New UK CVD Outcomes Strategy (2013) CVD Prediction and Prevention - PowerPoint PPT Presentation

New UK CVD Outcomes Strategy (2013)

CVD Prediction and Prevention Knowledge Communication Empowerment

JBS 2 Risk Guidelines (2005) Based on Short term (10yr) Absolute Risk  Treat ‘risk’ not risk factors  Focus on highest 10 year risk  But things have changed!  Lower the Bar for Statins?

Recent CV Guidelines USA: November 2013 UK: February 2014

New Cholesterol Guidelines to a Population-Based Sample 56 million people Mostly Elderly Men! Pencina NEJM 2014; 370: 1422-31

Statin Therapy Recommended Elderly man 79yr of age Total cholesterol 150 mg/dl HDL cholesterol 40 mg/dl Systolic blood pressure 120 mmHg Not taking antihypertensive medication Not diabetic Nonsmoker 13.7% Calculated 10-yr risk of CHD or stroke Kearney NEJM 2014; 370: 275-278

Statin Therapy Not Recommended Woman with hyperlipidemia and hypertension 46yr of age Total cholesterol 230 mg/dl HDL cholesterol 55 mg/dl Systolic blood pressure 150 mmHg Taking antihypertensive medication Not diabetic Nonsmoker 2.0% Calculated 10-yr risk of CHD or stroke Kearney NEJM 2014; 370: 275-278

Twin 64 year old Black Men SBP 127 mmHg 150 mmHg Smoking 0 0 Diabetes 0 0 Cholesterol 180 mg/dl 153 mg/dl HDL 70 mg/dl 70 mg/dl 10 years risk 7.0% 10.5%   NO STATIN STATIN

ESC CV Prevention Guidelines 2012 Disenfranchises the Young, especially Women! European Heart Journal 2012; 33: 1635-1701

Short Term v. Lifetime Risk in USA  Non-smoking men <45yrs  All women <65yrs <10% 10yr CHD Risk Marma Circ 2009;120:384-390  56% of US adults (87,000,000) have low (<10%) 10yr and high lifetime (≥39%) risk Marma Circ Cardiothoracic Qual Outcomes 2010;3:8-14

Young Man comes to your Clinic at 25 years 25 yrs 40yrs 58yrs “Waiting for dyslipidemic TC 310 mg/dl 310 mg/dl 310 mg/dl HDL 50 mg/dl 50 mg/dl 50 mg/dl patients to reach middle age TG 400 mg/dl 400 mg/dl 400 mg/dl before starting therapy is a LDL 180 mg/dl 180 mg/dl 180 mg/dl – – – FH of CVD failure of prevention” 25 kg/m 2 25 kg/m 2 25 kg/m 2 BMI Hazen 2014 – 10 yr risk 3.1% 7.5%

Lifetime Risk from Blood Pressure: NICE Short-term (10-year) risk underestimates lifetime CV risk of young people with hypertension... Lifetime risk with untreated stage 1 hypertension in this age group could be substantial. Lifetime risk assessments may be a better way to inform treatment decisions and evaluate cost effectiveness of earlier drug therapy.

Investing in Your Arteries! FH is paradigm for early, lifetime lowering of LDL for all of us…

Joint British Societies (JBS)3: March 26th 2014 Investing in Your Arteries for the rest of us!

JBS3 CVD Risk Approach Established CVD or Familial Hypercholesterolaemia Diabetes age >40 years Chronic Kidney Disease YES NO Lifestyle and drug therapy Use JBS3 risk calculator as recommended in JBS3 ABOVE current NICE threshold*: 10 year CVD risk score  Lifestyle + Drug therapy *Current NICE Guidance www.nice.org.uk BELOW current NICE threshold* Examine JBS3 ‘lifetime metrics’ Heart age Ongoing research on Projected CVD risk implementation and impact of To inform discussion on risk JBS3 recommendations and modification by: risk calculator Lifestyle changes Drug therapy when indicated www.jbs3risk.com

Joint British Societies(JBS 3) “Investing in Your Arteries”  Personalised , lifetime approach to CVD prevention  New CVD risk calculator with understandable risk metrics linked to interventions .Demonstrate the potential for benefit on a person’s risk over their lifetime .  Provides CV risk management guidance for the whole range of people . Heart March 2014 and www.jbs3risk.com

JBS3 Lifetime Risk Calculator Heart March 2014 and www.jbs3risk.com

JBS3 CVD Risk Calculator 35 year old female: adverse risk factors Heart March 2014 and www.jbs3risk.com

JBS3 CVD Risk Calculator 35 year old female: adverse risk factors Heart March 2014 and www.jbs3risk.com

Delayed Intensive Modification www.jbs3risk.com

Early Lifestyle Modification www.jbs3risk.com

Collect Data! National Healthchecks Programme

Next Steps: Formal Evaluation JBS3 Health Checks • Understanding • Behaviour • Risk factors • CV events

Impact of Heart Age Tool on Modifiable CVRFs 3153 subjects (47% male), Mean Age 46yrs, 12m FU 2 1.0 8 4 2.0 2.0 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 0.8 1 3 6 1.5 1.5 Systolic Blood Pressure (mmHg) 0.6 Total cholesterol (mg/dl) 2 4 1.0 1.0 0 Current smoking (%^) 0.4 Glucose (mg/dl) Heart Age (yrs) 1 2 0.5 0.5 Weight (kg) 0.2 -1 0.0 0 0 0.0 0.0 -2 -0.2 -2 -1 -0.5 -0.5 -0.4 -3 -4 -2 -1.0 -1.0 -0.6 -4 -0.8 -3 -6 -1.5 -1.5 -1.0 -5 -8 -4 -2.0 -2.0 Control FR Lopez-Gonzalez European Journal of Preventive Cardiology 2015: 22; 389 – 396 HA

JBS3 : Start of a new Process  Changes interactions with patients  Personalised approach  Empowers lifestyle  Not just a statin conversation!

Lifetime CVD Risk Management Launched on Feb 14th 2015

Heart Age NHS Calculator: 14/02/15-13/04/16 Total starts: 2,115,568 Total completes: 882,260 Patel BMJ Open 2016

World Heart Day: PHE Launch 29/09/16

CV RF lowering and Dementia Risk? Whats good for the Heart is good for the Brain!

Mid LifeCV RFs and Dementia Risk Factors CV composite Score 2.5 8845 HMO patients 2.0 Age 40-43 yrs Hazard Factor 1.5 1.0 0.5 0 1 2 3 4 Whitmer Neurology 2005; 64: 277-281

BP (1990-92) Gottesman JAMA Neurol 2014; 1646: E1-10

Multidomain Treatment and Cognitive Decline: FINGER Trial Ngandu Lancet 2015; 385: 2255-2263

National initiative for preventible dementia based on CV risk factor reduction

Final Thought… “ It should be the function of medicine to have people die young as late as possible ” Ernest L. Wynder M.D.