Mult ltidisciplinaire Ric ichtlijn CVRM NVIVG symposium September - - PowerPoint PPT Presentation

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Mult ltidisciplinaire Ric ichtlijn CVRM NVIVG symposium September - - PowerPoint PPT Presentation

Sep 06, 2023 271 likes •577 views

Mult ltidisciplinaire Ric ichtlijn CVRM NVIVG symposium September 7, 2018 Frank L.J. Visseren Disclosures Research ZonMw, Wellerdieck-de Goede fonds, Leatare foundation, Vrienden UMC Utrecht, Dutch Heart Foundation Honoraria

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Mult ltidisciplinaire Ric ichtlijn CVRM

NVIVG symposium September 7, 2018 Frank L.J. Visseren

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Disclosures

  • Research

ZonMw, Wellerdieck-de Goede fonds, Leatare foundation, Vrienden UMC Utrecht, Dutch Heart Foundation

  • Honoraria

None

  • Stocks

None

  • Other …

Fase II/III clinical research in the field of lipid-lowering (Sanofi, Medicines Company, Amgen, Pfizer, Eli Lilly, Merck, ISIS) Guideline committees: CV Risk Management, CV Risk Management in elderly, (Genetic) lipid disorders

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De nieuwe CVRM richtlijn

Concept richtlijn maart 2018 (basis = ESC richtlijn 2016) Commentaarronde Definitieve versie richtlijn September 2018 Accordering verenigingen (NIV, NVVC, NHG, Hart-Vaat groep, NVN, Hartstichting, NVHVV) Publicatie December 2018 / Januari 2019

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De nieuwe SCORE-NL tabel

Concept richtlijn april 2018:

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De nieuwe CVRM richtlijn

Concept richtlijn april 2018:

  • Risico schatten: SCORE-NL, bij patienten met DM2, vaatziekten

en ouderen

  • Healthy lifestyle ………
  • Lipiden: patienten met vaatziekte LDL-c <1,8 mmol/l,

patienten met (heel) hoog CV risico LDL-c <2,6 mmol/l Nog lager is prima als dat makkelijk mogelijk is

  • Bloeddruk: <140 mmHg, bij comorbiditeit <130 mmHg
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De nieuwe CVRM richtlijn

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De nieuwe CVRM richtlijn

Concept richtlijn april 2018:

  • Risico schatten bij:
  • Gezonde mensen (SCORE-NL)
  • Patienten met DM2 (ADVANCE)
  • Patienten met vaatziekten (SMART)
  • Ouderen >70 jaar (Elderly riskscore)
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10-year risk for recurrent CVD events in CVD patients: SMART risk score

Dorresteijn ea, Heart. 2013 Jun;99(12):866-72 Kaasenbrood ea, Circulation. 2016;134:1419–1429 www.escardio.org Piepoli ea, EHJ 2016;37, 2315–2381

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iARR: large variation iRRR: no variation

individual Risk Reduction

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Optimal risk reduction according to guidelines and remaining 10-year CV risk

N=6904 Kaasenbrood, et al Circulation 2016;134:1419-1429

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Challenges in CVD risk prediction in apparently healthy people.

OK problem problem

Specific risk score for elderly Lifetime CVD risk score

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Clin Res in Cardiol. 2017 Jan;106(1):58-68 De Vries et al, ESC congress 2018, abstract 114

10-year CV risk (adjusted for competing risks) Lipid-lowering

CVD risk prediction in elderly (>70 yrs)

Not all elderly at high risk

BP lowering

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‘Vaatrisico’ App

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Tot hier de (concept) CVRM richtlijn

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Challenges in CVD risk prediction in apparently healthy people.

OK problem problem

Specific risk score for elderly Lifetime CVD risk score

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Competing risks Level of modifiable risk factors Lifetime treatment

Therapy benefit Costs and harms

Baseline risk Therapy effectiveness

Wouldn’t it be great to have lifetime predictions?

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Progress – Model Development

Dorresteijn ea, BMJ. 2016 Mar 30;352:i1548

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Additional CV-free life from PCSK9-i

Initiation age ≥70 Lifetime 20 years 10 years Lifetime 20 years 10 years 20 years 10 years 10 years Risk <10% LDL<1.8 8 3 1 5 3 1 2 1 LDL 1.8-2.6 10 4 1 7 4 1 3 1 1 LDL ≥2.6 14 6 2 9 6 2 4 2 1 Risk 10-20% LDL<1.8 10 4 1 7 5 1 3 1 1 LDL 1.8-2.6 15 6 2 10 6 2 4 2 1 LDL ≥2.6 22 9 2 14 9 3 5 3 2 Risk 20-30% LDL<1.8 15 6 2 10 8 2 5 2 2 LDL 1.8-2.6 22 10 3 15 10 3 7 3 2 LDL ≥2.6 34 13 4 19 14 4 9 5 4 Risk >30% LDL<1.8 21 11 4 12 10 4 7 3 2 LDL 1.8-2.6 23 11 4 16 13 5 9 5 3 LDL ≥2.6 NA NA NA 32 22 8 16 7 5 Initiation age ≥40-<50 Initiation age ≥50-<60 Initiation age ≥60-<70 with this combination of characteristics to derive a reliable median. Importantly, expected benefit is also determined by a patient’s risk of other

Kaasenbrood et al, Heart. 2018 Apr 5. pii: heartjnl-2017-312510

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Lifetime predictions with Age as Time-Scale

Geskus, Biometrics 2011;67:39-49 Dorresteijn ea, BMJ. 2016 Mar 30;352:i1548

10-year risk Lifetime risk

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CVD risk prediction in apparently healthy people

LIFE-CVD model

N Jaspers, ESC congress 2018, Young Investigators Award, abstract 1149.

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Lifetime prediction of CV events in vascular patients: SMART-REACH model

C-statistic 0.67 (95% CI 0.66-0.68) C-statistic 0.68 (95% CI 0.67-0.70) Kaasenbrood ea, JAHA 2018 epub Dorresteijn, ESC congress 2018, abstract 3141

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Great challenge for a clinician: translating the results of large clinical trials to individual patients

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Much to consider, much to choose: what for whom and when?

Risk factor Drugs Dose / combi Treatment goal Lipids Statin Ezetimibe PCSK9-mab Dose? Combination? LDL-c <2.5 mmol/l LDL-c <1.8 mmol/l Even lower Blood pressure ACEi/ARB, Diuretics CCB, Betablocker, Spironolactone Dose? Combination? SBP <140 mmHg SBP <130 mmHg Elderly goal Antithrombotics Antiplatelet (COX, P2Y12, cAMP) DOAC Dose? Combination? Diabetes Metformin, SU,DPP- 4 insulin, GLP-1, SGLT-2 HbA1c <53, <58, <64 mmol/mol Inflammation Triglycerides, Lp(a)

CV prevention starts with healthy lifestyle.

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  • Apparently healthy people: LIFE-CVD model 1
  • Derived and externally validated in cohorts: ARIC, MESA, EPIC, Heinz Nixdorf Recall (total n=69,523)

Externally validated scores for Lifetime CVD risk and Lifetime therapy benefit

1 Jaspers, ESC congress 2018, abstract 1149 2 Kaasenbrood et al, JAHA 2018 3 Berkelmans et al, in revision

  • Patients with CV disease: SMART-REACH model 2
  • Derived and externally validated in cohorts: SMART, REACH (total n=40,388)
  • Patients with DM2: DIAL model 3
  • Derived and externally validated in cohorts: Swedish NDR, Scottish Diab Reg, ADVANCE, ACCORD,

ASCOT, ALLHAT, SMART (total n=587,151)

Lifetime CVD risk score in primary prevention Lifetime CVD risk prediction for CVD patients

  • Elderly patients: Elderly model 4,5
  • Derived and externally validated in cohorts: PROSPER, SMART, ASCOT, HYVET (total n=11,090)

CV risk prediction in elderly

4 Stam-Slob et al, Clin Res in Cardiol. 2017 Jan;106(1):58-68 5 De Vries et al, ESC congress 2018, abstract 114

Lifetime CVD risk prediction in patients with Diabetes

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Lifetime risk Treatment effects CVD-free life

Individual lifetime treatment effects: gain in CVD-free life

Much to consider, much to choose: what for who and when?

Riskfactor Drugs Dose / combi Treatment goal Lipids Statin Ezetimibe PCSK9-mab Dose? Combination? LDL-c <2.5 mmol/l LDL-c <1.8 mmol/l Lower better? Blood pressure ACEi/ARB, Diuretics CCB, Betablocker, Spironolactone Dose? Combination? SBP <140 mmHg SBP <130 mmHg Elderly? Antithrombotics Antiplatelet (COX, P2Y12) DOAC Dose? Combination? Diabetes SGLT-2 GLP-1 HbA1c <53, <58, <64 mmol/mol New treatments Inflammation Triglycerides, Lp(a)

CV prevention starts with healthy lifestyle.

+ =

  • Apparently healthy people: LIFE-CVD model 1
  • Derived and externally validated in cohorts: ARIC, MESA, EPIC, Heinz Nixdorf Recall (total n=69,523)

Externally validated scores for Lifetime CV risk and Lifetime therapy benefit

1 Jaspers, ESC congress 2018, abstract 1149 2 Kaasenbrood et al, JAHA 2018 3 Berkelmans et al, in revision

  • Patients with CV disease: SMART-REACH model 2
  • Derived and externally validated in cohorts: SMART, REACH (total n = 40,388)
  • Patients with DM2: DIAL model 3
  • Derived and externally validated in cohorts: Swedish NDR, Scottish diab reg, ADVANCE, ACCORD,

ASCOT, ALLHAT, SMART (total n = 587,151)

Lifetime CVD risk score in primary prevention Lifetime CVD risk prediction for CVD patients

  • Elderly patients: Elderly model 4,5
  • Derived and externally validated in cohorts: PROSPER, SMART, ASCOT, HYVET (total n=11,090)

CV risk prediction in elderly

4 Clin Res in Cardiol. 2017 Jan;106(1):58-68 5 DeVries et al, ESC congress 2018, abstract 114

Lifetime CVD risk prediction in patients with Diabetes

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Interactive calculator

www.U-Prevent.com

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Conclusie CVRM richtlijn

  • 1 CVRM richtlijn voor 1e en 2e lijn
  • Iets lagere treatment targets voor sommige patienten met HVZ

(lipiden) en voor patienten met hoge bloeddruk en comorbiditeit

  • Risicoschatten voor iedereen!
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Conclusion risk prediction

  • 10-year CVD Risk prediction in CVD patients, patients with DM2, Elderly
  • Lifetime CVD risk prediction for:
  • Apparently healthy people
  • Patients with vascular disease
  • Patients with Diabetes Mellitus
  • Estimating gain in CVD-free life from (combination of) smoking cessation, lipid-

lowering, blood pressure-lowering, antithrombotic treatment

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Treating based on level of risk factors

Benefit-based Medicine!

Some final thoughts

Treating based on risk Treating based on individual treatment benefit Treating based on level of risk factors

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www.U-Prevent.com