Gender and there are many others ( 000 RFs identified) Adapted from: Pyörälä K et al. Eur Heart J 99;5:00.

Global (Total) Risk Many patients have MULTIPLE CV risk factors OF ALL HYPERTENSIVES 65% have dyslipidaemia 6% have T diabetes 5% are obese/overweight OF ALL DYSLIPIDAEMICS 8% have HTN % have T diabetes 5% are obese/overweight OF ALL T DIABETICS 60% have HTN 60% have dyslipidaemia 90% are obese/overweight Modified after Erhardt LR. Berlin CV Forum, April 008

Global (Total) Risk Multiplicative risk:.9x.x.9x.=.6

When do I assess CVD risk? If the patient asks for it If during a consultation: The person is a middle-aged smoker There is obesity, especially abdominal One or more risk factors such as elevated BP, lipids, or glucose are present or known There is a family history of premature CVD or of risk factors There are symptoms suggestive of CVD Perk J et al. Joint ESC guidelines 0. Eur Heart J 0)

How do I quickly assess CVD risk? HIGH CVD RISK Known CVD TDM or TDM+microalbuminuria Very high levels of individual risk factors Chronic kidney disease (CKD) SCORE chart all others SCORE risk 5% high risk SCORE risk < 5% low to moderate risk Perk J et al. Joint ESC guidelines 0. Eur Heart J 0)

What do these people have in common? years FH Heterozygote TC,8, LDL 9, mmol/l 59 years TDM, HT, DLP TC 6,, LDL,6 mmol/l 66 years CKD, HT, DLP TC 5,, LDL,6 mmol/l. High CVD risk. Need of intensive risk factor modification. Need to achieve treatment goals

How do I quickly assess CVD risk? HIGH CVD RISK Known CVD TDM or TDM+microalbuminuria Very high levels of individual risk factors Chronic kidney disease (CKD) SCORE chart all others SCORE risk 5% high risk SCORE risk < 5% low to moderate risk Perk J et al. Joint ESC guidelines 0. Eur Heart J 0)

Q: How do you estimate CVD risk in your patients?. Using Heart SCORE. Using Framingham point score. Using Reynolds algorythm. Using my best clinical judgement 68% 6% 0% 6%....

Risk Assessment in Everyday Practice 5 years old male Family history: His father died of a heart attack at age 8 Grade hypertensive, sitting BP = 50/90 mm Hg Smoker 0 cigarettes/day for 0 years BMI = 7 kg/m Dyslipidemic: total cholesterol = 60 mg/dl (6.7 mmol/l) HDL-C = 5 mg/dl (. mmol/l) LDL-C = 5 mg/dl (.9 mmol/l) TG = 5 mg/dl (. mmol/l)

Global Risk Assessment Tools in Clinical Practice Several algorythms and charts Framingham UKPDS Risk Engine for TDM patients SCORE charts Heart-SCORE PROCAM Reynolds risk charts NZ Chart Pocock Risk Score

ATP III Framingham Risk Scoring Assessing CHD MM Risk in Men ATP III. JAMA 00;85:86-97

SCORE: Systematic COronary Risk Used since 00 Estimation Based on data from European cohort studies Includes 05 78 patients/79 cardiovascular deaths between years 970-988 European Guidelines on Cardiovascular Disease Prevention in Clinical Practice, ESC, 007

www.heartscore.org

Systolic blood pressure (mm Hg) Nonsmoking F Smoking Nonsmoking M Smoking 7 8 9 0 5 7 9 6 9 6 6 0 5 7 5 5 6 7 8 5 6 9 6 0 6 7 8 9 65 9 6 5 6 8 9 8 5 9 5 7 0 5 5 5 6 7 5 6 7 9 9 0 7 5 6 7 8 9 0 9 5 8 8 8 5 5 6 7 8 9 5 5 6 60 6 7 9 0 5 6 7 9 8 7 0 0 7 5 6 6 7 8 0 5 5 6 7 6 7 8 0 6 9 5 55 5 6 7 8 5 6 8 5 9 6 6 8 9 5 6 8 5 6 7 7 8 0 < 50 5 5 6 7 8 0 5 6 7 < < 5 < < < < < < < < < < < < < < < < < < 0 < < < < < < < < < < < < < < < < < < < < < < < 5 6 7 8 5 6 7 8 Age 5 6 7 8 5 6 7 8 Total cholesterol (mmol/l) Total cholesterol (mmol/l)

Systolic blood pressure (mm Hg) Nonsmoking F Smoking Nonsmoking M Smoking 7 8 9 0 5 7 9 6 9 6 6 0 5 7 5 5 6 7 8 5 6 5 6 7 5 9 6 5 8 5 0 6 GENDER 65 AGE BLOOD PRESSURE (untreated) 7 8 9 5 5 6 7 9 0 CHOLESTEROL (untreated) 6 7 8 9 SMOKING 5 5 6 60 9 5 6 6 8 9 9 6 5 6 7 9 5 8 7 9 0 5 6 7 9 8 9 8 8 5 9 5 7 0 0 7 8 7 0 0 7 5 6 6 7 8 0 5 5 6 7 6 7 8 0 6 9 5 5 6 7 8 55 5 6 0 YEAR RISK OF FIRST FATAL CV EVENT >5% RISK IS CONSIDERED AS INCREASED RISK 5 6 7 8 5 7 9 6 6 8 9 5 6 8 8 0 < 50 5 5 6 7 8 0 5 6 7 < < 5 < < < < < < < < < < < < < < < < < < 0 < < < < < < < < < < < < < < < < < < < < < < < 5 6 7 8 5 6 7 8 Age 5 6 7 8 5 6 7 8 Total cholesterol (mmol/l) Total cholesterol (mmol/l)

Risk Assessment in Everyday Practice 5 years old male Family history: His father died of a heart attack at age 8 Grade hypertensive, sitting BP = 50/90 mm Hg Smoker 0 cigarettes/day for 0 years BMI = 7 kg/m Dyslipidemic: total cholesterol = 60 mg/dl (6.7 mmol/l) HDL-C = 5 mg/dl (. mmol/l) LDL-C = 5 mg/dl (.9 mmol/l) TG = 5 mg/dl (. mmol/l)

Systolic blood pressure (mm Hg) Nonsmoking F Smoking Nonsmoking M Smoking 7 8 9 0 5 7 9 6 9 6 6 0 5 7 5 5 6 7 8 5 6 9 6 0 6 7 8 9 65 9 6 5 6 8 9 8 5 9 5 7 0 5 5 5 6 7 5 6 7 9 9 0 7 5 6 7 8 9 0 9 5 8 8 8 5 5 6 7 8 9 5 5 6 60 6 7 9 0 5 6 7 9 8 7 0 0 7 5 6 6 7 8 0 5 5 6 7 6 7 8 0 6 9 5 55 5 6 7 8 5 6 8 5 9 6 6 8 9 5 6 8 5 6 7 7 8 0 < 50 5 5 6 7 8 0 5 6 7 < < 5 < < < < < < < < < < < < < < < < < < 0 < < < < < < < < < < < < < < < < < < < < < < < 5 6 7 8 5 6 7 8 Age 5 6 7 8 5 6 7 8 Total cholesterol (mmol/l) Total cholesterol (mmol/l)

High Relative CVD Risk ESC 007 guidelines on cardiovascular disease prevention proposed a relative risk chart for young people with high levels of risk factors & low absolute risk.

Risk Maybe Higher obese patients (central obesity) family history of premature CVD socially deprived diabetes- risk maybe 5 fold higher in women fold higher in man low HDL cholesterol or high triglycerides asymptomatic patients with evidence of preclinical atherosclerosis (reduced ankle-brachial index, carotid ultrasonography or CT scanning) Perk J et al. Joint ESC guidelines 0. Eur Heart J 0)

Atherosclerosis Imaging in Risk Assessment

Q: Which imaging methods do you use in your practice to improve risk prediction?. Carotid ultrasound. Coronary calcium scoring. CT/MR angiography. I do not use imaging for the purpose of CVD risk stratification 9% 8% % %....

Carotid Ultrasound: INTIMA- MEDIA THICKNESS (CIMT) non-invasive sensitive reproducible technique for identifying and quantifying subclinical vascular disease and for evaluating CV risk

Use of Carotid Ultrasound to Identify Subclinical Vascular Disease and Evaluate Cardiovascular Disease Risk: A Consensus Statement from the American Society of Echocardiography 9 prospective studies, 50 685 asymptomatic patients CIMT significantly associated with risk of MI, stroke, CV death or combination of these events similar or even greater predictive power for carotid plaque and CVD J of ASE, February 008

Carotid Ultrasound: When? in patients with intermediate CVD 0-year risk family history of premature CVD in a first-degree relative < 60 y.o. patients with severe abnormalities in a single risk factor women < 60 y.o. with at least risk factors i.e. if the level of aggressiveness of therapy is uncertain J of ASE, February 008

Carotid Ultrasound: How to Interpret the Results? carotid plaque is defined as >50% wall thickening or CIMT >.5mm that protrudes into the lumen CIMT > or equal to 75th percentile of the patients age, gender and ethnicity are indicative of increased CVD risk J of ASE, February 008

Risk Assessment = Patients Stratification and Treatment Goals Setting Very high risk Documented CVD (angio, stress testing, carotid plaque etc.) T DM or TDM with other RFs and target organ damage /MAU/ Severe CKD (GFR < 0 ml/min/, 7m ) SCORE > 0% High risk Markedly increased levels of individual RFs (e.g. FH) TDM or TDM without RFs and target organ damage Moderate CKD (GFR 0-59ml/min/, 7m ) SCORE 5-0% Moderate risk SCORE -5% (consider other RFs, imaging etc.) Low risk SCORE < % Perk J et al. Joint ESC guidelines 0. Eur Heart J 0)

Target levels of plasma LDL-c according to EAS/ESC 0 Low risk (SCORE < %) + Moderatly increased risk (SCORE -5%) High risk (SCORE 5-0%, marked elevation of single risk factor, DM w/o RFs) Very high risk (SCORE > 0%, CVD+, DM or DM+MAU, CKD) <,8 LDLc (mmol/l) <,0 <,5 EAS/ESC Guidelines on management of DLP, 0 or reduction >50%

CVD Risk Assessment: Initial and Crucial Step in Cardiovascular Prevention The intensity of intervention should be guided by the level of global CV risk, but: Cutoff value for BP: /90 mmhg Cutoff value for TC: 00 mg/dl (?) General principles: The lower the better to targets The sooner the better The safer the better

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