Cardiovascular Risk Assessment and Management Making a Difference Norman Sharpe March 2014
Numbers and age-standardised mortality rates from all causes, by sex, 1950 2010 Death rates halved Life expectancy increased
Numbers and age-standardised mortality rates from ischaemic heart disease, by sex, 1950 2010 Heart disease death rates reduced by more than two-thirds since 1968
Age-standardised mortality rates for the five major causes of mortality, 1980 2010 Cancer and heart disease crossover late 1980s
Specific conditions contributing > 1% of total DALYs Males 2006
Specific conditions contributing > 1% of total DALYs Females 2006
Attributable burden (% of DALYs) for selected risk factors, 2006
Projections in health loss attributable to tobacco and high BMI, total population, 2006 to 2016 Obesity exceeds tobacco for health loss beyond 2015
Leading specific causes of absolute inequality between Māori and non-māori, 2006
Primary Care The Keystone to Heart Health Improvement
Why bother about CVD in primary care? In a population of 10,000 primary care patients, every year there are about: 10 coronary & stroke deaths 1 diabetic death 1 breast cancer death 1 prostate cancer death 1 suicide every year 1 road traffic death (1 cervical cancer death every 5 years)
EVIDENCE-BASED BEST PRACTICE GUIDELINE Cardiovascular Risk Assessment and Management Guideline December 2003
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 screening 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
Assessment of absolute CV risk What to measure and record Age and sex Ethnicity Smoking history Family history Lipid profile and fasting glucose Average of two sitting BPs BMI and waist circumference Assessment of absolute risk is the starting point for discussion
What does a Risk Assessment Involve? Weight Blood Pressure Smoking Diabetes Gender Family History Age Cholesterol Levels Ethnicity
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APCSC: blood pressure, cholesterol and body mass index and the risk of coronary heart disease Blood pressure Cholesterol Body mass index 4.0 4.0 4.0 2.0 2.0 2.0 1.0 1.0 Hypertension Hypercholesterolaemia 1.0 Obesity 0.5 110 120 130 140 150 160 170 0.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 16 20 24 28 32 36 Systolic blood pressure (mmhg) Total cholesterol (mmol/l) Body mass index (kg/m 2 ) 0.5
Hazard ratio & 95% CI APCSC: glucose and the risks of stroke, CHD, CV death 4.0 238,257 participants and 1.2M person years of follow up Total stroke 4.0 Total ischaemic heart disease 4.0 Cardiovascular death 2.0 2.0 2.0 1.0 1.0 1.0 0.5 0.5 0.5 4.5 5.0 5.5 6.0 6.5 7.0 7.5 4.5 5.0 5.5 6.0 6.5 7.0 7.5 4.5 5.0 5.5 6.0 6.5 7.0 7.5 Diabetes Care 27: 2836, 2004 Usual fasting glucose (mmol/l) 1mmol/l reduction in UFG relates to 23% reduced risk IHD
5 year CVD risk (percent) Absolute risk of CVD over 5 years by systolic BP + other risk factors Reference category is a 50 year old nondiabetic, non-smoker female with total cholesterol 4 0 mmol/l and HDL 1 6 mmol/l. 44% Risks are given for SBP levels of 110, 120, 130, 140, 150, 160, 170, and 180 mm Hg 33% 24% 18% 12% <1% 3% 6% Reference TC Smoker HDL Male Diabetes 60 years 7mmol/L 1 mmol/l Jackson R. Lat 2005;365:434
0 5 10 15 20 25 30 Clinically High Risk Adjusted CVD Risk Clinical CVD or High risk diabetes Some genetic lipid disorders Treatment Intensity Consider specialist referral Urgent + intense multifactor treatment Drug intervention directed at all risk factors Drug interventions General advice Specific advice Lifestyle Intensive individual advice interventions CVD Risk goal Reduce risk Reduce 5-year CVD risk to < 15%
So, what is shared decision making? Informed (benefits and harms) patient preference Health professional expertise Discussion Treatment and/or behaviour change goal The patient shares: Impact of risk/condition on their life. Personal attitude to the risk Values Preference Health beliefs The health professional shares: Knowledge Experience Treatment options and possible evidence based outcomes Coulter, A., Collins, A. (2011). Making shared decision-making a reality: No decision about me, without me. The King s Fund. http://www.kingsfund.org.uk/publications/making-shared-decision-making-reality https://www.youtube.com/watch?v=fhiwftnltyc -Health foundation you tube
Making it happen: practice change Leadership Champion Change management Team approach Quality improvement Data collection and clean up Achievable goals and targets Continual practice improvement Patient Access Improved patient outcomes Meeting health target Happy staff Innovation Person and family centred care Community outreach Self Management- organisational and individual