Update 2013: NZ Primary Care Handbook 2012

  • New CVDRA equation available 2014

  • Management options discussed with all patients

  • Increasingly graded approach to the intensity of management

  • Combined risk replaces absolute risk

  • Overarching principle is that intensity of interventions proportional to size of estimated cvd risk.

your heart forecast

Recommendations

  • All patients benefit from healthier lifestyles

  • Most patients with 5yr combined risk \<10% well managed without drug treatment

  • 5yr CVD risk 10-20%

  • discussion about benefits and harms of BP lowering and lipid lowering drugs

  • shared decision to initiate:

    • lifestyle only

    • add BP dec.

    • add lipid lowering

    • ALL

  • Most patients with CVD risk >20% benefit significantly from both BP and lipid lowering and antiplatelet drugs + intensive non-pharmacological interventions

  • Patients at any age with significant individual risk factors need to have them managed

Cardiovascular disease risk assessment

  • Shared treatment decisions form basis of managing cardiovascular risk

  • Take into account:

    • individuals estimated 5yr combined CVD risk

    • magnitude of absolute benefits

    • harms of intervention

Intervention

  • Lifestyle

    • diet

    • exercise

    • smoking

  • lipid lowering

  • blood pressure lowering

  • antiplatelet medication

  • diabetes care

  • medication after:

    • myocardial infarction

    • stroke

    • other cardiovascular events

  • Men 45/women 55

    • Asymptomatic without known risk factors:

  • Men 35yo/women 45yo

    • Maori/pacific/indo-asian:

    • with other known risk factors or high risk of developing diabetes

      • Family history risk factors:

        • Diabetes in 1st-degree relative

        • Premature CAD or ischaemic stroke in a first-degree relative (male \<55yrs, female \<65yrs)

    • Personal history risk factors

      • People who smoke (or who have quit in last 12 months)

      • Gestational diabetes, PCOS

      • Prior hypertension (BP >160/90)

      • Prior TC:HDL ratio >= 7

      • BMI >30 or truncal obesity: >100cm men, >90cm women

      • eGFR \<60

  • Annually from time of diagnosis

    • DM

      • type 1

      • type 2

  • It is reasonable to not see face-face if things have not significantly changed

  • if CVRA \<5% review/reassess within the next 10 years

What to measure and record for CVRA

History

  • Age

  • Gender

  • Ethnicity

  • Smoking status (if stopped \<12/12 record as smoker)

Family History

  • Premature coronary heart disease/ischaemic stroke first deg. rel

    • male \<55yo

    • female \<65

  • Type 2 DM

  • Genetic lipid disorder

Past medical history

  • Past history of cardiovascular disease

    • MI

    • PCI

    • CABG

    • Angina

    • Ischaemic stroke

    • TIA

    • peripheral vascular disease

  • Genetic lipid disorder

    • familial hypercholesterolaemia

    • Familial defective ApoB

    • Familial combined dyslipidaemia

Measure

  • Lipids

    • single non-fasting TC:HDL ratio used in calculation

    • If TC or TC:HDL >8mmol/l repeat the test

      • There is a possibility of genetic lipid disorder if TC>8 and/or strong FHx of premature CAD

  • HBA1c

    • Use single non-fasting HbA1c to screen for diabetes at same time as lipid profile

  • Blood pressure

    • Sitting BP measurement

    • 2 seated BP measurements recommended for initial risk assessment

      • one each arm

    • use appropriate cuff

      • Small adult (22-26cm = 24cm)

      • Adult (27-34cm = 30cm)

      • Large adult 35-44cm (38)

      • Adult thigh (45-52)

  • BMI

    • Doesn’t:

      • distinguish between fat and lean mass

      • ethnic differences

      • measure actual body fat or provide information about distribution of body fat

  • Waist circumference

    • midway between lower rib margin and iliac crest to nearest 1cm

Diabetes

  • Date of diagnosis

  • Type of diabetes

  • HBA1c

  • Urine albumin: creatinine (ACR)

  • eGFR and history of renal disease

Atrial fibrillation - confirmed on ECG

  • Echocardiogram

  • Past history of:

    • stroke

    • TIA

      heart failure

    • rheumatic or mitral heart disease

Estimating 5yr cardiovascular risk - the charts:

Very high risk groups: >20%

  • Previous CVD event

  • Some genetic lipid disorders (see above)

  • Diabetes with overt nephropathy

    • ACR 30mg/mmol

    • urinary albumin 200mg/L

  • Diabetes with other renal disease causing renal impairment

    • eGFR \<60

People aged 35-74 yrs

  • Calculate 5yr risk

  • AF confers additional risk over and above

  • These groups moved up one risk group cateogry (5%):

    • FHx of premature CAD or ischaemic stroke in 1st deg. relative (M \<55yo, F \<65)

    • Maori, pacific people or indo-asian peoples

    • Diabetes with microalbuminuria, persistent proteinuria, or DM for 10yrs, or HbA1c consistently >64mmol/L

People aged \<35yrs with known risk factors

  • All calculations outside age ranges of Framingham equation are approximate but can be useful

  • Age \<35:

    • calculate risk as if 35yrs old

    • Low HDL\<0.7mmol/L - because of risk of genetic lipid disorder

    • Known familial dyslipidaemias or suspected genetic lipid disorders

    • Type 1 DM, Type 2 DM with microalbuminauria, Type 2 DM of long duration (10yrs)

People aged >75yo; depending on other risk factors

  • calculate risk as if were 65-74yo

  • evidence for lipid lowering in the elderly limited as primary prevention

  • harms vs benefit analysis/discussion more difficult

  • Older people gain similar relative benefit from cholesterol lowering

    • but are more likely to have absolute benefit

    • much higher pre-treatment of cardiovascular risk

  • Cormorbidity is more common

  • time available to derive benefit will be shorter

  • patients' expectations should be taken into account

Note: risk charts may underestimate risk in:

  • single risk factors:

    • TC >= 8mmol/L

    • TC:HDL ratio >= 8

    • BP consistently above 170/100 mmHg

  • risk may be higher than assumed 5yr CVD risk of ≥15%

Follow-up intervals

  • \<5%

    • 10yrs

  • 2013:

    • all others: As soon as practicle

  • 5-10%

    • 5yrs

  • 10-15%

    • 2 years

  • ≥ 15%, DM or on lipid/BP lowering

    • annual

  • DM/medications/smoking cessation treatment/intensive lifestyle advice

    • 3mo until controlled then 6mo
Microalbuminuria definition

excretion between 30mg and 300mg of albumin a day in the urine.

less than 30mg is insignificant.

more than 300mg is albuminauria or macroalbuminuria.

Cardiovascular risk factor management goals

  • All treatment decisions should be informed by an individual's estimated 5 year combined CVD risk

  • discussion of magnitude of benefits and type and likelihood of potential harms

  • People will have their own risk thresholds

Aim of treatment is to reduce CVD risk

  • The order in which to start interventions should take into account :

  • individual risk factor levels

    • it is easier to modify risk that is very abN than one that is moderatley abN

  • potential sie effects

  • other concurrent illness

  • compliance

  • personal preference

  • Blood pressure lowering and statin medications work independently to lower risk

  • Either or both will be effective depending on the combined clinical risk

  • "Your heart forecast"(http://www.heartfoundation.org.nz)

Management guidance:

  • \<10%

    • lifestyle advice

    • evidence of benefit from antiHTN and statin unclear

    • offer CVD risk 5-10yrs

  • 10-20%

    • specific individualised lifestyle advice

      • diet

      • physical activity

      • smoking cessation

    • medications

      • good evidecne demonstrating benefti in this group

      • absolute beneftis smaller at lower levels of combined risk

        • increasing benefit for those with higher

      • shared decision making

    • follow-up

      • as clinically indicated

        • more intensive focus for higher combined risk patients

      • if not on drug treatment

        • 1yr 15-20%

        • 2yr 10-15%

  • >20%

    • intensive lifestyle

    • strong evidence for:

      • BP-lowering

      • statins

      • antiplatelet therapy

    • review annually or as clinically indicated

  • with established CVD

    • initially monitor @ 3mo then as clinically indicated

Medication Management

Blood pressure lowering

  • BP> 170/100 BP lowering treatment usually recommended irrespective of the combined CVD risk

  • \<170/100 informed by combined cardiovascular risk

Between 10-20%

  • discuss benefits and risks

  • lifestyle modification

  • aim is to achieve moderate blood pressure reduction to reduce combined risk -> no target

>20%

  • strongly recommended

  • caution if BP \<130/80