development and implementation cardiovascular clinical practice guidelines · 2017-11-09 ·...

Development and implementation cardiovascular

clinical practice guidelines

Professor David A WoodGarfield Weston Professor of

Cardiovascular MedicineInternational Centre for Circulatory

HealthImperial College London

UK

• Hypertension

• Hyperlipidaemia

• Hyperglycaemia

Primary preventionTraditional medical paradigm

Usual systolic blood pressure and risk of cardiovascular death in Asia and Australasia

Asia Pacific Cohort Studies Collaboration. J Hypertension 2003; 21:707-716

Primary preventionTraditional medical paradigm

Single risk factors

treated in silos

Relative risk estimates of CHD events and stroke for a blood pressure reduction of 10 mm Hg systolic and 5 mm Hg diastolic in the blood pressure difference trials and in epidemiological cohort

studies

Law MR et al. BMJ 2009; 338; b1665

Primary preventionNew medical paradigm

Total cardiovascular risk

Absolute risk (%) of having a cardiovascular event in 10 years according to age, BP and other risk

factors

Professor Rodney Jackson

Professor Ian Graham

www.escardio.org/guidelinesJoep Perk, Linnéuniversitetet, Campus Kalmar

5th Joint Europ

On behalf of:

The 5th Joint European Societies’ Task Force on Cardiovascular Disease Prevention in Clinical

Practice

SCORE: the European Risk Prediction System

1994199820033rd Joint European Societies Task Force

2004European Society of Cardiology

Score enabled HeartScore, an interactive tool

• 12 European cohort studies• wide geographic spread of

countries at different levels of cardiovascular risks

• 3-million person-years of observation

• 7,934 fatal cardiovascular events

Data from:

SCORE

Systematic coronary risk evaluation

Priorities in CVD PreventionVery high risk Documented CVD

Diabetes mellitus (type 1 or 2) with one or more CV risk

factors and/or target organ damage

Severe chronic kidney disease SCORE > 10% over 10 years

Priorities in CVD PreventionHigh risk

Markedly elevated single risk factors such as familial dyslipidaemia or

severe hypertension Diabetes mellitus (type 1 or 2) but

without other risk factors or target organ damage

Moderate CKD SCORE > 5% but < 10% over 10

years

Primary preventionNew medical paradigm

At what level of cardiovascular risk is it appropriate to intervene

with drug therapies?

Systematic coronary risk evaluation

Primary preventionNew medical paradigm

At what level of cardiovascular risk is it appropriate to intervene

with drug therapies?SCORE > 5%

Equivalent to 20% CVD risk over 10 years

Joint ACC/AHA GuidelineStatin benefit groups

• Clinical ASCVD• Primary elevations of LDL-C >

190 mg/dl• Diabetes (40-75 yrs) LDL-C 70 >

189 mg/dl

Joint ACC/AHA GuidelineNew medical paradigm Total risk assessment

Pooled Cohort Risk Assessment Equations

Joint ACC/AHA GuidelineStatin benefit groups

• Estimated CVD risk > 7.5% over 10 years with LDL-C 70-189

mg/dl

Joint ACC/AHA GuidelineEstimated CVD risk > 7.5% over

10 years with LDL-C 70-189 mg/dl

About 30 million US citizens potentially eligible for a statin

Primary preventionNew medical paradigm

SCORE > 5% Equivalent to 20% CVD risk over 10 years

ACC/AHA > 7.5% CVD risk over 10 years

NICE (UK) > 10% CVD risk over 10 years

SCORE: the European Risk Prediction System

1994199820033rd Joint European Societies Task Force

2004European Society of Cardiology

Score enabled HeartScore, an interactive tool

• 12 European cohort studies• wide geographic spread of

countries at different levels of cardiovascular risks

• 3-million person-years of observation

• 7,934 fatal cardiovascular events

Data from:

SCORE

Total risk assessment

Total Risk Assessment• Lifestyle: smoking, diet and

physical activity• Body mass index and central

adiposity• Risk factors: Blood pressure,

lipids and glucose• Family history

• Other risk markers

SCORE: the European Risk Prediction System

1994199820033rd Joint European Societies Task Force

2004European Society of Cardiology

Score enabled HeartScore, an interactive tool

• 12 European cohort studies• wide geographic spread of

countries at different levels of cardiovascular risks

• 3-million person-years of observation

• 7,934 fatal cardiovascular events

Data from:

SCORE

Total risk assessment

Total risk management

Total Risk Management

• Lifestyle: smoking cessation, diet, weight management and physical

activity• Risk factors: Blood pressure, lipid

and glucose control• Cardioprotective drug therapies

Joint ACC/AHA GuidelineCost effective for primary

prevention to identify and manage all adults with a total CVD risk >

7.5% over 10 years?

Total risk managementCost effective for primary

prevention?Screening adult population to estimate

total CVD riskFurther investigations will be required

for those at high CVD riskManaging people at high CVD risk will

require a multifactorial intervention

Joint ACC/AHA GuidelineCost effective for primary

prevention to identify and manage all adults with a total CVD risk >

7.5% over 10 years?

Primary preventionNew medical paradigm

Total cardiovascular risk

Single risk factor management

Primary preventionNew medical paradigm

Total cardiovascular risk

Single risk factor management

Established CVD orFamilial Hypercholesterolaemia

Diabetes age >40 yearsChronic Kidney Disease

Lifestyle and drug therapy as recommended in JBS3

10 year CVD risk scoreABOVE current NICE

threshold*:Lifestyle + Drug therapy

BELOW current NICE threshold*

Examine JBS3 ‘lifetime metrics’Heart age

Projected CVD riskTo 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

Male 37 years old

Male 37 years old

Male 37 years old

JBS3 Risk Calculatorwww.jbs3risk.com

Visit the App Store for your iPhone and iPad

Primary preventionTraditional medical paradigm

Single risk factors

treated in silos