management. Managing risk or risk factors? Igor Sergienko, PhD, MD - - PowerPoint PPT Presentation

Practical challenges in CV risk management. Managing risk or risk factors?

Igor Sergienko, PhD, MD Russian Cardiology Research Complex, Russian National Atherosclerosis Society

DYSIS study. Real clinical practice

Очень высокий и высокий риск Умеренный и низкий риск Начальные дозы статинов Средние и высокие дозы статинов

Gitt AK, et al., 2011

80%

20%

89%

11%

Very high and high risk Low and moderate risk High doses

• f statins

Low doses

• f statins

Despite on different target levels of C-LDL for very high, high and moderate rick categories, in real clinical practice C-LDL concentrations were similar

Средний уровень ХС ЛНП в зависимости от степени ССР, ммоль/л

LDL Cholesterol level in patients of different rick categories

CARD-1092656-0000; 08 2013

* Oganov RG, Kukharchuk VV. Cardiovascular therapy and prevention , №4, 2012.

Very high risk High risk Moderate risk

DYSIS – RUSSIA

Процент пациентов, достигших целевого уровня ХС ЛНП на фоне терапии статинами

% of patients, which reached C-LDL target level 53,4% 30,3% 12,2%

* Oganov RG, Kukharchuk VV. Cardiovascular therapy and prevention , №4, 2012.

DYSIS – RUSSIA

Very high risk High risk Moderate risk

Prevalence of behavioral risk factors for cardiovascular disease in the Russian population: Results of the ESSE-RF epidemiological study Objective: To study the prevalence of behavioral risk factors (dietary habits, low-intensity physical activity, smoking, and alcohol consumption) among the population of some Russian regions differing in climatic, geographic, economic, and demographic characteristics. 2012-2013, 13 Regions of Russia, 18305 people were included All the subjects were interviewed by the standard questionnaire (consisting of 12 modules) SA Shalnova AO Konrady Prophylactic medicine, 2015, №5

The prevalence of smoking in Russian population

Group Sex Total (n=18 272; 27,7%) Men (n=6903; 43,5%) Women (n=11 369; 4,2%) Absol. % Absol. % Absol. % Variation by region 456-757 34.9-48.9 860-1472 5.2-23.6 1457- 2136 18.7-34.6 By age 25-34 y. 1778 47.8 1944 19.9 3722 33.2 34-44 y. 1492 44.6 2091 17.2 3583 28.7 45-54 y. 1789 44.5 3360 12.0 5149 23.5 55-64 y. 1844 35.5 3974 5.9 5818 15.3 Education Low than secondary 354 53.7 481 23.4 835 37.3 Secondary 3566 50.7 6157 17.0 9723 30.7 Higher 2983 34.4 4731 11.3 7714 20.3

The alcohol consumption in Russian population, %

Group Sex Total Men Women

low moderate high low moderate high low moderate high

All 21.6 72.1 6.3 23.7 74.1 2.2 23.0 73.2 3.8 By age 25-34 y. 19.2 74.5 6.3 19.9 77.2 2.9 19.5 75.9 4.5 34-44 y. 19.2 71.5 9.3 21.1 76.0 2.9 20.4 74.1 5.6 45-54 y. 23.2 71.2 5.6 23.4 74.7 2.0 23.3 73.5 3.3 55-64 y. 25.7 70.9 3.4 32.4 66.9 0.7 30.3 68.1 1.6 Education Low than secondary 30.1 63.5 6.4 37.3 60.5 2.2 34.1 61.8 4.0 Secondary 22.0 71.2 6.8 25.0 72.5 2.5 23.8 71.9 4.4 Higher 20.3 73.8 5.9 21.4 76.7 1.9 21.0 75.6 3.5

In Russia alcohol consumption is the highest in Europe. For one person -15.1 l of ethanol per year!

• Low: Do not drink alcohol during the past year
• Moderate: rarely used, ≤168 g (men), ≤84 g (women) of ethanol per week
• High: >168 g (men), >84 g (women) of ethanol per week

The prevalence of physical inactivity in Russian population, %

Group Sex Total (n=18 305; 38,8%) Men (n=6919; 36,1%) Women (n=11 368; 0,8%) Variation by region 23.1-49.2 30.7-47.4 27.9-47.8 By age 25-34 y. 37.6 46.8 42.3 34-44 y. 39.5 44.1 42.2 45-54 y. 35.3 40.9 39.0 55-64 y. 30.9 28.9 29.5 Education Low than secondary 51.0 42.8 46.6 Secondary 54.4 39.0 45.5 Higher 45.2 32.2 37.3

Physical inactivity: for adults 150 minutes of moderate or 75 minutes of intense aerobic physical activity per week (walking in the middle or high rate, or the equivalent in intensity is another option loads)

Inadequate fruit and vegetable consumption in Russian population, %

Group Sex Total (n=18 304; 41,9%) Men (n=6918; 50,3%) Women (n=11 386; 36,2%) Variation by region 31.2-71.2 25.4-50.1 32.7-59.0 By age 25-34 y. 57.2 41.3 48.9 34-44 y. 52.9 37.4 44.0 45-54 y. 46.4 32.9 37.6 55-64 y. 42.1 32.3 35.7 Education Low than secondary 51.0 42.8 46.6 Secondary 54.4 39.0 45.5 Higher 45.2 32.2 37.3

Inadequate fruit and vegetable consumption: Considered insufficient intake of vegetables and fruits at least 1 times a day, fish at least 2 times a week

Inadequate fish consumption in Russian population, %

Group Sex Total (n=18 304; 36,9%) Men (n=6918; 34,2%) Women (n=11 386; 38,8%) Variation by region 18.8-53.3 20.7-59.2 20.6-57.1 By age 25-34 y. 40.5 45.2 42.0 34-44 y. 34.9 40.3 38.0 45-54 y. 31.1 34.4 33.2 55-64 y. 29.2 34.4 32.7 Education Low than secondary 36.5 47.8 41.8 Secondary 34.0 40.1 37.4 Higher 34.2 37.1 36.0

The prevalence of dyslipidemia in Russian population

• Total cholesterol > 5.2 mmol/l - 62%
• Total cholesterol > 6.2 mmol/l - 44%

Muromtseva G.A., Kontsevaya A.V., Konstantinov V.V. et al. Prevalence of risk factors for noncommunicable diseases in the Russian population in 2012-2013. The study ESSE-RF. Kardiovaskulyarnaya Terapiya i Profilaktika 2014; 6: 4-11. Ershova AI, Meshkov AN, Yakushin SS, et al. Diagnosis and treatment of patients with severe hypercholesterolemia in real outpatient practice (according to the register REKVAZA). Ration Pharmacother Cardiol 2014; 10 (6): 612-6.

Conclusion for ESSE-RF epidemiological study

• Although the smoking rate is reduced, it still remains high,

especially among men

• The frequency of alcohol abuse decreased as a result of

prevention at the population level

• Increased frequency of malnutrition, especially among

young and middle-aged people

• Experience of effective population-level power adjustment

demonstrates the effectiveness of cooperation with the food industry, for effective correction of RF development of infrastructure projects is necessary

• Significant geographic variation of RF requires the

establishment of the regional prevention programs

OUTPATIENT REGISTER OF CARDIOVASCULAR DISEASES IN THE RYAZAN REGION (RECVASA): PRINCIPAL TASKS, EXPERIENCE OF DEVELOPMENT AND FIRST RESULTS

S.A. Boytsov, S.S. Yakushin, S.Yu. Martsevich, M.M. Loukianov, N.N. Nikulina, A.V. Zagrebelnyy, A.N. Vorobyov, K.G. Pereverseva, E.A. Pravkina, A.D. Deev1, E.Yu. Andreenko, A.I. Ershova1, A.N. Meshkov, R.P. Myasnikov, S.E. Serdyuk, M.S. Kharlap State Research Centre for Preventive Medicine, Moscow Ryazan State Medical University named after academician I.P. Pavlov, Ryazan Rational Pharmacother. Card. 2013;9(1):4-14

Included: 3300 patients with hypertension (HT), ischemic heart disease (IHD), congestive heart failure (CHF), atrial fibrillation (AF)

Analysis of outpatient cards of patients who applied for general practitioners or cardiologists in 3 outpatient clinics of Ryazan and the Ryazan Region Enrollment in the register the total of 3300 patients with HT, IHD, CHF, AF and their combinations in 2012-2013 (including 1000 patients at the pilot stage in March-May of 2012)

Information of end points once in 12 months:

• hospital admission,
• ambulance call,
• Surgical intervention

(due to CVD),

• myocardial infarction,
• stroke,
• lethal outcome

Estimation of diagnostics and treatment quality in 600 randomized patients called to an outpatient clinic 12 months after the enrollment in the register Additional examination

• f patients in outpatient

and hospital setting in Ryazan and Moscow

Necessity of additional examination No Yes

Diagnoses of cardiovascular diseases and their combinations in HT, IHD, CHF and AF patients enrolled in the register, n=1000

10 20 30 40 50 60 18.0% 6.5% 10.6% 50.4% 12.9% ≥ 75 years old 55-74 years old 25-54 years old

%

HT HT+IHD HT+CHF HT+IHD +CHF HT+IHD +CHF+AF

Arterial hypertension (HT) – 990 patients (99.0%) Ischemic heart disease (IHD) – 709 (70.9%) Chronic heart failure (CHF) – 748 (74.8%) Atrial fibrillation (AF) – 137 (13.7%)

Diagnostic techniques used in patients with cardiovascular diseases applied for the Ryazan outpatient clinic

20 40 60 80 100

Number of patients

120 140 160 180 10 15 89 16 20 7 10 1 35 70 167 BP-monitoring Stress-test Coronary angiography ECO CG BCA sonography ECG monitoring Men, n=260 Women, n=740

Various drug groups prescription in patients with HT, IHD, CHF and AF applied for the Ryazan outpatient clinic (n=1000)

100 200 300 400 500

Number of patients

600 700 HT – 99.0% IHD – 70.9% CHF – 74.8% AF – 13.7%

ACE inhibitors ARA Β-blockers Ca antagonists Diuretics Statins Antiplatelet agents Anti- coagulants Nit- rates

529 295 439 223 431 359 605 21 56

4% 5%

32%

59%

1500 persons

The TC level in patients from Russian FH registry

The independent Research Laboratory INVITRO has provided the national atherosclerosis society the data Moscow adult population, including 18,000 consecutive people who had lipid panel measurement during one randomly taken month in 2013 Levels of TC ≥7.5 mmol/L were observed in 1505 individuals (9%)!

The genetic testing of patients from Russian FH registry

Mutations were detected in 30 pts from 60

LDLR 1 мут LDLR 2 мут ApoB Комбинир.

21 6 1 1

mutation mutations Several mutations

Lipid-lowering therapy in outpatient practice (according to the ARGO-2 study)

Aim To study the features of lipid-lowering therapy with rosuvastatin in high and very high cardiovascular risk patients in real outpatient practice Material and methods (n=10547) Patients ≥30 years, visited internists or cardiologists of district outpatient clinics in the period from October 2013 to July 2014. Each patient fill in questionnaire. Determination of TC level was performed Doctors prescribed rosuvastatin therapy when indicated, in accordance with the Guidelines, choosing the dose on their

• wn. Repeated TC level was determined after 1 month.

Ration Pharmacother Cardiol 2016;12(21):147-153 DOI: http://dx.doi.org/10.20996/1819-6446-2016-12-2-147-153

ARGO-2. Division of patients by baseline levels

• f cholesterol (n=10547)

20% 25% 20% 9% 7% 6% 13%

<5 5.0-5.4 5.5-5.9 6.0-6.4 6.5-6.9 7.0-7.4 >7.5 Total Cholesterol, mmol/l

ARGO-2. The frequency of rosuvastatin daily doses

(n=7897)

10 20 30 40 50

% of patients

60 70

2.5 5 10 15 20 30 40

n=2 9.2 62.5 27.3

Rosuvastatin, mg per day

n=5 0.1 n=12 0.5 n=50

ARGO-2. Changes in total cholesterol levels, depending on

the prescribed dose of rosuvastatin (n=7897)

• 2.5
• 2.0
• 1.5
• 1.0

Δ mmo;l/l

• 0.5

10 20 30 40 Rosuvastatin, mg per day 5

1.2±0.6 1.4±0.6 1.7±0.7 1.6±0.4 2.1±1.0

• 20%
• 22%
• 24%
• 26%
• 28%

The average dose of rosuvastatin is assigned depending on the level of cholesterol (n=10547)

2 4 8 10 12

Rosuvastatin daily dose

14 16

<4 4-4.4 4.5-5 5-5.4 5.5-5.9 6-6.4 6.5-6.9 7-7.4 >7.5

11.6 11.4 11.0 11.4 11.3 12.0 12.5 14.3 15.7 Baseline total cholesterol level, mmol/l)

11 mg 15 mg

Lipid-lowering therapy in outpatient practice (according to the ARGO-2 study)

Conclusion: In real clinical practice, rosuvastatin for treatment of patients with high or very high cardiovascular risk is

• ften

prescribed in moderate doses and rarely in the maximum dose despite the proven lipid-lowering effect