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European Guidelines on CVD

Prevention
Fourth Joint European
Societies Task Force on
cardiovascular disease
prevention in clinical
practice
September 2007
1

Recent developments in CVD prevention in Europe


1994

First Joint Task Force Recommendations

1994

Joint European Societies Implementation


Group on Coronary Prevention

1995-96

EUROASPIRE I

1998

Second Joint Task Force Recommendations

1999-2000

EUROASPIRE II

2000

Joint European Societies CVD Prevention


Committee

2003

Third Joint Task Force Recommendations

2007

Fourth Joint Task Force Recommendations


2

The partners
ESC

EAS

ESH

ESGP/FM

ISBM

Risk evaluation
SCORE

EHN

Report to
Third Joint Task Force
on CVD Prevention
Advice
from

Audit
EUROASPIRE

EASD

IDFEurope

ESC
Committee on
practical guidelines
and policy
conference

Joint Cardiovascular
Prevention Committee

4th Joint Task Force on Prevention:

MEMBERS

z
z
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z
z
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z
z
z

Dan Atar [ESC]


Knut Borch-Johnsen
[EASD/IDF Europe]
Gudrun Boysen [EUSI]
Gunilla Burell [ISBM]
Renata Cifkova [ESH]
Jean Dallongeville
Guy de Backer [ESC]
Shah Ebrahim [ESC]
Bjorn Gjelsvik
[ESGP/FM/Wonca]
Christoph HermannLingen [ISBM]
Arno W Hoes
[ESGP/FM/Wonca]

z
z
z
z
z
z
z
z
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Steve Humpries [ESC]


Mike Knapton [EHN]
Joep Perk [EACPR]
Sylvia G Priori [ESC]
Kalevi Pyorala [ESC]
Zeljko Reiner [EAS]
Luis Ruilope [ESC]
Susana Sans-Menendez
[ESC]
Wilma Scholte Op Reimer
[ESC council on CV Nursing]
Peter Weissberg [EHN]
David Wood [ESC]
John Yarnell [EACPR]
Jose Luis Zamorano
[ESC/CPG]
5

4th Joint Task Force on Prevention:


SPECIAL PEOPLE,
SPECIAL THANKS
INVITED EXPERTS

ESC STAFF

Marie-Therese Cooney
Alexandra Dudina
Tony Fitzgerald
Edmond Walma

Keith McGregor
Veronica Dean
Catherine Despres
Sophie Squarta

JTF4 on CVD PREVENTION

CONTENTS

1. Introduction
2. Scope of the problem;
past and future
3. Prevention strategies
and policy issues
4. How to evaluate
scientific evidence
5. Priorities total risk
estimation and
objectives
6. Behaviour change and
behavioural risk factors
7. Smoking
8. Nutrition, overweight
and obesity
9. Physical activity
10. Blood pressure

11. Plasma lipids


12. Diabetes and metabolic
syndrome
13. Psychosocial factors
14. Inflammation markers and
haemostatic factors
15. Genetic factors
16. New imaging methods to
detect asymptomatic
individuals at high risk
17. Gender issues: CVD in
women
18. Renal impairment as a risk
factor in CVD
19. Cardioprotective drug
therapy
20. Implementation strategies

Whats new in the Fourth Joint Task Force


Guidelines on the Prevention of CVD?
z
z
z
z
z
z
z

Increased input from general practice and


cardiovascular nursing.
Increased emphasis on exercise, weight,
and lifestyle.
More detailed discussion on the
limitations of present systems of grading
evidence.
Re-defined priorities and objectives.
Revised approach to risk in the young.
More information from SCORE on total
events, diabetes, HDL cholesterol, and
body mass index (BMI).
New sections on gender, heart rate,
BMI/waist circumference, other
manifestations of CVD including stroke
and renal impairment.
8

JTF4 on CVD Prevention


in Clinical Practice
1. INTRODUCTION

Why develop a preventive


strategy in clinical practice?
1.Cardiovascular disease (CVD) is the major cause
of premature death in Europe. It is an important
cause of disability and contributes substantially
to the escalating costs of health care.
2.The underlying atherosclerosis develops
insidiously over many years and is usually
advanced by the time that symptoms occur.
3.Death from CVD often occurs suddenly and
before medical care is available, so that many
therapeutic interventions are either inapplicable
or palliative.
4.The mass occurrence of CVD relates strongly to
lifestyles and to modifiable physiological and
biochemical factors.
5.Risk factor modifications have been shown to
reduce CVD mortality and morbidity,
particularly in high risk subjects.
10

What are the objectives of


these guidelines?

To help health professionals to reduce the


occurrence of coronary heart disease, stroke
and peripheral artery disease and their
complications.

To achieve this by providing practical and


accessible advice with regard to the rationale
for prevention, priorities, objectives, risk
assessment and management through lifestyle
measures and selective drug usage.

To encourage the development of national


guidance on CVD prevention through the
formation of multi-disciplinary national
guideline and implementation partnerships
that are compatible with local political, social,
economic and medical circumstances.
11

JTF4 on CVD Prevention


in Clinical Practice
2. THE SCOPE OF THE
PROBLEM:
PAST AND FUTURE

12

CVD Prevention: The scope of


the problem
z

z
z
z

z
z

CVDs are the major causes of death and disability


in Europe - 4.35 million in Europe, 1.9 million in the
EU.
MORE women than men die from CVD 2.3 million women, 2 million men.
10 fold regional differences, with reductions in the
West.
Reductions in age-specific CVD mortality
generally represent a transference of the problem
to older persons, with increasing heart failure.
Generally poor risk factor control (EuroAspire).
Improvements in smoking, BP and lipid control
offset by reduced activity, increasing obesity and
consequent diabetes.
13

CVD - the size of the problem


z
z
z
z
z
z
z

Current life expectancy 65 (45-80) yrs.


1900- <10% deaths due to CVD.
1970- biggest cause of death in developed
countries.
Falling in developed countries, rising fast
in developing ones.
2000- biggest cause of death worldwide.
1996- 15,000,000 deaths.
2020- 25,000,000 deaths.
(Source WHO)
14

CVD Prevention:
CHALLENGES

z Inactivity
z

Obesity

Stroke

Heart failure

Gender and social class inequalities

Renal failure

Implementation
15

JTF4 on CVD Prevention


in Clinical Practice

3. PREVENTION
STRATEGIES AND
POLICY ISSUES

16

WHO report on the Prevention of


CHD (and hence CVD) defined three
components to preventive strategy:
1. Population
2. High risk
3. Secondary prevention
z

The prevention paradox- high risk individuals


gain most from preventive measures- but most
CVD deaths come from apparently low risk
subjects because they are so numerous.

The three strategies should be complementary,


not competitive.

Policy is defined further in the Osaka


declaration.
17

Fig. 1 - The expected number of CVD deaths at increasing levels of predicted risk.
Illustration of the fact that most events occur in low risk subjects with few deaths
among high risk subjects.

CVD Deaths (all cohorts)

80

60

40

20

9 10 11 12 13 14 15 16 17 18 19

Predicted Risk (Men aged 50-59 )

18

The European Heart Health Charter


and the Guidelines on
Cardiovascular Disease Prevention
z

The European Heart Health Charter advocates


the development and implementation of
comprehensive health strategies, measures
and policies at European, national, regional,
and local level that promote cardiovascular
health and prevent CVD.
These guidelines aim to assist physicians and
other health professionals to fulfil their role in
this endeavour, particularly with regard to
achieving effective preventive measures in
day-to-day clinical practice.
They reflect the consensus arising from a
multi-disciplinary partnership between the
major European professional bodies
represented.
19

JTF4 on CVD Prevention


in Clinical Practice

4. HOW TO EVALUATE
SCIENTIFIC EVIDENCE

20

Desirable attributes of guidelines


(4th Joint European Societies
Task Force on CVD Prevention)
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z
z
z
z
z
z
z
z

Validity
Reproducibility
Reliability
Representative development
Clinical applicability
Clinical flexibility
Clarity
Meticulous documentation
Scheduled review
21

ESC classification of
evidence. Is it appropriate?
Classes of recommendations:
I
II
IIa
IIb
III

Evidence/general agreement that a treatment


is benefical, useful and effective
Conflicting evidence/divergence of opinion
Weight of evidence in favour
Less well established
Not useful/effective, may be harmful

Levels of evidence:
A
B
C

Multiple RCTs or meta-analyses


Single RCT or large non-randomized studies
Consensus of opinion of experts and/or small
studies, retrospective studies, registries
22

Guidelines- refinement of the


concepts of evidence-based medicine
z

The evidence must be appropriate to the question,


eg causality with regard to a risk factor, evaluation
of a diagnostic test, therapy- benefits and harm.

Emphasis on the randomized controlled trial for


TREATMENTS is entirely appropriate.

But lifestyle measures may not be amenable to


RCTs- eg smoking.

Therefore drug treatments may be given undue


emphasis.

The weighting given to evidence must therefore


reflect what is possible in any given discipline.

Being re-examined by NICE, SIGN and the WHO


GRADE system.
23

JTF4 on CVD Prevention


in Clinical Practice
5. PRIORITIES, TOTAL
RISK ESTIMATION
AND OBJECTIVES

24

0 3 5 140 5 3 0

People who stay healthy tend


to have certain characteristics:
0
No tobacco
3
Walk 3 km daily, or 30 mins any
5
140
5
3
0

moderate activity

Portions of fruit and vegetables a day


Blood pressure less than 140 mm Hg
systolic
Total blood cholesterol <5 mmol/l
LDL cholesterol <3 mmol/l
Avoidance of overweight and diabetes
25

What are the PRIORITIES for


CVD prevention in clinical practice?
1.

Patients with established atherosclerotic


CVD.

2.

Asymptomatic individuals who are at


increased risk of CVD because of :

2.1 Multiple risk factors resulting in raised total CVD risk


(5% 10-year risk of CVD death);
2.2 Diabetes type 2 and type 1 with microalbuminuria;
2.3 Markedly increased single risk factors especially if
associated with end-organ damage.
3

Close relatives of subjects with premature


atherosclerotic CVD or of those at
particularly high risk.
26

What are the OBJECTIVES of


CVD prevention?
1.

To assist those at low risk of CVD to maintain


this state lifelong, and to help those at
increased total CVD risk to reduce it.

2.

To achieve the characteristics of people who


tend to stay healthy:
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8

No smoking;
Healthy food choices;
Physical activity: 30 min of moderate activity a day;
BMI <25 kg/m2 and avoidance of central obesity;
BP <140/90 mmHg;
Total cholesterol <5 mmol/L (~190 mg/dL);
LDL cholesterol <3 mmol/L (~115 mg/dL);
Blood glucose <6mmo/L (~110 mg/dL).

27

What are the OBJECTIVES of


CVD prevention?
3.

To achieve more rigorous risk factor control


in high risk subjects, especially those with
established CVD or diabetes:
3.1 Blood pressure under 130/80 mmHg if feasible;
3.2 Total cholesterol <4.5 mmol/L (~175 mg/dL)
with an option of <4 mmol/L (~155 mg/dL) if
feasible;
3.3 LDL cholesterol <2.5 mmol/L (~100 mg/dL)
with an option of <2mmol/L (~80 mg/dL) if
feasible;
3.4 Fasting blood glucose <6 mmol/L (~110 mg/dL)
and HbA1c <6.5% if feasible.

4.

To consider cardioprotective drug therapy in


these high risk subjects especially those with
established atherosclerotic CVD.
28

When do I assess
cardiovascular risk?
z
z

If the patient asks for it.


If, during a consultation:
- The person is a middle aged smoker.
- There is obesity, especially abdominal.
- One or more risk factors such as blood
pressure, lipids or glucose is raised.
- There is a family history of premature CVD
or of other risk factors.
- There are symptoms suggestive of CVD. If
confirmed, risk factors should be assessed
but use of the SCORE chart is not necessary
as the person is already at high risk.
29

Why stress assessment of


total CVD risk ?
zMultiple

risk factors usually contribute


to the atherosclerosis that causes
CVD.

zThese

risk factors interact, sometimes


multiplicatively.

zThus

the aim should be to reduce


total risk; if a target cannot be
reached with one risk factor, total
risk can still be reduced by trying
harder with others.
30

Fig 2
The relationship of total cholesterol / HDL cholesterol ratio to 10 year fatal
CVD events in men and women aged 60 yrs with and without risk factors,
based on a risk function derived from the SCORE project.

10 yr risk of fatal CVD (%)

30

Men, smoking,
SBP=160 mmHg

25

Men, non-smoking,
SBP=120 mmHg

20

15

Women, smoking,
SBP=160 mmHg

10

Women, nonsmoking, SBP=120


mmHg

TC/HDL ratio

31

Table 1

Impact of combinations of risk


factors on 10 year risk of CVD death
SEX

AGE

60

60

60

60

CHOL

BP

SMOKE RISK %

120

NO

140

YES

160

NO

180

YES

21

32

How do I assess CVD risk


quickly and easily?
z

Those with~known CVD;


~type 2 diabetes or type 1 diabetes with
microalbuminuria;
~ very high levels of individual risk factors.
are already at INCREASED CVD RISK and
need management of all risk factors.

For all other people, the SCORE risk charts


can be used to estimate total risk-this is
critically important because many people
have mildly raised levels of several risk
factors that, in combination, can result in
unexpectedly high levels of total CVD risk.
33

Assessing cardiovascular risk:


What are the components?
z

History: Previous CVD or related diseases, family history


of premature CVD, smoking, exercise and dietary habits,
social and educational status.

Examination: BP, heart rate, heart and lung auscultation,


foot pulses, height, weight, (Body mass index), waist
circumference. Fundoscopy in severe hypertension.

Lab test: Urine for glucose and protein, microalbuminuria


in diabetics. Cholesterol and if practicable, fasting lipids
(LDL and HDL cholesterol, triglycerides) glucose,
creatinine.

ECG and exercise ECG if angina suspected.

ECG and consider echocardiogram in hypertensive


persons.

Premature or aggressive CVD, especially with a family


history of premature CVD: Consider High sensitivity CRP,
lipoprotein (a), fibrinogen, homocysteine if feasible,
specialist referral.
34

How do I use the SCORE charts to


assess total CVD risk in
asymptomatic persons?

1. Use the low risk chart in Belgium*, France, Greece*,


Italy, Luxembourg, Spain*, Switzerland, and Portugal;
use the high risk chart in other countries of Europe
* Updated, re-calibrated charts are now available for
Belgium, Germany, Greece, The Netherlands, Poland,
Spain, and Sweden.
2. Find the cell nearest to the persons age, cholesterol,
and BP values, bearing in mind that risk will be higher
as the person approaches the next age, cholesterol or
BP category.
3. Check the qualifiers.
4. Establish the absolute 10-year risk for fatal CVD.
Note that a low absolute risk in a young person may conceal
a high relative risk; this may be explained to the person by
using the relative risk chart. As the person ages, a high
relative risk will translate into a high absolute risk. More
intensive lifestyle advice will be needed in such persons.

35

Risk estimation using SCORE: qualifiers


The charts should be used in the light of the clinicians
knowledge and judgement, especially with regard to local
conditions.
z As with all risk estimation systems, risk will be
overestimated in countries with a falling CVD mortality
rate, and underestimated if it is rising.
z At any given age, risk appears lower for women than men.
This is misleading since, ultimately, more women than men
die from CVD. Inspection of the charts shows that their risk
is merely deferred by 10 years.
z Risk may be higher than indicated in the chart in:
z

~Sedentary or obese subjects, especially those with central


obesity;
~Those with a strong family history of premature CVD
~The socially deprived;
~Subjects with diabetesrisk may be 5-fold higher in women with
diabetes and 3-fold higher in men with diabetes compared with
those without diabetes;
~Those with low HDL cholesterol or high triglycerides;
~Asymptomatic subjects with evidence of pre-clinical
atherosclerosis, for example a reduced ankle-brachial index,
or on imaging such as carotid ultrasonography or CT scanning.

36

10 year risk of fatal CVD in


high risk regions of Europe

37

10 year risk of fatal CVD in low


risk regions of Europe

38

Relative Risk Chart


This chart may used to show younger people at low absolute
risk that, relative to others in their age group, their risk may
be many times higher than necessary. This may help to
motivate decisions about avoidance of smoking, healthy
nutrition and exercise, as well as flagging those who may
become candidates for medication

39

How do I manage the


components of total CVD risk?
z

The patient and the doctor agree


that a risk assessment is indicated,
and the patient is informed that the
result may lead to suggestions
regarding life style change and the
possibility of life long medication.

There are time and resources to


discuss and follow up advice and
treatment.

The doctor should be aware of and


respect the patients own values and
choices.
40

Total CVD risk management:


A key message
z

Management of the individual


components of risk such as smoking,
diet, exercise, blood pressure and
lipids impacts on total risk.

Thus, if perfect control of a risk factor


is difficult (for example, blood
pressure control in the elderly), total
CVD risk can still be reduced by
reducing other risk factors such as
smoking or blood cholesterol.
41

When do I assess total CVD risk?


If the patient asks for it

If, during a consultation:


The person is a middle-aged smoker
One or more risk factors such as a
raised blood cholesterol is known about

There is a family history of premature


CVD or of major risk factors such as
hyperlipidaemia
Symptoms suggestive of CVD

Assessing risk: what do I do?


Use SCORE unless known CVD, diabetes, very high single risk factors
History: Previous diseases,
family history of premature CVD,
smoking, exercise, and dietary
habits
Examination: BP, HR, heart and
lung auscultation, foot pulses,
height, weight, (Body mass index),
waist circumference.

Established
CVD

Lab tests: Urine for glucose and


protein. Cholesterol and fasting lipids
if practicable (LDL and HDL
cholesterol, triglycerides) glucose,
creatinine
ECG and exercise ECG if angina
suspected

DM2 or DM1 with


microalbuminuria

Markedly
elevated single
risk factor

ECG and consider


echocardiogram in young or
severely hypertensive persons
Consider high sensitivity CRP,
lipoprotein (a), fibrinogen,
homocysteine, specialist referral
if premature CVD or family
history of same

SCORE risk 5%

SCORE risk < 5%

42

Lifestyle recommendations
No smoking

Healthy diet

Weight reduction if BMI 25 kg/m2


and especially if BMI 30 kg/m2

Wide variety of foods


Energy intake adjusted to avoid
overweight
Encourage: fruits, vegetables,
wholegrain cereals and bread, fish
(especially oily), lean meat, low fat
dairy products
Replace saturated fat with
monounsaturated and polyunsaturated
fats (vegetable and marine)
Hypertensive subjects should reduce
salt intake

No further weight gain if WC 80-88


cm in women and WC 94-102 cm
in men. Advise weight loss if WC
88 cm in women and 102 cm in
men
30 min of moderately vigorous
exercise on most days of the week;
exercise and weight reduction can
prevent diabetes

Lifestyle advice
to maintain low risk
status
Re-assess total
risk at regular
intervals

Drug treatment
More likely as SCORE risk exceeds 5% and especially as it approaches 10%, or
if there is end-organ damage. In the elderly, drug treatment is generally not
recommended below 10% risk unless a specific indication exists
Consider BP-lowering drugs when BP 140/90
Consider statins when total cholesterol 5 or LDL 3
In patients with CVD: Aspirin. Statins for most
In patients with diabetes: consider glucose-lowering drugs

43

JTF4 on CVD Prevention


in Clinical Practice
6. PRINCIPLES OF
BEHAVIOUR CHANGE AND
MANAGEMENT OF
BEHAVIOURAL RISK
FACTORS
44

Managing total riskTIPS TO HELP BEHAVIOUR


CHANGE
z
z
z
z
z
z
z
z
z
z

Develop a sympathetic alliance with the patient.


Ensure the patient understands the relationship
between lifestyle and disease.
Use this to gain commitment to lifestyle change.
Involve the patient in identifying the risk factors
to change.
Explore potential barriers to change.
Help design a lifestyle change plan.
Be realistic and encouraging- ANY increase in
exercise is good and can be built on.
Reinforce the patients efforts to change.
Monitor progress through follow-up contacts.
Involve other health care staff wherever possible.
45

Managing total CVD risk:


Why do people find it hard to
change their lifestyle?
z

Socio-economic status: Low SES, including

low educational level and low income, impedes


the ability to adopt lifestyle change.

Social isolation: People living alone are more

Stress: Stress at work and at home makes it

Negative emotions: Depression, anxiety and

likely to have unhealthy lifestyles.

more difficult for people to adopt and sustain a


healthy lifestyle.

hostility impede lifestyle change.

Complex or confusing advice


Increased physician awareness of these factors
facilitates empathy, counselling, and the provision
of sympathetic, simple, and explicit advice.
46

JTF4 on CVD Prevention


in Clinical Practice

7. SMOKING

47

Smoking and CVD


z

Smoking is a strong and independent


causal risk factor for both first and
subsequent CVD events, as well as for
multiple other diseases.

Passive smoking also increases risk.

Smoking greatly increases the risks


associated with other risk factors.

Those who stop smoking after a CHD


event have half the mortality of those
who continue. No drug is so effective.

48

Managing total CVD risk:


SMOKING

All smokers should be professionally encouraged to


permanently stop smoking all forms of tobacco
The 5 As can help-

A- ASK systematically identify all smokers at


every opportunity.
A- ASSESS: Determine the persons degree of
addiction and his/her readiness to cease
smoking.
A- ADVISE: Unequivocally urge all smokers to
quit.
A- ASSIST: Agree on a smoking cessation
strategy including behavioural counselling,
nicotine replacement therapy, and/or
pharmacological intervention.
A- ARRANGE a schedule of follow-up visits.
49

JTF4 on CVD Prevention


in Clinical Practice
8. NUTRITION,
OVERWIGHT AND
OBESITY

50

Managing total CVD risk:


HEALTHY FOOD CHOICES
All individuals should be advised about food choices that are
associated with a lower CVD risk. High risk persons should
receive specialist dietary advice if feasible
General recommendations should suit the local culture
z

A wide variety of foods should be eaten

Energy intake should be adjusted to avoid overweight.

Encourage: Fruits, vegetables, wholegrain cereals and


bread, fish (especially oily), lean meat, low fat dairy
products

Replace saturated fats with the above foods and with


monounsaturated and polyunsaturated fats from
vegetable and marine sources to reduce total fat to
<30% of energy, of which less than 1/3 is saturated.

Reduce salt intake if blood pressure is raised by avoiding


table salt and salt in cooking, and by choosing fresh or
frozen unsalted foods. Many processed and prepared
foods, including bread, are high in salt.
51

Managing total CVD risk:


BODY WEIGHT
Increasing body weight is associated with increased
total and CVD mortality and morbidity, mediated in
part through increases in blood pressure and blood
cholesterol, reduced HDL cholesterol, and an
increased likelihood of diabetes.
z Weight reduction is recommended for obese people
(BMI 30 kg/m2) and should be considered for those
who are overweight (BMI 25 and <30 kg/m2).
z

Men with a waist circumference of 94102 cm and


women with a waist circumference of 8088 cm are
advised not to increase their weight. Men above 102
cm and women above 88 cm are advised to lose
weight.
z Restriction of total calorie intake and regular physical
exercise are the cornerstones of weight control. It is
likely that improvements in central fat metabolism
occur with exercise even before weight reduction
occurs.
z

52

JTF4 on CVD Prevention


in Clinical Practice
9. PHYSICAL
ACTIVITY

53

Managing total CVD risk:


PHYSICAL ACTIVITY

Stress that positive health benefits occur with


almost any increase in activity; small amounts of
exercise have an additive effect; exercise
opportunities exist in the workplace, for example by
using stairs instead of the lift.

Try to find leisure activities that are positively


enjoyable.

30 min of moderately vigorous exercise on most


days of the week will reduce risk and increase
fitness.

Exercising with family or friends tends to improve


motivation.

Added benefits include a sense of well-being,


weight reduction, and better self-esteem.

Continued physician encouragement and support


may help in the long term.
54

JTF4 on CVD Prevention


in Clinical Practice

1O. BLOOD PRESSURE

55

JTF4 Blood pressure


z

Risk factor for all atherosclerotic CVDs, heart failure and


renal failure, cognitive impairment.

Risk rises progressively from <120/80 on.

Other RFs such as diabetes and dyslipidaemia are more


likely in hypertensives, and interact to greatly increase risk.

Direct association with body weight- 5 KG reduction


reduces BP by 4.4/3.6 mm Hg.

Physical training can reduce BP by 3.5/3.2 mm Hg.

Multiple nutritional factors affect BP- encourage fruit,


vegetables, low-fat dairy products, reduced saturated fat
and salt.

Benefits of BP reduction apply to both sexes, up to at least


age 80, and to CHD, stroke, heart failure, renal function and
possibly to cognitive impairment.

Effective BP control is more important than the choice of


agent.

56

Managing total CVD risk:


Blood Pressure
In ALL cases, look for and manage all risk factors. Those with established CVD,
diabetes or renal disease are at markedly increased risk, and a BP of <130/80 is
desirable if feasible. For all other people, check SCORE risk. Those with target organ
damage are managed as increased risk.
SCORE
CVD risk

Normal
<130/85

High Normal
130139/
8589

Grade 1
140159/
9099

Grade 2
160179/
100109

Grade 3

Low
<1%

Lifestyle
advice

Lifestyle
advice

Lifestyle
advice

Drug Rx
if persists

Drug Rx

Moderate
14%

Lifestyle
advice

Lifestyle
advice

+consider
drug Rx

Drug Rx
if persists

Drug Rx

Increased
5-9%

Lifestyle
advice

+consider
drug Rx

Drug Rx

Drug Rx

Drug Rx

Markedly
increased
10%

Lifestyle
advice

+consider
drug Rx

Drug Rx

Drug Rx

Drug Rx

180/110

57

JTF4 on CVD Prevention


in Clinical Practice

11. PLASMA LIPIDS

58

JTF4 Lipids
z

z
z
z

Total and LDL cholesterol relate to CVD risk causally,


strongly, independently and progressively and are the primary
focus of management. Reduction unequivocally reduces CVD
risk, including stroke.
Moderately raised triglycerides (>1.7 mmol/l, ~150 mg/dl)
relate to risk; may relate to particle size; inverse association
with HDL cholesterol; associations with abdominal obesity &
blood sugar and possible thrombogenic effects- LOOK for
these!
HDL cholesterol relates inversely to CVD risk. HDL is
antiatherogenic, anti-inflammatory and anti-thrombotic, and is
involved in reverse cholesterol transport. <1 mmol/l (~40
mg/dl) in men and <1.2 mmol/l (~45 mg/dl) in women
denotes increased risk.
Total cholesterol:HDL ratio relates to risk but better risk
estimation may be possible if they are considered separately.
Apo B/A1 ratio relates strongly to risk but it is not known if
it should be a treatment goal.
Lp(a) relates to risk, is genetically determined, but resistant
to modification.
59

Managing total CVD risk: Lipids

In ALL cases, look for and manage all risk factors. Those with established CVD, diabetes
type 2 or type 1 with microalbuminuria, or with severe hyperlipidaemia are already at high
risk. For all other people, the SCORE charts can be used to estimate total risk

Established
CVD

Diabetes as
above

Markedly
raised lipid
levels

Dietary and exercise advice together


with attention to all risk factors comes
first.
Aim to reduce total cholesterol to <4.5
mmol/L (~175 mg/dL) or <4 mmol/L
(~155 mg/dL) if feasible, and LDLcholesterol to <2.5 mmol/L (~100
mg/dL) or <2 mmol/L (~80 mg/dL) if
feasible.
This will require statin treatment in
many. Some recommend statins for all
CVD and most diabetic patients
regardless of baseline levels.

SCORE risk 5%

SCORE risk < 5%

Lifestyle advice for 3


months, then reassess
SCORE and fasting lipids

SCORE risk
still 5%

TC <5 mmol/l
and LDL-C <3
mmol/l and
SCORE now
<5%

Treatment goals are not defined for HDL cholesterol and triglycerides, but
HDL-C <1.0 mmol/L (~40 mg/dL) for men and <1.2 mmol/L (~45 mg/dL)
for women and fasting triglycerides of >1.7 mmol/L (~150 mg/dL) are
markers of increased cardiovascular risk

60

Lifestyle
advice to
reduce
total chol
<5
mmol/L
(~190
mg/dL)
and LDL-C
<3
mmol/L
(~115
mg/dL)
Regular
follow-up

JTF4 on CVD Prevention


in Clinical Practice
12. DIABETES AND
THE METABOLIC
SYNDROME

61

JTF4 Diabetes and the


metabolic syndrome
z

z
z
z
z
z

Linear, graded relationship between glucose and CVD risk,


especially for 2 hour post load glucose and for HbA1c
from levels well within the normal range
Relative risk of CVD for impaired glucose tolerance is
approx 1.5, for diabetes 2-4, maybe more in women
Risk relates to both the diabetic state and related factors,
and to associated conventional, modifiable risk factors
The ideal is to prevent the occurrence of diabetes if
possible
Good metabolic control prevents microvascular
complications
Lipid targets are total cholesterol < 4.5 mmol/l (~175
mg/dl), or <4.0 mmol/l (~155 mg/dl), if feasible, and LDL
chol <2.5 mmol/l (~100 mg/dl) or < 2.0 mol/l (~80
mg/dl) if feasible
BP target is < 130/80 mm Hg if feasible
62

Treatment targets in patients with type 2 diabetes


Unit

Target

HbA1c (DCCTaligned)

HbA1c (%)

6.5 if feasible

Plasma glucose

Fasting/pre-prandial
mmol/L (mg/dL)

<6.0 (110) if feasible

Post-prandial
mmol/L (mg/dL)

<7.5 (135) if feasible

Blood pressure

mmHg

130/80

Total cholesterol

mmol/L (mg/dL)
mmol/L (mg/dL)

<4.5 (175)
<4.0 (155) if feasible

LDL cholesterol

mmol/L (mg/dL)
mmol/L (mg/dL)

<2.5 (100)
<2.0 (80) if feasible
63

The Metabolic Syndrome


z

The term metabolic syndrome refers to


the combination of several factors that
tend to cluster together- central obesity,
hypertension, low HDL cholesterol, raised
triglycerides, and raised blood sugar- to
increase risk of diabetes and CVD.
This implies that, if one component is
identified, a systematic search for the
others is indicated, together with an active
approach to managing all of these risk
factors.
Physical activity and weight control can
radically reduce the risk of developing
diabetes in those with the metabolic
syndrome.
64

JTF4 on CVD Prevention


in Clinical Practice
13. PSYCHOSOCIAL
FACTORS

65

JTF4 Psychosocial factors


z

Appear to contribute independently to CVD


risk- both of developing CVD and for
prognosis thereafter.

Also act as barriers to achieving lifestyle


change and to adhering to treatment.

Factors include low socio-economic status,


social isolation, poor social support, work
stress (high demand, low control; high
effort, low reward) domestic stress,
hostility, depression.

Hard to quantify the benefits of


interventions. Stress management programs
may improve well-being, risk factor levels
and CVD outcomes.
66

JTF4 on CVD Prevention


in Clinical Practice
14. INFLAMMATION
MARKERS AND
HAEMOSTATIC FACTORS

67

Inflammation markers and


haemostatic factors
z

Criteria for evaluation include applicability


to all relevant CVD events; ability to predict
in short, intermediate and long-term followup; standardised measurements;
examination of variability; degree of
correlation with established risk factors;
improvement in overall prediction of events.

Reverse causality may be a problem- sub


clinical disease my increase the factor.

Incorporation of CRP, fibrinogen and other


emerging risk factors for the estimation of
CVD risk may be premature.
68

JTF4 on CVD Prevention


in Clinical Practice

15. GENETIC FACTORS

69

Genetic factors
z

A family history of CVD in a first degree


relative aged <55 (male) or 65 (female)
carries an independent relative risk of 1.5-1.7.

Heritability of lipid phenotypes is 40-60%,


>90% for Lp(a).

Dominant genotypes such as familial


hypercholesterolaemia exert large effects but
are infrequent. Screening for multiple
poymorphisms with small but cumulative
effects on risk is not yet realistic.

Close relatives of persons with premature CVD


should have risk assessments; some will have,
for example, familial hyperlipidaemia. Others
will share high risk lifestyles.
70

JTF4 on CVD Prevention


in Clinical Practice
16. NEW IMAGING METHODS
TO DETECT ASYMPTOMATIC
INDIVIDUALS AT HIGH RISK
FOR CARDIOVASCULAR
EVENTS
71

New imaging methods

z
z
z

Atherosclerosis in often advanced before the first clinical


manifestation such as sudden death, myocardial infarction
or stroke. Therefore it is logical to seek easy and reliable
methods to detect sub clinical disease.
Criteria for accepting the clinical utility of new imaging
techniques have been defined; clinical benefit without
harm is required.
MR imaging of carotid and coronary plaque is possible but
remains a research tool thus far.
Multi-slice CT coronary arteriography has a high negative
predictive value. The presence of coronary calcium seems
to add independent prognostic information, especially in
medium risk subjects, but may also lead to unnecessary
tests and interventions.
Ultrasound carotid intima-media thickness appears to
allow a modest improvement in risk estimation after
allowing for conventional risk factors; the hazard ratio
may be greater in women. Meticulous technique is
required.
Ankle-brachial index is easy, cheap and inexpensive and
relates strongly to future CVD. It deserves further study
to define its role in risk estimation.
72

JTF4 on CVD Prevention


in Clinical Practice
17. GENDER ISSUES:
CARDIOVASCULAR
DISEASE IN WOMEN

73

Gender issues: cardiovascular


disease in women

Ultimately, more women (55%) die of CVD


than men (45%), particularly of stroke. Cf
3% breast cancer deaths in women.
The apparent lower risk in women in SCORE
reflects the fact that women develop CVD 10
years later.
The evidenced base for risk factor advice,
especially regarding drug treatments is
hampered by under-representation of women
in clinical trials.
Women are disadvantaged at all stages in the
evolution of CVD- they are less likely to be
offered risk assessment, to have chest pain
evaluated or investigated, and to be offered
therapy and interventions.
Mortality from acute coronary syndromes and
after CABG is frequently higher in women.
74

CVD in women:
Management implications I
1.

European and national public health


policy needs to address the problem
of inadequate recognition of the size
of the problem of CVD in women
and to reflect this through publicity
and education of both the public and
the medical profession.

2. Clinicians likewise need vigilance in


understanding the need to think risk
and CVD in dealing with female
patients.
75

CVD in women:
Management implications II
3. The principles of total risk estimation
and management are the same for
both sexes. In women, emphasise the
evaluation of smoking, weight,
glucose tolerance and oral
contraceptive use.
4. A low absolute risk in a younger
woman may conceal a very high
relative risk. Detailed lifestyle advice
may prevent this from changing into a
high absolute risk in later life.
76

JTF4 on CVD Prevention


in Clinical Practice
18. RENAL IMPAIRMENT
AS A RISK FACTOR IN
CARDIOVASCULAR
DISEASE

77

Renal impairment and


cardiovascular risk
z

Risk of CVD rises progressively from


microalbuminuria with preserved GFR to
end-stage renal disease, when it is 20
30x that of the general population.
Applies to apparently healthy people and
to those with hypertension, CVD, and
heart failure.
Associated with high blood pressure,
hyperlipidaemia, metabolic syndrome,
uric acid, homocysteine, and anaemia.
Particularly vigorous risk factor control
needed.
78

JTF4 on CVD Prevention


in Clinical Practice

19. CARDIOPROTECTIVE
DRUG THERAPY

79

When to prescribe cardioprotective drugs


in addition to those used to treat blood
pressure, lipids, and diabetes
z

Aspirin for virtually all with established CVD,


and in persons at >10% SCORE risk once
blood pressure has been controlled.

-blockers after myocardial infarction and,


in carefully titrated doses, in those with
heart failure.

ACE inhibitors in those with left ventricular


dysfunction and in diabetic subjects with
hypertension or nephropathy.

Anticoagulants in those at increased risk of


thromboembolic events, particularly atrial
fibrillation.
80

JTF4 on CVD Prevention


in Clinical Practice
20. IMPLEMENTATION
STRATEGIES

81

What would make the practice


of CVD prevention easier?
z

Simple, clear, credible guidelines.

Sufficient time.

Positively helpful government


policies (defined prevention strategy
with resources, and incentives
including remuneration for
prevention as well as treatment).

Educational policies that facilitate


patient adherence to advice.
82

Implementation strategies:
European level
1.

Publication of guidelines in relevant


journals.

2. Presentations at international
conferences of the participating
societies.
3. Directly influencing EU health policy
- for example through the
Luxembourg Declaration and the
European Health Charter.
83

Implementation strategies:
National level

1.Adapt the European Guidelines to suit


the local culture.
2.Formation of a multidisciplinary
implementation group: professional
bodies, medical and other health
professionals, basic scientists,
educators, business people, politicians.
Needs to be more than merely
advisory: should inform and shape
health policy.
3. Multi-faceted communications using
all available media to doctors, medical
and para-medical students, and
ultimately all adults and children,
including schools.
84

4th Joint Task Force on


cardiovascular disease
prevention in clinical practice
a special word of thanks to:

z Veronica

Dean
z Catherine Despres
z Marie-Therese Cooney
z Alexandra Dudina
z Sophie Squarta
85