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

New UK CVD Outcomes Strategy (2013)

Knowledge Communication

CVD Prediction and Prevention

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

Pencina NEJM 2014; 370: 1422-31

56 million people Mostly Elderly Men!

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 Calculated 10-yr risk of CHD or stroke

13.7%

Statin Therapy Recommended

Kearney NEJM 2014; 370: 275-278

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 Calculated 10-yr risk of CHD or stroke

2.0%

Statin Therapy Not Recommended

Kearney NEJM 2014; 370: 275-278

SBP 127 mmHg 150 mmHg Smoking Diabetes Cholesterol 180 mg/dl 153 mg/dl HDL 70 mg/dl 70 mg/dl 10 years risk 7.0% 10.5%   NO STATIN STATIN

Twin 64 year old Black Men

European Heart Journal 2012; 33: 1635-1701

ESC CV Prevention Guidelines 2012

Disenfranchises the Young, especially Women!

Non-smoking men <45yrs All women <65yrs <10% 10yr CHD Risk 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 Marma Circ 2009;120:384-390

Short Term v. Lifetime Risk in USA

25 yrs 40yrs 58yrs TC 310 mg/dl 310 mg/dl 310 mg/dl HDL 50 mg/dl 50 mg/dl 50 mg/dl TG 400 mg/dl 400 mg/dl 400 mg/dl LDL 180 mg/dl 180 mg/dl 180 mg/dl FH of CVD – – – BMI 25 kg/m2 25 kg/m2 25 kg/m2 10 yr risk – 3.1% 7.5%

Young Man comes to your Clinic at 25 years

“Waiting for dyslipidemic patients to reach middle age before starting therapy is a failure of prevention” Hazen 2014

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.

Lifetime Risk from Blood Pressure: NICE

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

• f us!

Established CVD or Familial Hypercholesterolaemia Diabetes age >40 years Chronic Kidney Disease Lifestyle and drug therapy as recommended in JBS3 10 year CVD risk score ABOVE current NICE threshold*:

• Lifestyle + Drug therapy

BELOW current NICE threshold* Examine JBS3 ‘lifetime metrics’ Heart age Projected CVD risk To inform discussion on risk modification by: Lifestyle changes Drug therapy when indicated Ongoing research on implementation and impact of JBS3 recommendations and risk calculator

*Current NICE Guidance www.nice.org.uk

NO YES Use JBS3 risk calculator

JBS3 CVD Risk Approach

www.jbs3risk.com

Joint British Societies(JBS3)

“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

www.jbs3risk.com

Early Lifestyle Modification

Collect Data!

National Healthchecks Programme

Health Checks

JBS3

• Understanding
• Behaviour
• Risk factors
• CV events

Next Steps: Formal Evaluation

Systolic Blood Pressure (mmHg)

P<0.001

2 1

• 1
• 2
• 3
• 4
• 5

Weight (kg)

P<0.001

1.0 0.8 0.6 0.2

• 0.2
• 0.4
• 0.8
• 1.0

0.4 0.0

• 0.6

Glucose (mg/dl)

P<0.001

4 3 2 1

• 2
• 3
• 4
• 1

Total cholesterol (mg/dl)

P<0.001

8 6 4 2

• 4
• 6
• 8
• 2

Current smoking (%^)

P<0.001

2.0 1.5 1.0 0.5 0.0

• 1.0
• 1.5
• 2.0
• 0.5

Heart Age (yrs)

P<0.001

2.0 1.5 1.0 0.5 0.0

• 1.0
• 1.5
• 2.0
• 0.5

Impact of Heart Age Tool on Modifiable CVRFs

3153 subjects (47% male), Mean Age 46yrs, 12m FU

Lopez-Gonzalez European Journal of Preventive Cardiology 2015: 22; 389–396

Control FR 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

Whats good for the Heart is good for the Brain!

CV RF lowering and Dementia Risk?

Whitmer Neurology 2005; 64: 277-281

Mid LifeCV RFs and Dementia

2.5 2.0 1.5 1.0 0.5

1 2 3 4

Hazard Factor

Risk Factors CV composite Score

8845 HMO patients Age 40-43 yrs

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

• n CV risk factor reduction

“It should be the function of medicine to have people die young as late as possible”

Ernest L. Wynder M.D.

Final Thought…