Primary Prevention

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Primary Prevention

• Cardiovascular Study day
• Cheltenham Racecourse
• 10th
  October 2006
• Dr
  Jim Moore

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What is Primary Prevention?

• Identification of people at risk of coronary
  heart disease who have no clinical manifestation
  of the condition.
• Assessment and treatment of people at risk of CHD

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At risk groups

• Diabetes /Glucose intolerance
• Hypertension
• Smokers
• Abnormal Lipid profile including Familial
  hyperlipidaemia ( FH )
• Family history of CHD
• Ethnic groups-South East Asians.
• Obese
• Premature menopause

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Joint British Society Guidelines on Prevention of
Cardiovascular Disease in Clinical Practice.
JBS 2

• 25th September 2006
• Dr Jim Moore

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Overall aim of JBS 2

• To promote a consistent multidisciplinary
  approach to the personalised management of people
  with established atherosclerotic CVD,diabetes and
  others at high risk of developing symptomatic
  CVD
• To emphasise a total risk approach to CVD risk
  assessment in the asymptomatic population
• To define lifestyle and risk factor interventions
  with thresholds and targets which reflect a
  growing scientific evidence base for managing
  high risk people

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Priorities for CVD Prevention

• People with any form of established
  atherosclerotic CVD Secondary prevention
• Asymptomatic people without established CVD -
  Primary Prevention
• high total risk 20 over 10 years
• People with diabetes mellitus
• type 1 or 2

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JBS 2 Guidelines 2005Significant changes in
Recommendations for Risk assessment

• Based on cardiovascular risk and not coronary
  heart disease risk alone with different risk
  bands.
• Type 2 Diabetes excluded from risk calculations
  as their overall level of risk is equivalent to
  someone with overt CHD
• Three age bands only- under 50years 50-59years
  and 60years and over

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Primary Prevention Risk assessment

• CVD risk prediction chart/table
• Computer risk assessment using JBS 2 CD-Rom
• GP computer systems integral risk assessment
  software in development

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JBS 2 CVD Risk Prediction Charts
Figure 1 Joint British Societies cardiovascular
disease (CVD) risk prediction chart non-diabetic
men
Figure 2 Joint British Societies cardiovascular
disease (CVD) risk prediction chart non-diabetic
women
Heart December 2005 Vol 91 Supplement V (Inside
Covers) Reproduced with permission from the BMJ
Publishing Group
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JBS 2 Guidelines 2005Changes in Risk assessment

• Type 2 Diabetes excluded from risk calculations
  as their overall level of risk is equivalent to
  someone with overt CHD
• Based on cardiovascular risk and not coronary
  heart disease risk alone with different risk
  bands.
• Three age bands only- under 50years 50-59years
  and 60years and over
• CVD risk assessment
• - lt1010-20 or lt20 over next 10years

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Coronary heart disease vs Cardiovascular
disease risk

• A 10 year Coronary heart disease risk of 15
  over 10years is equivalent to a 20
  Cardiovascular disease risk and is the level of
  risk at which pharmacological interventions
  should be considered.
• ( CVD risk CHD risk 4/3)

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JBS 2 Guidelines 2005Significant changes in
Recommendations for Risk assessmentAGE BANDS

• Under 50s will be assessed on the basis of their
  risk factors and an age of 49years old.
• Age 50-59 will be assessed on the basis of risk
  factors and an age of 59years.
• Over 60s will be assessed on the basis of their
  risk factors and an age of 69years.

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Who to Screen?

• All adults from 40 years onwards
• No history of CVD or diabetes and who are not
  already on treatment for blood pressure or lipids
• Opportunistic comprehensive risk assessment
• Younger adults (lt40 years)
• Family history of premature atherosclerotic
  disease

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Data for Cardiovascular Disease Risk assessment
(2004)

• Age
• Sex
• Smoking status
• Systolic blood pressure
• Total cholesterol/HDL ratio

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Practical considerations when risk calculating !
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Special considerations

• Family history (risk increased by1.5)
• Ethnicity (South Asian risk increased by1.4)
• Raised Triglyceride levels above 1.7 mmol/l
  (risk increased by 1.3)
• Pre-existing treatment of hypertension or
  hyperlipidaemia (risk underestimated)

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Special considerations Risk assessing
Established hypertensives on treatment

• If up to date BP used risk will be underestimated
  therefore do not use
• Use pre-treatment BP and present age where
  possible.
• If pre-treatment BP not available then use
  systolic BP of 160.

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Risk Factors for Cardiovascular disease

• BLOOD PRESSURE

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Risk Factors for Cardiovascular disease

• What is a NORMAL blood pressure?

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CVD preventionHigh risk groups

• Established CVD
• Diabetes mellitus
• Total CVD risk 20 over 10 years
• In addition the following groups with
  significant (elevated) risk factors should be
  considered as high risk and do not require
  formal risk assessment
• Elevated BP 160 systolic or 100 diastolic or
  lesser degrees of blood pressure with target
  organ damage
• Total cholesterol to HDL ratio 6.0
• Familial dyslipidaemia

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How many patients are estimated to have a 10year
CVD risk 20?

• 23 of men and 8 of women aged 40-74years !

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Risk thresholds and targets for blood pressure in
asymptomatic people without CVD
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• Blood Pressure TARGETS for antihypertensive drug
  treatment
• For most patients a target of 140 mm Hg
  systolic blood pressure and 85 mm Hg diastolic
  blood pressure is recommended (B). For patients
  with diabetes, renal impairment or established
  cardiovascular disease a lower target of 130/80
  mm Hg is recommended
• When using ambulatory blood pressure readings,
  mean daytime pressures are preferred and this
  value would be expected to be approximately 10/5
  mm Hg lower than the office blood pressure
  equivalent for both thresholds and targets.
  Similar adjustments are recommended for averages
  of home blood pressure readings

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General Medical Service ContractCardiovascular
Prevention Quality Indicators

• Audit Standards Minimum Standard of Care
• Coronary heart disease, stroke or transient
  ischaemic attacks, hypertension and diabetes
• Blood pressure lt 150/90 mmHg (lt 145/85 mmHg in
  diabetes)
• Total cholesterol lt 5.0 mmol/l
• Glycated haemoglobin lt 7.5

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Risk Factors for Cardiovascular disease

• CHOLESTEROL AND LIPIDS

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Lowering serum cholesterol reduces CHD mortality
rate
References 1-9 can be found at the end of the
presentation
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Diet and cholesterol.

• Diet low in saturated fat and cholesterol can
  result in a 10 reduction in LDL cholesterol
  though in practice only 3-6 is obtained.
• 2 g of Plant stanols/sterols (benecol/ flora pro
  activ ) daily can reduce LDL cholesterol by 9-14
  depending on age
• 15 reduction in LDL cholesterol reduces the risk
  of CHD over a lifetime by 25

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Significant changes to cholesterol management in
Primary and Secondary prevention JBS 2 (2005)

• Existing Threshold Total cholesterol level of
  5mmol for initiation of treatment replaced by
  level of 3.5 mmol (HPS study)
• New Audit and Optimal Treatment
  (target)standards set.

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Optimal and audit standard lipid targets
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Cholesterol metabolism

• Two main sources of plasma cholesterol
• Absorption of cholesterol from the intestine
• Production of cholesterol in the liver

16. Shepherd J. Eur Heart J Supplements
20013E2-E5.
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Cholesterol balance absorption and synthesis
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HDL vs LDL cholesterol

• High Density (Highly desirable) Lipoprotein is
  inversely related to CHD risk.Average HDL value
  in the UK is 1.2 for men and 1.4 for women.
• Low Density (Less desirable) Lipoprotein is
  directly related to CHD risk.
• Total chol /HDL ratio greater predictive value
  for CHD than LDL .

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Cholesterol treatment triallistsEfficacy and
safety of cholesterol lowering treatment

• Irrespective of initial pre-treatment LDL and
  lipid profile
• Lowering LDL by 1mmol over a 5 year period
  reduced major vascular event rate by
  21-translates into 48 fewer vascular events per
  1000 in CHD patients and 25 per 1000 in those
  with no history.
• 23 reduction in CHD events and 17 reduction in
  Stroke events per mmol LDL reduction over 5 years
  
• Significant reduction in major vascular events by
  10 per mmol reduction in LDL at 1 year
• Overall there was a 12 reduction in all cause
  mortality per mmol LDL reduction over 5 years
• Postulated that a 1.5mmol reduction in LDL should
  reduce major vascular events by one third over 5
  years

Lancet 2005
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GLOS.PCCAG Primary care CHD Audit April l2005

• 92 have had a cholesterol measurement in the
  past 15months. (nGMS max threshold gt 90)
• 78.2 have had a statin in the last 6months.
• 74 have a total cholesterol 5mmol/l or less in
  the past 15mths. (nGMS max threshold gt 60)

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New drugs and multiple drug therapy !
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Ezetimibe - EZETROL

• Novel agent first in a new class
• Ezetimibe selectively inhibits intestinal
  absorption of cholesterol20
• Has a unique mechanism of action, which is
  complementary to statins20
• Using the ezetimibe together with a statin
  together should have an additive effect on LDL-C
  lowering20

20. Shepherd J. Eur Heart J Supplements
20013E2-E5.
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Summary Ezetimibe added to ongoing statin
therapy

• LDL-C decrease of -25.1 from baseline (versus
  -3.7 from baseline in the statin only group),
  plt0.001
• Near maximal cholesterol lowering was seen by
  week 2

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Dual inhibition
x
EZETIMIBE
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Common Lipid Treatment Options

• Simvastatin 40mg used as standard for secondary
  prevention and diabetes
• -lipid profile not to target
• Options
• Atorvastatin 40mg
• Simvastatin /Ezetemibe combination
• Rosuvastatin 10mg .

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JBS 2 -Summary

• Consistent multidisciplinary approach
• Focus equally on people with
• established CVD
• people with diabetes
• high risk 20
• Reduce the risk of recurrent disease and increase
  life expectancy
• Reflect growing scientific evidence base for
  managing high risk patients
• Lower is Better

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Antiplatelet therapy in Primary prevention

• Aspirin use 75 mg daily if blood pressure
  controlled to lt 150/90 mm Hg and 10 year risk
  of cardiovascular disease of 20 or more
  (measured by using the new Joint British
  Societies' cardiovascular disease risk chart)
• In women the primary prevention of CVD events
  using aspirin was only seen in those aged 65years
  or older.