CVD Prevention, Who to Consider

Continuing Professional Development 3rd annual McGill CME Cruise September 20 27, 2015 CVD Prevention, Who to Consider Dr. Guy Tremblay Excellence in Health Care and Lifelong Learning

Global CV risk assessment.. Art and / or Science Learning Objectives CV risk assessment: art & science Upon completion of this activity, participants should be able to: Do a critical appraisal of CV risk assessment Evaluate indications and limitations of CV risk stratification Calculate vascular age; discuss how vascular age assessment can help in CV risk reduction http://jrqj.files.wordpress.com/2009/03/bus stop.jpg CV; cardiovascular 4 Global Cardiovascular Risk Assessment and Risk Reduction in Hypertensive Women Module 2 Global Cardiovascular Risk Assessment and Reduction in Women with Hypertension Pamela A 54-year-old, post-menopausal woman presents to your office for an annual examination This program meets the accreditation criteria of The College of Family Physicians of Canada and has been accredited for up to X Mainpro M1 credits. Pamela Pamela Patient history Pamela, a 54-year-old teacher who is post-menopausal, presents for an annual exam She attends aerobic classes 2x/week She admits to smoking 3-4 cigarettes/day, and occasionally more, when stressed She has no health complaints and is not on any medications Family history Mother, aged 74, diagnosed with intermittent claudication at 62 years of age Father, aged 79, no history of CV disease Physical exam BMI: 26.8 kg/m 2 ; waist circumference: 87 cm BP: 148/88 (avg. of repeated measures with validated oscillometric device [eg, Bp-TRU]) HR: 72 bpm Nothing else of significance on physical exam You send Pamela for routine labs CV: cardiovascular; BMI: body mass index; BP: blood pressure; HR: heart rate Bp TRU (BPM 100) Vsm Medtech, Coquitlam, BC, Canada 1

Pamela: Laboratory Investigations Practical Recommendations for CV Risk Assessment Test Results Normal values Fasting glucose 6.0 mmol/l 4.0-6.0 mmol/l Urea 4.0 mmol/l 3.0-7.0 mmol/l Creatinine 76 µmol/l; egfr 116 ml/min 44-106 umol/l K 4.1 mmol/l 3.5-5.0 mmol/l A1 c 0.06 0.04-0.06 Hb 124 g/l 115-165 g/l LDL 3.3 mmol/l <3.3 mmol/l TC 5.2 mmol/l <5.2 mmol/l TG 1.7 mmol/l <2.2 mmol/l HDL 0.9 mmol/l >0.9 mmol/l TC:HDL 5.78 <6.0 egfr: estimated glomerular filtration rate; K: potassium; A1 c: glycated hemoglobin a l; Hb: hemoglobin; LDL: low density lipoprotein; TC: total cholesterol; TG: triglycerides; HDL: high density lipoprotein; TC:HDL: total cholesterol high density lipoprotein ratio SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation; CV: cardiovascular; LDL-C: low density lipoprotein-cholesterol; BP: blood pressure Systolic Blood Pressure and CV death Accuracy of CVD risk stratification Distribution de la pression artérielle (%) 40 30 20 10 0 60 BP distribution 50 40 Mortality 30 20 10 0 100 120 140 160 180 200 60 50 40 30 20 10 0 Événements (n) Discrimination Calibration http://jrqj.files.wordpress.com/2009/03/bus stop.jpg Systolic Blood pressure Proportion of CHD Cases Predicted by Established Risk Factors Discussion Question 1 Based on the lab findings and history, what is Pamela s CV risk? Using Framingham table? Using SCORE Canada? Define CV risk? Blood Cholesterol, high blood pressure & cigarette smoking explain at least 75% of CHD cases. Add diabetes to list and explain about 85% or more of CHD cases. Source: Magnus P & Beaglehole R. Arch Intern Med 2001;161:2657-60. CV: cardiovascular; SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation 2

CV Risk Estimation: The Framingham Heart Study CV Risk Estimation: The Framingham Heart Study CV: cardiovascular 14-16 Genest et al. Can J Cardiol 2009;25:567-79; Adapted from D Agostino et al. Circulation 2008;117:743-53 Genest et al. Can J Cardiol 2009;25:567 79; Adapted from D Agostino et al. Circulation 2008;117:743 53 Description of 10-Year High Risk Canadian Working Group on Dyslipidemia SCORE Canada: 10 Year Risk of CVD Mortality Year % Description 2003 30% 2006 20% Total CHD (eg, death, MI, unstable angina and chest pain) Hard CHD (eg, death or MI) High 5% Moderate 2-4% 2009-2013 20% CVD: composite of CHD (coronary death, MI, coronary insufficiency, and angina), cerebrovascular events (including ischemic stroke, hemorrhagic stoke, and TIA), PAD (intermittent claudication), and heart failure Low 1% CHD: coronary heart disease; MI: myocardial infarction; CVD: cardiovascular disease; TIA: transient ischemic attack; PAD: peripheral artery disease CVD: cardiovascular disease; SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation Pamela = 2 3 % Pamela: 3-Month Follow-Up CV Risk Estimation: The Framingham Heart Study Now 55 years old (was 54) TC: 5.2 mmol/l; HDL-C: 0.9 mmol/l; LDL-C: 3.3 mmol/l; TG: 1.7 mmol/l BP: 152/88 (148/88) mmhg with validated oscillometric device (BP-100) Non diabetic Smoker 17 19 TC: total cholesterol; HDL: high density lipoprotein; LDL: low density lipoprotein; TG: triglycerides; BP: blood pressure CV: cardiovascular Genest et al. Can J Cardiol 2009;25:567 79; Adapted from D Agostino et al. Circulation 2008;117:743 53 3

CVD Risk For the Next 10 Years Accuracy of CVD risk stratification Who should we treat.first? Risk assessment method FRAMINGHAM Points Risk estimate (%) Interpretation Description T - 0 14-16 11.7-15.9 Moderate Risk of multiple CVD incidents T + 3 months SBP + 4 mmhg 17-19 18.5-25.8 Moderate - High Risk of multiple CVD incidents SCORE Canada T - 0-2-3 Moderate Risk of CV death T + 3 months SBP + 4 mm Hg - 2-3 Moderate Risk of CV death CVD: cardiovascular disease; SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation; SBP: systolic blood pressure http://jrqj.files.wordpress.com/2009/03/bus stop.jpg Concepts of Discrimination and Calibration of a risk prediction method Estimation of cardiovascular risk: a comparison between the Framingham and the SCORE model in people under 60 years of age. Scheltens T. et al. Eur Cardiovasc Prev Rehabil. 2008 Oct;15(5):562 6. 32 World Heart and Stroke Forum Strategic Principles for Dev of National Clinical Guidelines 1. Governments, national societies, and foundations should collaborate to develop clinical and public health guidelines 2. Evidence-based guidelines should incorporate professional judgment on the translation of such evidence into effective and efficient care 3. Assessment of total CVD risk should be based on epidemiologic risk factor data appropriate to the population to which it is applied Relative Risks for CVD Mortality Hazard Ratio (95% CI) Systolic blood Pressure 1.21 (1.19, 1.24) (10 mmhg) Total Cholesterol 1.20 (1.19, 1.20) (1 mmol/l) Smoking 2.00 (1.90, 1.21) Systematic Cerebrovascular and Coronary Risk Evaluation chart, calibrated for Canada Canadian mortality data Cardiovascular risk factors prevalence (2002) by Michel Joffres MD, Simon Fraser University; Expert consulting: Anthony P. Fitzgerald MD, Ronan Conroy, epidemiologists and statisticians, Dublin, Ireland, for SCORE-Europe. 4

Risk stratification models should be calibrated..for populations.. Comparative chart of two CV risk assessment techniques: CHD ou CVD Death? Framingham CHD* SCORE CVD Population 5251 men: 2439 women: 2812 205 178 men: 117 098 women: 88 080 Age < ------ > 45-64 Follow up (years) 10 y 10-14 y Persons years of follow-up 60 000 ± 2 700,000 (12 European cohort studies) Death CVD - 7 934 Death CHD men: 8% = 195 women: 2.8% = 79 5 652 Conclusions The sex-specific Framingham CHD prediction functions perform well... after recalibration for differing prevalences of risk factors and underlying rates of CHD events. JAMA. 2001; 286:180-187 Hard CHD MI + Death CHD : 274 - Type of calculation points equation 40 * ATP-III and Canadian Working Group on Dyslipidemia 2003-2006 DD/GT 2010 SCORE Canada: 10 Year Risk of CVD Mortality Factors to Consider When Using SCORE Risk Prediction Method High 5% Moderate 2-4% Low 1% Person approaching next age category Pre-clinical evidence of atherosclerosis (imaging test) Strong family history of premature CVD Multiply risk by 1.7 (men) or 2.0 (women) Obesity BMI: >30 kg/m 2 Waist circumference: >102 cm (men), >88 cm (women) Sedentary lifestyle Diabetes Multiply risk by 3 (men) or 5 (women) Raised serum TG level Raised level of fibrinogen, homocystéine, apob, or Lp(a) CVD: cardiovascular disease; SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation; CVD: cardiovascular disease; BMI: body mass index; TG: triglycerides; CRP: c reactive protein; apob: apolipoprotein B; Lp(a): lipoprotein(a) Relative Risk for CHD by Family History Predictive ability of the SCORE Belgium for CVD mortality Relative Risk at Ages CHD FHx Prevalence 20-39 50-69 70+ 1 + Affected 38% 2.9 1.3 1.3 1 + Age < 55 13% 3.9 1.5 1.1 2 + Affected 8% 5.9 1.8 2.0 2 + Age < 55 2% 12.7 2.9 0.7 Source: Utah Family Study Int J Cardiology 2009.03.101 De Bacquer D, De Backer G 5

Rx Implications of SCORE Spain vs. Framingham (D Agostino Revision) in Hypertensive Patients B) Discuss Important Risk Assessment Points with Pamela Risk, benefit, communication important points when discussing risk assessment with patients Risk assessment Need for action? Effect evaluation What kind of action? Risk reduction Health promotion Epidemiology RCCT Behavioural Science SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation Gómez-Marcos et al. BMC Cardiovascular Disorders 2009;9:17 What is vascular age? The age of the vascular system of a patient, based on the aggregate of their cardiovascular risk factors compare The age is calculated as the age a person would be if the risk factors were all within normal ranges. E) Pamela: Estimating Vascular Age with SCORE Canada Female, age 55 Smoker SBP 152/88 mmhg TC/HDL-C ratio 5.9 Non diabetic 10-year CVD risk of death is 2-3% Female, age 65 Non smoker SBP 130mmHg TC/HDL-C ratio 3 Vascular age: 65 SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation; BP: blood pressure; TC/HDL C: total cholesterol high density lipoprotein ratio 33 10-year CVD Mortality Rates in Canada, age 65 and above How to Use SCORE Canada 10 year CVD Death Men º Women What if the patient was <40 years of age? Relative risk table for patients <40 years of age % Statistics Canada 2002 SCORE: Systematic Cerebrovascular and Coronary Risk Evaluation; HDL C: high density lipoprotein cholesterol; BP: blood pressure 6

Risk prediction is improved by adding markers of subclinical organ damage to SCORE Thomas Sehestedt et al, European Heart Journal (2010) 31, 883 891 7