CardioVascular Risk Prevention by the Internists

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Cardio-Vascular Risk Prevention by the
Internists

• Prof. Benoit Boland
• Internal Medicine
• St-Luc University Hospital
• UCL-Brussels
• boland_at_mint.ucl.ac.be

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This patient comes to my medical office Im
addressing his/her CV Risk ?

• No. Why ?
• Yes. Why ? How ?
• 8 clinical cases

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8 clinical cases, reason for (first) visit to
the internist

• F 37, cholesterol 280 (gyn PAME)
• M 52, rhumatoïd arthritis (MI 2003)
• M 54, familial HBPressure
• F 51, fatigue
• M 48, chronic LBPain (obesity)
• F 55, hypoglycaemic prescription
• M 38, check-up
• M 42, stressed (father IM age 63)

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Objectives of the Workshop to present
provide you with

• A strategy for CV Risk assessment, suited to the
  outpatient care setting (fast, valid, easy)
• A global CV risk management approach
• A discussion on drugs for CV protection

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Cardio-Vascular (CV) Prevention

• CV Attacks heavy burden
• frequent (1st mortality cause)
• early (25 of MI in men lt 55 years)
• silent (75 of MI  out of a blue sky)
• High Risk priority
• frequent (15), severe, detectable, treatable
  (EBM)
• target patient group (60 of all first MI)
• Mission GPs Internists
• systematic  case-finding 

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High CV Risk definitions

• probability of a major acute ischaemic event
  within 10 years reaches
• 20 coronary, fatal or not
• ( Framingham )
• or
• 5 coro-cerebro, only fatal
• ( Score )

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CVP approach in 2 steps

• ASSESS CV Risk in all patients 30-75 years
  ( 1min )
• SCREEN 8 clinical RF (brochure p 2)
• CLASSIFY in clinical risk groups (brochure p 3-4)
• Risk Tables (Framingham or Score)
  (brochure p 5-6 )
• EXPLAIN CV TREATMENT
• EXPLAIN the main therapeutic targets, according
  to CV risk level (brochure p 7-8)
• ADVISE of a visit to the GP, who should define
  implement an individualized CV prevention program

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step 1.a Screen for 8 CV RF

• Systematic screening (adults aged 30-75 yrs)
• during the visit to the Internist
• Clinical A B C D E F G H
• A ge B MI (fat) C igarette
• D yslipidemia E vén. CV F amilial CV
• G lucose/t2DM H ypertension
• (Blood tests not needed at this step)

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RF definition, clinical (not biological)

• A Age at risk ( gt 50 years)
• B BMI (gt 30 kg/m² and/or Waist gt 102 88
  cm)
• C Cigarette ( gt 1 cigarette / day)
• D Dyslipidaemia (known lipid abnormality)
• E Event (ischaemic CV event)
• F Familial (CV event lt55/65 yrs, 1 degree
  relative)
• G Glucose gt 126 or known type 2 diabetes
• H Hypertension (traited or sBPgt140 or dBPgt90
  mmHg)

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step 1.b Classify in CV risk groups 4 groups
(colours) according to  ABCDEFGH 
Frequency in GP

• C isolated (Cigarette only) gt smoking related
  risk
• Stop smoking key message 8
• E or/and G gt obvious high CV risk
• Need of intensive, long-term management 18
• Other(s) RF (A,B,D,F,H) gt undetermined CV risk
• lipid results risk table 52
• (-) for all RF gt obvious low CV risk
• OK healthy life-style 22

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Use of a Risk Table ?

• Inappropriate in obvious High Risk patients !
• E (vent) G (lycaemia gt 126)
• HFHz (LDL-C gt 240) HTA III (gt 180/110 mmHg)
• Useless in obvious Low risk and in Smoking
  only patients
• Needed in patients at Undetermined risk
• Lipids Total Cholesterol HDL-C) ( Tg
  glycaemia if fasting)
• Risk Table 10 year risk Framingham Score
  Risk level
• Red ? 20 ? 5 High
• Orange 10-19 2-4 Moderate
• Green lt 10 0-1 Low
• (NB  increased risk  when F, HDL-C lt 40,
  Tg gt150, )

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Risk Tables comparison Framingham Score

• 1960-1980
• US East Coast
• City (5.000)
• Coronary only
• Morbi Mortality
• 5 age groups
• HRcoro ? 20 at 10 yrs
• Tables for diabetics yes
• 5 RF (A/S,C,D,H)

• 1980-2000
• Europe
• populations (200.000)
• Cardio-vascular
• only Mortality
• 6 age groups
• HRdeath ? 5 at 10 yrs
• tables for diabetics no
• 5 RF (A/S,C,D,H)

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Score Belgium

• Belgian Populations (BIRNH, MONICA, Bel-stress)
• Primary Prevention
• Methods
• CV Mortality at 10 yrs mean RF prevalence RR
  (Europe !)
• Specific features
• 5 1 (gt 68 yrs) age groups 4x4 cell squares
• risk (numbers) in each cell
• CV MORTALITY at 10 years
• Risk levels / colours
• Green Low 0 - 1
• Orange Moderate 2 - 4
• Red High 5 - 9
• Black very High gt 10

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CV Risk levels (GP) in 3231 patients

• Smoking related risk 8
•  see your GP to quit smoking 
• High CV risk (E, G, or Table) 24
•  see your GP to work on your main risk
  factors  
• Moderate CV risk 17
•  see your GP to improve your life-style 
• Low CV risk 37
•  keep a healthy life-style 
• 14

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2. Explain the therapeutic targets

•  each step toward a target is beneficial 
• Low CV risk  keep healthy life-style 
• Smoking related risk  stop smoking 
• Moderate CV risk 6 validated targets
• 0 smoking normal Weight (BMIlt25)
• Diet, mediterranean normal sBP (lt 140 mmHg)
• Activity, physical normal dBP (lt90 mmHg)
• High CV risk 12 validated targets

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High CV Risk(CV event, t2 diabetes,
multifactorial) 12 therapeutic targets (EBM
level)
III cas/control study IV experts opinion
I RCTrial(s) a multiple/MA b single
II prospective cohort(s)
0 D A . P C A
0 M E - P C A

• 0 smoking (II a)
• D iet, mediterrean (I b)
• A ctivity, physical (II b)
• P latelets (aspirin, ...) (I a)
• C holesterol (statins, ...) (I a)
• A rterial wall (IEC, BBl) (I b)

• HbA1c lt 7 (for Db2) (II a)
• Total Chol. lt 190 mg/dl (IV)
• LDL-Chol. lt 115 mg/dl (IV)
• systol BP. lt 130 mmHg (IV)
• diastol BP. lt 85 mmHg (IV)
• BMIndex lt 25 Kg/m² (IV)

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CV Risk Algorithm

• Avantages
• Global approach, easy
• EBM
• Close to recommandations
• Tested and validated
• Acta Cardiologica 200459598
• Adopted by GPs
• GP consensus (Cfçaise 2003)
• ABV-RBP for GPs (WvvH 2006)

• Limits
• Need of training
• MD initiative
• Change of medical practice
• No treatment advice

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8 clinical casesreason for (first) visit to the
internist

• F 37, cholesterol 280 (gyn PAME)
• M 52, rhumatoïd arthritis (MI 2003)
• M 54, HBPressure
• F 51, fatigue
• M 48, chronic LBPain (obesity)
• F 55, hypoglycaemic prescription
• M 38, check-up
• M 42, prevention (IM father)

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Case 1. F 37, dyslipidaemia (CT 280)

• RF screening gt
• A- B- C- D E- F- G- H- (126 mmHg)
• Clinical Classification ?
•   one other RF  undetermined risk (grey)
• Risk table Lipid profile ?
• Yes TC 290 HDL-C 73 ratio 4.0
• CV risk level ?
• Risk Low (green) Fr lt 5 Sc 0
• CV treatments ?

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Case 2. M 52, RArthritis (MI 2003)

• RF screening gt
• A B- C- D- E F- G- H- (132 mmHg)
• Clinical Classification ?
• obvious High risk (red)
• Risk table ?
• No !
• Lipid profile ?
• (CT 235 HDL 45 ratio 5.2 TG 150 LDL ? )
• CV treatments ?

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Case 3. M 54, hypertension

• RF screening gt
• A B- C D E- F- G- H (138 mmHg)
• Clinical Classification ?
• undetermined risk (grey) probably ?
• Risk table Lipid profile ?
• Yes CT 240 HDL 42 ratio 5.7
• CV risk level ?
• Risk High (red) Fr gt20 Sc 7
• Risk 1 year after stop smoking ?
• CV treatments ?

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Case 4. F 51, fatigue

• RF screening gt
• A B- C- D- E- F- G- H- (136 mmHg)
• Clinical Classification ?
• undetermined risk (grey )
• Risk table Lipid profile ?
• Yes CT 225 HDL 50 ratio 4.5
• CV risk level ?
• Risk Low (green) Fr lt 5 Sc 1
• CV treatments ?

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Case 5. M 48, low back pain (BMI)

• RF screening gt
• A B C- D- E- F G- H (152 mmHg)
• Clinical Classification ?
• undetermined risk (grey)
• Risk table Lipid profile ?
• Yes CT 240 HDL 45 ratio 5.3
• CV risk level ?
• Risk Moderate (orange) Fr 10-15 Sc 2
• CV treatments ?

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Case 6. F 55, type 2 diabetes

• RF screening gt
• A B- C- D- E- F- G H (146 mmHg)
• Clinical Classification ?
• obvious High Risk (red)
• Risk table ?
• No !
• Blood tests ?
• HbA1c 7.8 creatinin 1.2 mg/dl
• (CT 230 HDL 40 ratio 5.7 TG 200 LDL ?)
• CV treatments ?

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Case 7. M 38, first check-up

• RF screening gt
• A- B- C- D- E- F- G- H- (138 mmHg)
• Clinical Classification ?
• obvious Low Risk (green)
• Risk table Lipid profile ?
• No
• CV risk level ?
• Risk Low (green)
• CV treatments ?

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Case 8. M 42, stressed (paternal MI)

• RF screening gt
• A- B C- D- E- F G- H- (138 mmHg)
• Clinical Classification ?
• undetermined risk (grey)
• Risk table Lipid profile ?
• Yes TC 264 HDL 42 ratio 6.3
• CV risk level ?
• Risk green Fr lt 5 Sc 1
• CV treatments ?

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Take Home Tools

• 8 CV RF ?
• A B C D E F G H
• 4 groups typologies of clinical risk ?
• obvious Red grey Brown obvious Green
• grey become Red, Orange or Green
• Ranking of medical Priorities ?
• Red gt Brown gt Orange
• Main targets in High Risk patients

0 D A . P C A