Cardiovascular Guidelines: A workshop

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Cardiovascular GuidelinesA workshop
RNZCGP Conference 17 July 2004
Bruce Arroll Stewart Mann Rob Cook
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Outline

• How the guidelines were developed
• Whats new
• Case study (4 parts)

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Guideline teams

• CVD Risk
• Jim Mann (chair)
• Bruce Arroll
• Janice Bremer
• Jenny Carryer
• Michael Crooke
• Paul Drury
• Euan Grigor
• Rod Jackson
• Laura Lambie
• Tim Maling
• Stewart Mann
• Richard Milne
• Ate Moala
• Diana North

• Tania Ridell
• David Roberts
• Russell Scott
• Harvey White
• Medication sub-group
• Norman Sharpe (chair)
• Andrew Kerr
• Neil Marshall
• Maika Veikune
• Rosemary Viskovic
• Diabetes
• Patrick Manning (chair)
• Angela Bayley
• Kirsten Coppell
• Marilyn Cullens

• Rick Cutfield
• Murray Dear
• Mark Donaldson
• Paul Drury
• Betty Dunn
• Andrew McGill
• Krishan Madhan
• Justine Mesui
• Luana Murray
• Helen Pahau
• Robert Scragg
• Mary Sievers
• Mark Webster
• Cathy Pikholz

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Guideline teams (cont)

• Atrial Fibrillation
• Hugh McAlister (chair)
• Anne Lethaby
• Carole Webb
• P Alan Barber
• Naomi Brewer
• Malcolm Clarke
• Rob Cook
• Mavis Fenelon
• John Fink
• Matire Harwood
• David Heaven
• Margaret Hood
• Lisa Hughes
• Stephen May
• Lee Pearce
• Tim Wilkinson
• Andy Williams

• Stroke
• Jonathan Baskett
• Harry McNaughten
• (co-editors)
• Neil Anderson
• P Alan Barber
• Tim Cookson
• Karen Dady
• John Fink
• John Gommans
• Carl Hanger
• Matire Harwood
• Sue Lord
• Catherin Marshall
• John McArthur
• Brian OGrady
• Katie Price
• Api Talemaitonga
• Helen Williams

• Cardiac Rehab
• Norman Sharpe (chair)
• Sue Wells
• Fiona Doolan-Noble
• Chris Baldi
• Stephen Burden
• Tim Corbett
• Rob Doughty
• Stewart Eadie
• Euan Grigor
• Ngaire Kerse
• Helen McGrinder
• Henare Mason
• Dahlia Naepi
• Diana North
• Tania Riddell
• David Roberts
• Riki Robinson
• Iutita Rusk

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Guidelines 2002-4

• In partnership with NHF, Stroke Foundation,
  Diabetes NZ and Cardiac Society
• Cardiac rehabilitation guidelines
• Stroke
• CVD Risk assessment
• Diabetes
• Out of hospital thrombolysis
• Atrial fibrillation and flutter
• Acute coronary syndromes

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Whats new - CVD Risk assessment

• Combines advice on BP, lipids CVD risk in
  diabetes and some angina, MI, TIA and stroke
• All treatment decisions based on absolute
  cardiovascular risk
• Shows that assessment and treatment of CVD risk
  above 15 is cost effective
• Fasting bloods recommended

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What is different
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Who to risk assess
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High risk groups for CVD/diabetes

• Family history of premature CVD or diabetes
• Personal history of gestational diabetes or
  polycystic ovary syndrome
• Current smoking
• Prior BP 160/95 or TCHDL ratio 7
• IGT or IFG
• Obesity (BMI 30)
• Truncal obesity Waist Circ 100cm men
• or 90cm women

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Adjust risk

• 5 can be added for people with
• Family history of premature CHD
• Maori or Pacific or from the Indian sub continent
• Diabetes and microalbuminuria
• Diabetes for 10 years or HbA1c 8
• Metabolic syndrome

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Cholesterol in men with and without CHD over 15
yrs
British Heart study
British Heart Study
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Clinically High Risk
30
15
20
5
25
10
0
Adjusted CVD Risk
Clinical CVD or High risk diabetes Some
genetic lipid disorders
Consider specialist referral
Drug interventions
Treatment Intensity
Urgent intense multifactor treatment
Drug intervention directed at all risk factors
Intensive individual advice

Lifestyle interventions
Specific advice
General advice
CVD Risk goal
Reduce risk
Reduce 5-year CVD risk to 14
Lipid Targets
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BP Targets
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Whats new - Diabetes

• Optimums
• BP control
• TC
• Triglycerides
• HbA1c as close to physiological as possible
  (preferably
• ACE-inhibitor or A2 receptor-blocker for
  microalbuminuria and overt nephropathy

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Whats new - after MI or stroke

• Aspirin 75mg -150 mg routinely
• as soon as possible after stroke (CT scan prior
  to starting)
• Beta-blockers for all (including those with LV
  dysfunction and stable heart failure
• ACE-inhibitors for all
• Statins (20-40 mg simvastatin) dose dependent on
  lipid profile

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Whats new AF

• AF is common 10 of 80 yr old
• Majority will require anticoagulation
• Rate control and TE prophylaxis is best treatment
  for most people
• Echocardiography is NB part of assessment
• Sotalol should not be used for rate control

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Select people for risk assessment
Reduce 5 year CVD risk to 3
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Case Study William age 50

• William is a Maori shopkeeper
• He smokes (5 a day) and usually drinks a few jugs
  at the week-end
• He is not known to have diabetes and has no
  family history of diabetes
• Medication paracetamol and diclofenac 75 mg prn
  for his back

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William - age 50

• Pulse 80 reg, BP 160/95, Chest clear, Good
  peripheral pulses,
• BMI 27, Waist circumference 103 cm
• You arrange for fasting lipids and glucose and
  see him in 2 weeks
• Repeat BPs 165/100, 160/95, 155/90 mm Hg
• Glucose (mmol/L) 5.7 (fasting)
• Lipids (mmol/L) TC 6.6, HDL 1.1, LDL 3.7, Trigs
  2.0, TCHDL 6.0
• BMI (kg/m2) 27
• Waist circ (cm) 103

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William - age 50

• What is his CVD risk?
• If you were to tackle his blood pressure what
  would you choose?
• Would you prescribe any other drugs?
• Anything else you would do?

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Risk Key
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NNT for 5 years to prevent one CVD event
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Adjustments to CVD risk

• 5 can be added for people with
• Family history of premature CHD
• Maori or Pacific or from the Indian sub continent
• Diabetes and microalbuminuria
• Diabetes for 10 years or HbA1c 8
• Metabolic syndrome

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Metabolic syndrome
NCEP ATP III. Circulation. 20021063143-3421.
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Who should get an OGTT after the Fasting Plasma
Glucose
non-european, family history diabetes, PMH of
gestational diabetes or the metabolic syndrome
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Average daily doses

• Reproduced with permission from Professor Russell
  Scott.
• Note At the time of publication Rosuvastatin was
  not currently subsidised in New Zealand

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William - age 60

• He has stopped smoking
• taking aspirin 100 mg daily,
• bendrofluazide 2.5 mg daily,
• quinapril 10 mg daily
• simvastatin 20 mg daily.
• BP 150/90
• Glucose (mmol/L) 8.5
• Lipids (mmol/L) TC 5.0, HDL 1.3, LDL 3.5, Trig
  3.0, TCHDL 3.8
• BMI (Kg/m2) 33
• Waist circ (cm) 115
• HbA1c () 9
• ACR (mg/mmol) 1.2

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William age 60

• What is his CVD risk?
• What else do you want to check?
• Would you prescribe any other drugs?
• Anything else you would do?

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Diabetes
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William - age 65

• aspirin 100mg daily,
• Accuretic 10/12.5,
• simvastatin 40mg,
• glipizide 5 mg bd
• metformin 500 mg bd
• metoprolol 95 mg daily
• BP 140/85
• Glucose (mmol/L) 6.5
• Lipids (mmol/L) TC 4.0, HDL 1.3, LDL 2.7, Trig
  3.0, TCHDL 3.1
• BMI (Kg/m2) 30
• Waist circ (cm) 100
• HbA1c () 7.8
• ACR (mg/mmol) 1.4

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William age 65

• What is his CVD risk?
• What else do you want to check?
• Would you prescribe any other drugs?
• Anything else you would do?

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Medication after MI or stroke

• Aspirin 75mg -150 mg routinely
• as soon as possible after stroke (CT scan prior
  to starting)
• Beta-blockers for all (including those with LV
  dysfunction and stable heart failure
• ACE-inhibitors for all
• Statins (20-40 mg simvastatin) dose dependent on
  lipid profile

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William - age 70

• aspirin 100mg daily, Accuretic 20/12.5,
• simvastatin 40mg, glipizide 5 mg bd
• metformin 1g bd metoprolol 95 mg daily
• ECG confirms AF with an ECG/apical rate of 120
• BP 135/80
• Glucose (mmol/L) 6.0
• Lipids (mmol/L) TC 3.8, HDL 1.2, LDL 2.4, Trig
  2.0, TCHDL 3.1
• BMI (Kg/m2) 28
• Waist circ (cm) 100
• HbA1c () 7.5
• ACR (mg/mmol) 1.6

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William - age 70

• What is his risk of embolic stroke from AF?
• What else do you want to check?
• Would you prescribe any other drugs?
• Anything else you would do?

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AF and either rheumatic mitral stenosis, prior
stroke or TIA are at VERY-HIGH risk
AF and either LV dysfunction or past
de-compensated heart failure are at HIGH risk
Men
Women
Diabetes
Diabetes
No Diabetes
No Diabetes
180
180
13
22
23
37
160
160
AGE
AGE
11
19
20
34
80
80
140
140
10
17
18
31
120
120
9
15
16
28
180
180
10
17
18
29
160
160
AGE
AGE
9
15
16
27
Systolic BP (mmHg)
70
70
140
140
8
13
14
24
120
120
7
12
13
21
180
180
7
13
13
22
160
160
AGE
AGE
6
11
12
20
60
60
140
140
6
10
11
17
120
120
5
9
10
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Source Wang, Massaro,,Levy, etal,. A Risk Score
for Predicting Stroke or Death for Individuals
with New-Onset Atrial Fibrillation in the
Community The Framingham Heart Study. JAMA
20032901049-1056
Very High
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15 - 20
High
Risk Key
(5 year stroke risk)
10 -15
Moderate
Mild
.
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Treatment with warfarin
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Benefits and harms of treatment with warfarin
instead of aspirin
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Contraindications to warfarin
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Summary

• Major reductions in CV risk are possible
• GPs and practice nurses are ideally placed to
  detect CV risk, advise and promote lifestyle
  change. Discussing the benefits of drug therapy
  where indicated.
• These guidelines encourage us to think of
  diabetes, stroke and heart disease together

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Available in print or to download

• www.nzgg.org.nz