European Guidelines on CVD Prevention Fourth Joint European Societies Task Force on cardiovascular disease prevention in clinical practice September 2007 1
Recent developments in CVD prevention in Europe 1994 First Joint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention 1995-96 EUROASPIRE I 1998 Second Joint Task Force Recommendations 1999-2000 EUROASPIRE II 2000 Joint European Societies CVD Prevention Committee 2003 Third Joint Task Force Recommendations 2007 Fourth Joint Task Force Recommendations 2
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The partners ESC EAS ESH ESGP/FM ISBM EHN EASD IDF- Europe Risk evaluation SCORE Audit EUROASPIRE Third Joint Task Force on CVD Prevention Report to Advice from ESC Committee on practical guidelines and policy conference Joint Cardiovascular Prevention Committee 4
4 th Joint Task Force on Prevention: Dan Atar [ESC] Knut Borch-Johnsen [EASD/IDF Europe] Gudrun Boysen [EUSI] Gunilla Burell [ISBM] Renata Cifkova [ESH] Jean Dallongeville Guy de Backer [ESC] Shah Ebrahim [ESC] Bjorn Gjelsvik [ESGP/FM/Wonca] Christoph Hermann- Lingen [ISBM] Arno W Hoes [ESGP/FM/Wonca] MEMBERS Steve Humpries [ESC] Mike Knapton [EHN] Joep Perk [EACPR] Sylvia G Priori [ESC] Kalevi Pyorala [ESC] Zeljko Reiner [EAS] Luis Ruilope [ESC] Susana Sans-Menendez [ESC] Wilma Scholte Op Reimer [ESC council on CV Nursing] Peter Weissberg [EHN] David Wood [ESC] John Yarnell [EACPR] Jose Luis Zamorano [ESC/CPG] 5
4 th Joint Task Force on Prevention: SPECIAL PEOPLE, SPECIAL THANKS INVITED EXPERTS Marie-Therese Cooney Alexandra Dudina Tony Fitzgerald Edmond Walma ESC STAFF Keith McGregor Veronica Dean Catherine Despres Sophie Squarta 6
JTF4 on CVD PREVENTION CONTENTS 1. Introduction 2. Scope of the problem; past and future 3. Prevention strategies and policy issues 4. How to evaluate scientific evidence 5. Priorities total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drug therapy 20. Implementation strategies 7
What s new in the Fourth Joint Task Force Guidelines on the Prevention of CVD? Increased input from general practice and cardiovascular nursing. Increased emphasis on exercise, weight, and lifestyle. More detailed discussion on the limitations of present systems of grading evidence. Re-defined priorities and objectives. Revised approach to risk in the young. More information from SCORE on total events, diabetes, HDL cholesterol, and body mass index (BMI). New sections on gender, heart rate, BMI/waist circumference, other manifestations of CVD including stroke and renal impairment. 8
JTF4 on CVD Prevention in Clinical Practice 1. INTRODUCTION 9
Why develop a preventive strategy in clinical practice? 1.Cardiovascular disease (CVD) is the major cause of premature death in Europe. It is an important cause of disability and contributes substantially to the escalating costs of health care. 2.The underlying atherosclerosis develops insidiously over many years and is usually advanced by the time that symptoms occur. 3.Death from CVD often occurs suddenly and before medical care is available, so that many therapeutic interventions are either inapplicable or palliative. 4.The mass occurrence of CVD relates strongly to lifestyles and to modifiable physiological and biochemical factors. 5.Risk factor modifications have been shown to reduce CVD mortality and morbidity, particularly in high risk subjects. 10
What are the objectives of these guidelines? To help health professionals to reduce the occurrence of coronary heart disease, stroke and peripheral artery disease and their complications. To achieve this by providing practical and accessible advice with regard to the rationale for prevention, priorities, objectives, risk assessment and management through lifestyle measures and selective drug usage. To encourage the development of national guidance on CVD prevention through the formation of multi-disciplinary national guideline and implementation partnerships that are compatible with local political, social, economic and medical circumstances. 11
JTF4 on CVD Prevention in Clinical Practice 2. THE SCOPE OF THE PROBLEM: PAST AND FUTURE 12
CVD Prevention: The scope of the problem CVDs are the major causes of death and disability in Europe - 4.35 million in Europe, 1.9 million in the EU. MORE women than men die from CVD - 2.3 million women, 2 million men. 10 fold regional differences, with reductions in the West. Reductions in age-specific CVD mortality generally represent a transference of the problem to older persons, with increasing heart failure. Generally poor risk factor control (EuroAspire). Improvements in smoking, BP and lipid control offset by reduced activity, increasing obesity and consequent diabetes. 13
CVD - the size of the problem Current life expectancy 65 (45-80) yrs. 1900- <10% deaths due to CVD. 1970- biggest cause of death in developed countries. Falling in developed countries, rising fast in developing ones. 2000- biggest cause of death worldwide. 1996-15,000,000 deaths. 2020-25,000,000 deaths. (Source WHO) 14
CVD Prevention: CHALLENGES Inactivity Obesity Stroke Heart failure Gender and social class inequalities Renal failure Implementation 15
JTF4 on CVD Prevention in Clinical Practice 3. PREVENTION STRATEGIES AND POLICY ISSUES 16
WHO report on the Prevention of CHD (and hence CVD) defined three components to preventive strategy: 1. Population 2. High risk 3. Secondary prevention The prevention paradox- high risk individuals gain most from preventive measures- but most CVD deaths come from apparently low risk subjects because they are so numerous. The three strategies should be complementary, not competitive. Policy is defined further in the Osaka declaration. 17
Fig. 1 - The expected number of CVD deaths at increasing levels of predicted risk. Illustration of the fact that most events occur in low risk subjects with few deaths among high risk subjects. 80 CVD Deaths (all cohorts) 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Predicted Risk (Men aged 50-59 ) 18
The European Heart Health Charter and the Guidelines on Cardiovascular Disease Prevention The European Heart Health Charter advocates the development and implementation of comprehensive health strategies, measures and policies at European, national, regional, and local level that promote cardiovascular health and prevent CVD. These guidelines aim to assist physicians and other health professionals to fulfil their role in this endeavour, particularly with regard to achieving effective preventive measures in day-to-day clinical practice. They reflect the consensus arising from a multi-disciplinary partnership between the major European professional bodies represented. 19
JTF4 on CVD Prevention in Clinical Practice 4. HOW TO EVALUATE SCIENTIFIC EVIDENCE 20
Desirable attributes of guidelines (4th Joint European Societies Task Force on CVD Prevention) Validity Reproducibility Reliability Representative development Clinical applicability Clinical flexibility Clarity Meticulous documentation Scheduled review 21
I II IIa IIb III A B C ESC classification of evidence. Is it appropriate? Classes of recommendations: Evidence/general agreement that a treatment is benefical, useful and effective Conflicting evidence/divergence of opinion Weight of evidence in favour Less well established Not useful/effective, may be harmful Levels of evidence: Multiple RCTs or meta-analyses Single RCT or large non-randomized studies Consensus of opinion of experts and/or small studies, retrospective studies, registries 22
Guidelines- refinement of the concepts of evidence-based medicine The evidence must be appropriate to the question, eg causality with regard to a risk factor, evaluation of a diagnostic test, therapy- benefits and harm. Emphasis on the randomized controlled trial for TREATMENTS is entirely appropriate. But lifestyle measures may not be amenable to RCTs- eg smoking. Therefore drug treatments may be given undue emphasis. The weighting given to evidence must therefore reflect what is possible in any given discipline. Being re-examined by NICE, SIGN and the WHO GRADE system. 23
JTF4 on CVD Prevention in Clinical Practice 5. PRIORITIES, TOTAL RISK ESTIMATION AND OBJECTIVES 24
0 3 5 140 5 3 0 People who stay healthy tend to have certain characteristics: 0 No tobacco 3 Walk 3 km daily, or 30 mins any moderate activity 5 Portions of fruit and vegetables a day 140 Blood pressure less than 140 mm Hg systolic 5 Total blood cholesterol <5 mmol/l 3 LDL cholesterol <3 mmol/l 0 Avoidance of overweight and diabetes 25
What are the PRIORITIES for CVD prevention in clinical practice? 1. Patients with established atherosclerotic CVD. 2. Asymptomatic individuals who are at increased risk of CVD because of : 2.1 Multiple risk factors resulting in raised total CVD risk ( 5% 10-year risk of CVD death); 2.2 Diabetes type 2 and type 1 with microalbuminuria; 2.3 Markedly increased single risk factors especially if associated with end-organ damage. 3 Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk. 26
What are the OBJECTIVES of CVD prevention? 1. To assist those at low risk of CVD to maintain this state lifelong, and to help those at increased total CVD risk to reduce it. 2. To achieve the characteristics of people who tend to stay healthy: 2.1 No smoking; 2.2 Healthy food choices; 2.3 Physical activity: 30 min of moderate activity a day; 2.4 BMI <25 kg/m 2 and avoidance of central obesity; 2.5 BP <140/90 mmhg; 2.6 Total cholesterol <5 mmol/l (~190 mg/dl); 2.7 LDL cholesterol <3 mmol/l (~115 mg/dl); 2.8 Blood glucose <6mmo/L (~110 mg/dl). 27
What are the OBJECTIVES of CVD prevention? 3. To achieve more rigorous risk factor control in high risk subjects, especially those with established CVD or diabetes: 3.1 Blood pressure under 130/80 mmhg if feasible; 3.2 Total cholesterol <4.5 mmol/l (~175 mg/dl) with an option of <4 mmol/l (~155 mg/dl) if feasible; 3.3 LDL cholesterol <2.5 mmol/l (~100 mg/dl) with an option of <2mmol/L (~80 mg/dl) if feasible; 3.4 Fasting blood glucose <6 mmol/l (~110 mg/dl) and HbA1c <6.5% if feasible. 4. To consider cardioprotective drug therapy in these high risk subjects especially those with established atherosclerotic CVD. 28
When do I assess cardiovascular 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 blood pressure, lipids or glucose is raised. - There is a family history of premature CVD or of other risk factors. - There are symptoms suggestive of CVD. If confirmed, risk factors should be assessed but use of the SCORE chart is not necessary as the person is already at high risk. 29
Why stress assessment of total CVD risk? Multiple risk factors usually contribute to the atherosclerosis that causes CVD. These risk factors interact, sometimes multiplicatively. Thus the aim should be to reduce total risk; if a target cannot be reached with one risk factor, total risk can still be reduced by trying harder with others. 30
Fig 2 The relationship of total cholesterol / HDL cholesterol ratio to 10 year fatal CVD events in men and women aged 60 yrs with and without risk factors, based on a risk function derived from the SCORE project. 30 10 yr risk of fatal CVD (%) 25 20 15 10 5 Men, smoking, SBP=160 mmhg Men, non-smoking, SBP=120 mmhg Women, smoking, SBP=160 mmhg Women, nonsmoking, SBP=120 mmhg 0 3 4 5 6 7 TC/HDL ratio 31
Table 1 Impact of combinations of risk factors on 10 year risk of CVD death SEX AGE CHOL BP SMOKE RISK % F 60 8 120 NO 2 F 60 7 140 YES 5 M 60 6 160 NO 8 M 60 5 180 YES 21 32
How do I assess CVD risk quickly and easily? Those with- ~known CVD; ~type 2 diabetes or type 1 diabetes with microalbuminuria; ~ very high levels of individual risk factors. are already at INCREASED CVD RISK and need management of all risk factors. For all other people, the SCORE risk charts can be used to estimate total risk-this is critically important because many people have mildly raised levels of several risk factors that, in combination, can result in unexpectedly high levels of total CVD risk. 33
Assessing cardiovascular risk: What are the components? History: Previous CVD or related diseases, family history of premature CVD, smoking, exercise and dietary habits, social and educational status. Examination: BP, heart rate, heart and lung auscultation, foot pulses, height, weight, (Body mass index), waist circumference. Fundoscopy in severe hypertension. Lab test: Urine for glucose and protein, microalbuminuria in diabetics. Cholesterol and if practicable, fasting lipids (LDL and HDL cholesterol, triglycerides) glucose, creatinine. ECG and exercise ECG if angina suspected. ECG and consider echocardiogram in hypertensive persons. Premature or aggressive CVD, especially with a family history of premature CVD: Consider High sensitivity CRP, lipoprotein (a), fibrinogen, homocysteine if feasible, specialist referral. 34
How do I use the SCORE charts to assess total CVD risk in asymptomatic persons? 1. Use the low risk chart in Belgium*, France, Greece*, Italy, Luxembourg, Spain*, Switzerland, and Portugal; use the high risk chart in other countries of Europe * Updated, re-calibrated charts are now available for Belgium, Germany, Greece, The Netherlands, Poland, Spain, and Sweden. 2. Find the cell nearest to the person s age, cholesterol, and BP values, bearing in mind that risk will be higher as the person approaches the next age, cholesterol or BP category. 3. Check the qualifiers. 4. Establish the absolute 10-year risk for fatal CVD. Note that a low absolute risk in a young person may conceal a high relative risk; this may be explained to the person by using the relative risk chart. As the person ages, a high relative risk will translate into a high absolute risk. More intensive lifestyle advice will be needed in such persons. 35
Risk estimation using SCORE: qualifiers Risk estimation using SCORE: qualifiers The charts should be used in the light of the clinician s knowledge and judgement, especially with regard to local conditions. As with all risk estimation systems, risk will be overestimated in countries with a falling CVD mortality rate, and underestimated if it is rising. At any given age, risk appears lower for women than men. This is misleading since, ultimately, more women than men die from CVD. Inspection of the charts shows that their risk is merely deferred by 10 years. Risk may be higher than indicated in the chart in: ~Sedentary or obese subjects, especially those with central obesity; ~Those with a strong family history of premature CVD ~The socially deprived; ~Subjects with diabetes risk may be 5-fold higher in women with diabetes and 3-fold higher in men with diabetes compared with those without diabetes; ~Those with low HDL cholesterol or high triglycerides; ~Asymptomatic subjects with evidence of pre-clinical atherosclerosis, for example a reduced ankle-brachial index, or on imaging such as carotid ultrasonography or CT scanning. 36
10 year risk of fatal CVD in high risk regions of Europe 37
10 year risk of fatal CVD in low risk regions of Europe 38
Relative Risk Chart This chart may used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication 39
How do I manage the components of total CVD risk? The patient and the doctor agree that a risk assessment is indicated, and the patient is informed that the result may lead to suggestions regarding life style change and the possibility of life long medication. There are time and resources to discuss and follow up advice and treatment. The doctor should be aware of and respect the patients own values and choices. 40
Total CVD risk management: A key message Management of the individual components of risk such as smoking, diet, exercise, blood pressure and lipids impacts on total risk. Thus, if perfect control of a risk factor is difficult (for example, blood pressure control in the elderly), total CVD risk can still be reduced by reducing other risk factors such as smoking or blood cholesterol. 41
When do I assess total CVD risk? If the patient asks for it If, during a consultation: The person is a middle-aged smoker One or more risk factors such as a raised blood cholesterol is known about There is a family history of premature CVD or of major risk factors such as hyperlipidaemia Symptoms suggestive of CVD Assessing risk: what do I do? Use SCORE unless known CVD, diabetes, very high single risk factors History: Previous diseases, family history of premature CVD, smoking, exercise, and dietary habits Examination: BP, HR, heart and lung auscultation, foot pulses, height, weight, (Body mass index), waist circumference. Lab tests: Urine for glucose and protein. Cholesterol and fasting lipids if practicable (LDL and HDL cholesterol, triglycerides) glucose, creatinine ECG and exercise ECG if angina suspected ECG and consider echocardiogram in young or severely hypertensive persons Consider high sensitivity CRP, lipoprotein (a), fibrinogen, homocysteine, specialist referral if premature CVD or family history of same Established CVD DM2 or DM1 with microalbuminuria Markedly elevated single risk factor SCORE risk 5% SCORE risk < 5% 42
Lifestyle recommendations No smoking Weight reduction if BMI 25 kg/m 2 and especially if BMI 30 kg/m 2 No further weight gain if WC 80-88 cm in women and WC 94-102 cm in men. Advise weight loss if WC 88 cm in women and 102 cm in men 30 min of moderately vigorous exercise on most days of the week; exercise and weight reduction can prevent diabetes Healthy diet Wide variety of foods Energy intake adjusted to avoid overweight Encourage: fruits, vegetables, wholegrain cereals and bread, fish (especially oily), lean meat, low fat dairy products Replace saturated fat with monounsaturated and polyunsaturated fats (vegetable and marine) Hypertensive subjects should reduce salt intake Lifestyle advice to maintain low risk status Re-assess total risk at regular intervals Drug treatment More likely as SCORE risk exceeds 5% and especially as it approaches 10%, or if there is end-organ damage. In the elderly, drug treatment is generally not recommended below 10% risk unless a specific indication exists Consider BP-lowering drugs when BP 140/90 Consider statins when total cholesterol 5 or LDL 3 In patients with CVD: Aspirin. Statins for most In patients with diabetes: consider glucose-lowering drugs 43
JTF4 on CVD Prevention in Clinical Practice 6. PRINCIPLES OF BEHAVIOUR CHANGE AND MANAGEMENT OF BEHAVIOURAL RISK FACTORS 44
Managing total risk- TIPS TO HELP BEHAVIOUR CHANGE Develop a sympathetic alliance with the patient. Ensure the patient understands the relationship between lifestyle and disease. Use this to gain commitment to lifestyle change. Involve the patient in identifying the risk factors to change. Explore potential barriers to change. Help design a lifestyle change plan. Be realistic and encouraging- ANY increase in exercise is good and can be built on. Reinforce the patient s efforts to change. Monitor progress through follow-up contacts. Involve other health care staff wherever possible. 45
Managing total CVD risk: Why do people find it hard to change their lifestyle? Socio-economic status: Low SES, including low educational level and low income, impedes the ability to adopt lifestyle change. Social isolation: People living alone are more likely to have unhealthy lifestyles. Stress: Stress at work and at home makes it more difficult for people to adopt and sustain a healthy lifestyle. Negative emotions: Depression, anxiety and hostility impede lifestyle change. Complex or confusing advice Increased physician awareness of these factors facilitates empathy, counselling, and the provision of sympathetic, simple, and explicit advice. 46
JTF4 on CVD Prevention in Clinical Practice 7. SMOKING 47
Smoking and CVD Smoking is a strong and independent causal risk factor for both first and subsequent CVD events, as well as for multiple other diseases. Passive smoking also increases risk. Smoking greatly increases the risks associated with other risk factors. Those who stop smoking after a CHD event have half the mortality of those who continue. No drug is so effective. 48
Managing total CVD risk: SMOKING All smokers should be professionally encouraged to permanently stop smoking all forms of tobacco The 5 As can help- A- ASK systematically identify all smokers at every opportunity. A- ASSESS: Determine the person s degree of addiction and his/her readiness to cease smoking. A- ADVISE: Unequivocally urge all smokers to quit. A- ASSIST: Agree on a smoking cessation strategy including behavioural counselling, nicotine replacement therapy, and/or pharmacological intervention. A- ARRANGE a schedule of follow-up visits. 49
JTF4 on CVD Prevention in Clinical Practice 8. NUTRITION, OVERWIGHT AND OBESITY 50
Managing total CVD risk: HEALTHY FOOD CHOICES All individuals should be advised about food choices that are associated with a lower CVD risk. High risk persons should receive specialist dietary advice if feasible General recommendations should suit the local culture A wide variety of foods should be eaten Energy intake should be adjusted to avoid overweight. Encourage: Fruits, vegetables, wholegrain cereals and bread, fish (especially oily), lean meat, low fat dairy products Replace saturated fats with the above foods and with monounsaturated and polyunsaturated fats from vegetable and marine sources to reduce total fat to <30% of energy, of which less than 1/3 is saturated. Reduce salt intake if blood pressure is raised by avoiding table salt and salt in cooking, and by choosing fresh or frozen unsalted foods. Many processed and prepared foods, including bread, are high in salt. 51
Managing total CVD risk: BODY WEIGHT Increasing body weight is associated with increased total and CVD mortality and morbidity, mediated in part through increases in blood pressure and blood cholesterol, reduced HDL cholesterol, and an increased likelihood of diabetes. Weight reduction is recommended for obese people (BMI 30 kg/m 2 ) and should be considered for those who are overweight (BMI 25 and <30 kg/m 2 ). Men with a waist circumference of 94 102 cm and women with a waist circumference of 80 88 cm are advised not to increase their weight. Men above 102 cm and women above 88 cm are advised to lose weight. Restriction of total calorie intake and regular physical exercise are the cornerstones of weight control. It is likely that improvements in central fat metabolism occur with exercise even before weight reduction occurs. 52
JTF4 on CVD Prevention in Clinical Practice 9. PHYSICAL ACTIVITY 53
Managing total CVD risk: PHYSICAL ACTIVITY Stress that positive health benefits occur with almost any increase in activity; small amounts of exercise have an additive effect; exercise opportunities exist in the workplace, for example by using stairs instead of the lift. Try to find leisure activities that are positively enjoyable. 30 min of moderately vigorous exercise on most days of the week will reduce risk and increase fitness. Exercising with family or friends tends to improve motivation. Added benefits include a sense of well-being, weight reduction, and better self-esteem. Continued physician encouragement and support may help in the long term. 54
JTF4 on CVD Prevention in Clinical Practice 1O. BLOOD PRESSURE 55
JTF4 Blood pressure Risk factor for all atherosclerotic CVDs, heart failure and renal failure, cognitive impairment. Risk rises progressively from <120/80 on. Other RFs such as diabetes and dyslipidaemia are more likely in hypertensives, and interact to greatly increase risk. Direct association with body weight- 5 KG reduction reduces BP by 4.4/3.6 mm Hg. Physical training can reduce BP by 3.5/3.2 mm Hg. Multiple nutritional factors affect BP- encourage fruit, vegetables, low-fat dairy products, reduced saturated fat and salt. Benefits of BP reduction apply to both sexes, up to at least age 80, and to CHD, stroke, heart failure, renal function and possibly to cognitive impairment. Effective BP control is more important than the choice of agent. 56
Managing total CVD risk: Blood Pressure In ALL cases, look for and manage all risk factors. Those with established CVD, diabetes or renal disease are at markedly increased risk, and a BP of <130/80 is desirable if feasible. For all other people, check SCORE risk. Those with target organ damage are managed as increased risk. SCORE CVD risk Normal <130/85 High Normal 130 139/ 85 89 Grade 1 140 159/ 90 99 Grade 2 160 179/ 100 109 Grade 3 180/110 Low <1% Lifestyle advice Lifestyle advice Lifestyle advice Drug Rx if persists Drug Rx Moderate 1 4% Lifestyle advice Lifestyle advice +consider drug Rx Drug Rx if persists Drug Rx Increased 5-9% Lifestyle advice +consider drug Rx Drug Rx Drug Rx Drug Rx Markedly increased 10% Lifestyle advice +consider drug Rx Drug Rx Drug Rx Drug Rx 57
JTF4 on CVD Prevention in Clinical Practice 11. PLASMA LIPIDS 58
JTF4 Lipids Total and LDL cholesterol relate to CVD risk causally, strongly, independently and progressively and are the primary focus of management. Reduction unequivocally reduces CVD risk, including stroke. Moderately raised triglycerides (>1.7 mmol/l, ~150 mg/dl) relate to risk; may relate to particle size; inverse association with HDL cholesterol; associations with abdominal obesity & blood sugar and possible thrombogenic effects- LOOK for these! HDL cholesterol relates inversely to CVD risk. HDL is antiatherogenic, anti-inflammatory and anti-thrombotic, and is involved in reverse cholesterol transport. <1 mmol/l (~40 mg/dl) in men and <1.2 mmol/l (~45 mg/dl) in women denotes increased risk. Total cholesterol:hdl ratio relates to risk but better risk estimation may be possible if they are considered separately. Apo B/A1 ratio relates strongly to risk but it is not known if it should be a treatment goal. Lp(a) relates to risk, is genetically determined, but resistant to modification. 59
Managing total CVD risk: Lipids In ALL cases, look for and manage all risk factors. Those with established CVD, diabetes type 2 or type 1 with microalbuminuria, or with severe hyperlipidaemia are already at high risk. For all other people, the SCORE charts can be used to estimate total risk Established CVD Diabetes as above Markedly raised lipid levels SCORE risk 5% SCORE risk < 5% Dietary and exercise advice together with attention to all risk factors comes first. Aim to reduce total cholesterol to <4.5 mmol/l (~175 mg/dl) or <4 mmol/l (~155 mg/dl) if feasible, and LDLcholesterol to <2.5 mmol/l (~100 mg/dl) or <2 mmol/l (~80 mg/dl) if feasible. This will require statin treatment in many. Some recommend statins for all CVD and most diabetic patients regardless of baseline levels. Lifestyle advice for 3 months, then reassess SCORE and fasting lipids SCORE risk still 5% TC <5 mmol/l and LDL-C <3 mmol/l and SCORE now <5% Treatment goals are not defined for HDL cholesterol and triglycerides, but HDL-C <1.0 mmol/l (~40 mg/dl) for men and <1.2 mmol/l (~45 mg/dl) for women and fasting triglycerides of >1.7 mmol/l (~150 mg/dl) are markers of increased cardiovascular risk 60 Lifestyle advice to reduce total chol <5 mmol/l (~190 mg/dl) and LDL-C <3 mmol/l (~115 mg/dl) Regular follow-up
JTF4 on CVD Prevention in Clinical Practice 12. DIABETES AND THE METABOLIC SYNDROME 61
JTF4 Diabetes and the metabolic syndrome Linear, graded relationship between glucose and CVD risk, especially for 2 hour post load glucose and for HbA1c from levels well within the normal range Relative risk of CVD for impaired glucose tolerance is approx 1.5, for diabetes 2-4, maybe more in women Risk relates to both the diabetic state and related factors, and to associated conventional, modifiable risk factors The ideal is to prevent the occurrence of diabetes if possible Good metabolic control prevents microvascular complications Lipid targets are total cholesterol < 4.5 mmol/l (~175 mg/dl), or <4.0 mmol/l (~155 mg/dl), if feasible, and LDL chol <2.5 mmol/l (~100 mg/dl) or < 2.0 mol/l (~80 mg/dl) if feasible BP target is < 130/80 mm Hg if feasible 62
Treatment targets in patients with type 2 diabetes HbA 1c (DCCTaligned) Plasma glucose Unit HbA 1c (%) Fasting/pre-prandial mmol/l (mg/dl) Target 6.5 if feasible <6.0 (110) if feasible Post-prandial mmol/l (mg/dl) <7.5 (135) if feasible Blood pressure Total cholesterol LDL cholesterol mmhg mmol/l (mg/dl) mmol/l (mg/dl) mmol/l (mg/dl) mmol/l (mg/dl) 130/80 <4.5 (175) <4.0 (155) if feasible <2.5 (100) <2.0 (80) if feasible 63
The Metabolic Syndrome The term metabolic syndrome refers to the combination of several factors that tend to cluster together- central obesity, hypertension, low HDL cholesterol, raised triglycerides, and raised blood sugar- to increase risk of diabetes and CVD. This implies that, if one component is identified, a systematic search for the others is indicated, together with an active approach to managing all of these risk factors. Physical activity and weight control can radically reduce the risk of developing diabetes in those with the metabolic syndrome. 64
JTF4 on CVD Prevention in Clinical Practice 13. PSYCHOSOCIAL FACTORS 65
JTF4 Psychosocial factors Appear to contribute independently to CVD risk- both of developing CVD and for prognosis thereafter. Also act as barriers to achieving lifestyle change and to adhering to treatment. Factors include low socio-economic status, social isolation, poor social support, work stress (high demand, low control; high effort, low reward) domestic stress, hostility, depression. Hard to quantify the benefits of interventions. Stress management programs may improve well-being, risk factor levels and CVD outcomes. 66
JTF4 on CVD Prevention in Clinical Practice 14. INFLAMMATION MARKERS AND HAEMOSTATIC FACTORS 67
Inflammation markers and haemostatic factors Criteria for evaluation include applicability to all relevant CVD events; ability to predict in short, intermediate and long-term followup; standardised measurements; examination of variability; degree of correlation with established risk factors; improvement in overall prediction of events. Reverse causality may be a problem- sub clinical disease my increase the factor. Incorporation of CRP, fibrinogen and other emerging risk factors for the estimation of CVD risk may be premature. 68
JTF4 on CVD Prevention in Clinical Practice 15. GENETIC FACTORS 69
Genetic factors A family history of CVD in a first degree relative aged <55 (male) or 65 (female) carries an independent relative risk of 1.5-1.7. Heritability of lipid phenotypes is 40-60%, >90% for Lp(a). Dominant genotypes such as familial hypercholesterolaemia exert large effects but are infrequent. Screening for multiple poymorphisms with small but cumulative effects on risk is not yet realistic. Close relatives of persons with premature CVD should have risk assessments; some will have, for example, familial hyperlipidaemia. Others will share high risk lifestyles. 70
JTF4 on CVD Prevention in Clinical Practice 16. NEW IMAGING METHODS TO DETECT ASYMPTOMATIC INDIVIDUALS AT HIGH RISK FOR CARDIOVASCULAR EVENTS 71
New imaging methods Atherosclerosis in often advanced before the first clinical manifestation such as sudden death, myocardial infarction or stroke. Therefore it is logical to seek easy and reliable methods to detect sub clinical disease. Criteria for accepting the clinical utility of new imaging techniques have been defined; clinical benefit without harm is required. MR imaging of carotid and coronary plaque is possible but remains a research tool thus far. Multi-slice CT coronary arteriography has a high negative predictive value. The presence of coronary calcium seems to add independent prognostic information, especially in medium risk subjects, but may also lead to unnecessary tests and interventions. Ultrasound carotid intima-media thickness appears to allow a modest improvement in risk estimation after allowing for conventional risk factors; the hazard ratio may be greater in women. Meticulous technique is required. Ankle-brachial index is easy, cheap and inexpensive and relates strongly to future CVD. It deserves further study to define its role in risk estimation. 72
JTF4 on CVD Prevention in Clinical Practice 17. GENDER ISSUES: CARDIOVASCULAR DISEASE IN WOMEN 73
Gender issues: cardiovascular disease in women Ultimately, more women (55%) die of CVD than men (45%), particularly of stroke. Cf 3% breast cancer deaths in women. The apparent lower risk in women in SCORE reflects the fact that women develop CVD 10 years later. The evidenced base for risk factor advice, especially regarding drug treatments is hampered by under-representation of women in clinical trials. Women are disadvantaged at all stages in the evolution of CVD- they are less likely to be offered risk assessment, to have chest pain evaluated or investigated, and to be offered therapy and interventions. Mortality from acute coronary syndromes and after CABG is frequently higher in women. 74
CVD in women: Management implications I 1. European and national public health policy needs to address the problem of inadequate recognition of the size of the problem of CVD in women and to reflect this through publicity and education of both the public and the medical profession. 2. Clinicians likewise need vigilance in understanding the need to think risk and CVD in dealing with female patients. 75
CVD in women: Management implications II 3. The principles of total risk estimation and management are the same for both sexes. In women, emphasise the evaluation of smoking, weight, glucose tolerance and oral contraceptive use. 4. A low absolute risk in a younger woman may conceal a very high relative risk. Detailed lifestyle advice may prevent this from changing into a high absolute risk in later life. 76
JTF4 on CVD Prevention in Clinical Practice 18. RENAL IMPAIRMENT AS A RISK FACTOR IN CARDIOVASCULAR DISEASE 77
Renal impairment and cardiovascular risk Risk of CVD rises progressively from microalbuminuria with preserved GFR to end-stage renal disease, when it is 20 30x that of the general population. Applies to apparently healthy people and to those with hypertension, CVD, and heart failure. Associated with high blood pressure, hyperlipidaemia, metabolic syndrome, uric acid, homocysteine, and anaemia. Particularly vigorous risk factor control needed. 78
JTF4 on CVD Prevention in Clinical Practice 19. CARDIOPROTECTIVE DRUG THERAPY 79
When to prescribe cardioprotective drugs in addition to those used to treat blood pressure, lipids, and diabetes Aspirin for virtually all with established CVD, and in persons at >10% SCORE risk once blood pressure has been controlled. β-blockers after myocardial infarction and, in carefully titrated doses, in those with heart failure. ACE inhibitors in those with left ventricular dysfunction and in diabetic subjects with hypertension or nephropathy. Anticoagulants in those at increased risk of thromboembolic events, particularly atrial fibrillation. 80
JTF4 on CVD Prevention in Clinical Practice 20. IMPLEMENTATION STRATEGIES 81
What would make the practice of CVD prevention easier? Simple, clear, credible guidelines. Sufficient time. Positively helpful government policies (defined prevention strategy with resources, and incentives including remuneration for prevention as well as treatment). Educational policies that facilitate patient adherence to advice. 82
Implementation strategies: European level 1. Publication of guidelines in relevant journals. 2. Presentations at international conferences of the participating societies. 3. Directly influencing EU health policy - for example through the Luxembourg Declaration and the European Health Charter. 83
Implementation strategies: National level 1.Adapt the European Guidelines to suit the local culture. 2.Formation of a multidisciplinary implementation group: professional bodies, medical and other health professionals, basic scientists, educators, business people, politicians. Needs to be more than merely advisory: should inform and shape health policy. 3. Multi-faceted communications using all available media to doctors, medical and para-medical students, and ultimately all adults and children, including schools. 84
4th Joint Task Force on cardiovascular disease prevention in clinical practice a special word of thanks to: Veronica Dean Catherine Despres Marie-Therese Cooney Alexandra Dudina Sophie Squarta 85