Title: CVD Diabetes Guidelines
1CVD / Diabetes Guidelines
Rob Cook 13th May 2004 IPAC Conference
2Overview
- Whats new in the guidelines ?
- What is important ?
- Where to put it ?
Not in the round filing cabinet
3(No Transcript)
4Guidelines 2002-4
- Cardiac rehabilitation guidelines
- Stroke
- CVD Risk assessment
- Diabetes
- Out of hospital thrombolysis
- AF
- Acute coronary syndromes
5Guideline 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
- Secondary medication
- 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
6Whats 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
7What is different
8Who to risk assess
9High 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 gt 160/95 or TCHDL ratio gt 7
- IGT or IFG
- Obesity (BMI gt 30)
- Truncal obesity Waist Circ gt 100cm men
- or gt 90cm women
10Select people for risk assessment
Reduce 5 year CVD risk to lt15
3
11What to measure
- Age and sex
- Ethnicity
- Smoking history
- Family history
- Fasting lipid profile and fasting glucose
- Average of two sitting BP
- BMI and waist circumference
12Type 2 Diabetes A Progressive Disease
100
80
60
?-Cell Function ( ?)
40
20
0
?10
?9
?8
?7
?6
?5
?4
?3
?2
?1
0
1
2
3
4
5
6
Years
Adapted from UK Prospective Diabetes Study
(UKPDS) Group. Diabetes. 1995 441249-1258.
13CVD by HbA1c and self reported diabetes
14Type 2 Diabetes andCoronary Heart Disease
Nondiabetic
Diabetic
50
45.0
Plt0.001
Plt0.001
40
30
Incidence ()
20.2
18.8
20
10
3.5
n 69
n 890
n 169
n 1304
0
No DM, No MIn 1304
No DM, MIn 69
DM, No MIn 890
DM, MIn 169
7-Year Incidence of Fatal/Nonfatal MI
Haffner SM et al. N Engl J Med. 1998339229-234.
15Charts
16Adjust 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 gt 10 years or HbA1c gt 8
- Metabolic syndrome
17Metabolic syndrome
NCEP ATP III. Circulation. 20021063143-3421.
18Clinically 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
Lifestyle interventions
General advice
Intensive individual advice
Specific advice
CVD Risk goal
Reduce risk
Reduce 5-year CVD risk to lt 15
19NNT for 5 years to prevent one CVD event
20Treatments (gt20)
- Simultaneous drug treatment of all modifiable
risk factors - Aspirin (low dose)
- BP lowering (two drugs often needed)
- Lipid modification (statin usually)
- (Glycaemic control if diabetes)
21Goals
- Overall goal is to reduce risk 5 year
cardiovascular risk to lt15
22Lipid Targets
23BP Targets
24Who should get an OGTT after the Fasting Plasma
Glucose
non-european, family history diabetes, PMH of
gestational diabetes or the metabolic syndrome
25Follow up
- Cardiovascular risk assessments at least annually
- Risk factor monitoring 3 to 6 monthly
- ALT at baseline and once thereafter
- CK only if symptomatic with muscle aches
- Reduce dose 3-10 x normal
- Stop at 10 X normal
26Summary
- 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 and CVD together
27Whats new - Diabetes
- Optimums
- BP control lt 130/80
- TC lt 4 mmol/L
- Triglycerides lt 1.7 mmol/L
- HbA1c as close to physiological as possible
(preferably lt7) - ACE-inhibitor or A2 receptor-blocker for
microalbuminuria and overt nephropathy
28Whats new Diabetes 2
- Screening for microalbuminuria
- ACR gt 2.5 mg/mmol in men
- ACR gt 3.5 mg/mmol in women
- Overt nephropathy
- ACR gt30mg/mmol
29Whats new 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) see next slide,
dose dependent on lipid profile
30Average daily doses
- Reproduced with permission from Professor Russell
Scott. - Note At the time of publication Rosuvastatin was
not currently subsidised in New Zealand
31Whats new AF
- AF is common 10 of gt80 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
32Implementation
- Desktop resource
- Electronic decision support
- Consumer resource
- Train the trainer and teaching resources
- Case study (BPACnz)
- NZ Doctor how to treat article
- PHARMAC campaign
- Consortium formed (NHF / Stroke foundation /
Diabetes NZ / NZGG) to promote pilot projects
33Available in print or to download