Transcript Cardiovascular Risk Factors

Pete and Mihir
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Why they’re important
Which risk factors?
Risk assessment
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Curriculum statements
◦ 5 Healthy people, promoting health and preventing
disease
◦ 15.1 Cardiovascular problems
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QOF - In those patients with a new diagnosis of
hypertension (excluding those with preexisting CHD, diabetes, stroke and/or TIA)
recorded between the preceding 1 April to 31
March: the percentage of patients aged 30 to
74 years who have had a face-to-face
cardiovascular risk assessment at the outset of
diagnosis (within 3 months of the initial
diagnosis) using an agreed risk assessment
tool
8 Points
Disease Prevalence
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That warm fuzzy feeling that comes in the
knowledge you are saving people’s lives (by
reducing 10 year cardiovascular end point
incidence)
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45,000
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Lifestyle factors you can change
Factors you can’t change
Factors that can be treated
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Family History
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Male
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Age
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Extreme baldness
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Early menopause
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Age
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Ethnic group
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Smoking
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Sedentary lifestyle
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Obesity
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Salt/diet
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Alcohol
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Hypertension
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Cholesterol
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triglycerides
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diabetes
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Chronic kidney disease
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Anyone age 40-74 who is likely to be at high
risk – calculate risk with data already
available (NICE)
Anyone over 40 (JBS2)
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The following patients should not have their risk
calculated, as they are considered already to be
at high enough risk to justify lifestyle and other
interventions
◦ Patients with atherosclerotic CVD.
◦ Hypertension (≥160/100 mm Hg) with target organ
damage.
◦ Patients with type 1 or type 2 diabetes mellitus.
◦ Renal dysfunction (including diabetic nephropathy).
◦ Familial hypercholesterolaemia, familial combined
hyperlipidaemia
◦ People aged 75 or older should also be considered at
increased risk of CVD, particularly if hypertensive or
smokers.
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Use a validated tool to calculate estimated 10
year risk.
Discuss lifestyle modification
Start/change treatment
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Framingham with JBS2 adjustments
QRisk2
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Type 2 diabetes (early on)
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◦ UKPDS
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Tends to
overestimate UK
population risk
Underestimates risk
of socially
deprived/south
asian/female
populations
Age (30-74)
Smoking Status
Sex
Glucose
LVH
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BP
Central Obesity
Total Cholesterol
South Asian Origin
HDL Cholesterol
Family History of
CVD
(Men <55 and
women <65 years)
Total /HDL Ratio
Serum TG mmol/L
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Patient age (30-84).
Patient gender.
Current smoker
(yes/no).
Diabetic.
Family history of
heart disease aged
<60 (yes/no).
Treatment with blood
pressure agent .
Postcode (Townsend
score)
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Body mass index
(height and weight).
Systolic blood
pressure (use current
not pre-treatment
value).
Total and HDL
cholesterol.
Ethnicity.
Rheumatoid arthritis.
Chronic kidney
disease.
Atrial fibrillation.
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http://www.patient.co.uk/doctor/PrimaryCardiovascular-Risk-Calculator.htm
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www.qrisk.org
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www.dtu.ox.ac.uk
Is it a disease? Is it an illness?
Is it a condition?
Is it a syndrome?
What is it?
Hypertension is the one of the most important
preventable causes of morbidity and mortality in
the UK
It is a major risk factor for cardiovascular disease
At least one quarter of adults (and more than half
of those are above 60) in the UK have high blood
pressure
2mmHg rise in systolic BP causes 7% increased risk
of mortality in IHD and 10% increased risk of
mortality from stroke
The NHS spent £1 billion on drug costs alone on
blood pressure management in 2006
140/90?
135/85?
160/100?
180/110???
Stage 1 Hypertension:
Clinic blood pressure is 140/90mmHg or higher
and subsequent ABPM daytime average or HBPM
average blood pressure of135/85mmHg or higher
Stage 2 Hypertension:
Clinic blood pressure is 160/100mmHg or higher
and subsequent ABPM daytime average or HBPM
average blood pressure of 150/95mmHg or higher
Severe Hypertension:
Clinic systolic BP is 180mmHg or higher, or clinic
diastolic BP is 110mmHg or higher
Adequate initial training and periodic review
Automated devices regularly recalibrated. Do
not use automated devices if there is pulse
irregularity
Standardize environment. Patient should be
quiet and seated, with an outstretched and
supported arm
For postural hypotension patient should be
stood for at least 1 minute before BP
measurement (If SBP falls by ≥20mmHg –
Review medication/Specialist referral)
If clinic BP is ≥140/90, offer ABPM to confirm diagnosis of HTN
Clinic BP
Measure BP in both arms (Use arm with higher reading), if BP
≥140/90mmHg repeat BP. If substantially different repeat a third time.
Record the lower of the last 2 measurements as clinic BP
ABPM
At least 2 measurements per hour during waking hours
Use the average value of at least 14 measurements taken during usual
waking hours
HBPM
For each BP reading, two consecutive measurements are taken, at least 1
minute apart and with the person seated
Record twice daily, ideally morning and evening
Record for at least 4 days, ideally 7 days (Discard first day’s readings)
Use formal calculator
Test for proteinuria and haematuria
Estimation of the albumin:creatinine ratio
Bloods for plasma glucose, U&E, eGFR and lipids
Fundus examination
12 lead ECG
Clinic blood pressure
< 140/90 mmHg
Normotensive
Clinic blood pressure
≥ 140/90 mmHg
Clinic blood pressure
≥180/110 mmHg
If accelerated
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hypertension or
suspected
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phaeochromocytoma
Consider starting antiHTN drug
treatment immediately
Offer ABPM
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Refer
same day
for
specialist
care
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(or HBPM if ABPM is declined or not
tolerated)
Offer to assess cardiovascular risk and target organ
damage
ABPM/HBPM
< 135/85 mmHg
Normotensive
If evidence of target
organ damage
ABPM/HBPM
≥ 135/85 mmHg
Stage 1 hypertension
Consider
alternative
causes for
target
organ
damage
ABPM/HBPM
≥ 150/95 mmHg
Stage 2 hypertension
If target organ damage
present or 10-year
cardiovascular risk > 20%
If younger than
40 years
Offer antihypertensive
drug treatment
Consider specialist
referral
Offer lifestyle interventions
Offer to check blood pressure at least
every 5 years, more often if blood
pressure is close to140/90 mmHg
Offer patient education and interventions to support adherence to treatment
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Signs of papilloedema or retinal
haemorrhage.
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Labile or postural hypotension, headache,
palpitations, pallor and diaphoresis.
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Ambulatory blood pressure monitoring.
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Home blood pressure monitoring.
Offer annual review of care to monitor blood pressure, provide support and
discuss lifestyle, symptoms and medication
Lifestyle – Who? When? How?
Medication – Who? When? How?
What?
Refer – Who? Where? When?
Lifestyle advice should be offered initially then
periodically
Diet patterns:
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Five a day
Bulk of most meals should be starch based
Not much fatty foods – Use low-fat, mono- or poly-unsaturated fats
Include 2-3 portions of fish per week, at least one should be oily
Limit salt to 6g/day – Current UK average is 9g (Na content X 2.5 = Salt
Content)
If you ‘have’ to fry, choose a vegetable oil
Exercise patterns:
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30 minutes in a day is probably minimum to gain health benefits
Moderate physical activity means you get warm, mildly out of breath and
mildly sweaty
On most days – You cannot ‘store up’ the benefits of physical activity
Alcohol:
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Men 21 units/week – No more than 4 units/day
Women 14 units/week – No more than 3 units/day
Relaxation therapies
Excessive consumption of caffeinated products
Do not offer magnesium, calcium and
potassium supplements
Stop smoking
Local initiatives
Aged over 55
years/ black
person of
African/Caribbean
family origin of any
age
Aged under
55 years
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Step 1
Step 2
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A
C
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A+C
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Step 3
A+C+D
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Step 4
Resistant hypertension
A + C + D + consider further
diuretic or alpha- or
beta-blocker
Consider seeking expert advice
Choose a low-cost ARB.
A CCB is preferred but consider a
thiazide-like diuretic if a CCB is not
tolerated or the person has
oedema, evidence of heart failure
or a high risk of heart failure.
Consider a low dose of
spironolactone or higher doses of
a thiazide-like diuretic.
At the time of publication (August
2011), spironolactone did not have
a UK marketing authorisation for
this indication. Informed consent
should be obtained and
documented.
Consider an alpha- or beta-blocker
if further diuretic therapy is not
tolerated, or is contraindicated or
ineffective.
Offer step 1 treatment to people under 80 with stage 1
hypertension and one or more of:
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Target organ damage
Established cardiovascular disease
Diabetes
Renal disease
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10 year cardiovascular risk higher than 20%
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Offer step 1 treatment to people at any age with stage 2
hypertension
ACEi (Low cost ARB) for people under 55 years
CCB for over 55 years/Afro-Caribbean origin – If
unsuitable/intolerant to CCB then start with thiazide like diuretic
(Indapamide/Chlortalidone)
Use beta-blockers in younger patients only if ACEi/ARBs are
contraindicated, or there is evidence of increased sympathetic drive,
and for women with child-bearing potential
Offer CCB in combo with ACEi/ARB
Thiazide like diuretic if CCB unsuitable
If beta-blocker was used in step 1 add
CCB rather than thiazide like diuretic
Optimise doses
Offer ACEi/ARB in combo with a
CCB and thiazide-like diuretic
If clinic BP ≥140/90mmHg
regard as resistant hypertension
Consider low dose (25mg) spironolactone if
serum potassium level ≤ 4.5mmol/L – Monitor
renal function
If serum potassium level ≥ 4.5mmol consider
higher dose of thiazide like diuretic
If further diuretic therapy is
contraindicated/ineffective, consider alpha- or
beta-blockers
If BP remains uncontrolled maximum tolerated
doses, seek expert advice
Under 80s:
 Clinic BP – 140/90mmHg
 ABPM/HBPM – 135/95mmHg
Over 80s:
 Clinic BP – 150/90mmHg
 ABPM/HBPM – 145/95mmHg
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A few key points
Optimise everything else before giving a
statin
Add TFTs to hypertension/CV risk
assessment bloods if dyslipidaemia present
Offer a statin to those with a 20% or greater
10 year risk of CVD
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A few key points
Support, advice, “stop date” “blips vs “failure”
Intensive support service
Pharmacotherapy
NRT vs NNRT (varenicline, bupropion – MHRA
warning)
1 go every 6 months
How much to prescribe
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Patches 5, 10, 15 mg/16 hr (Nicorette®); 7,
14, 21 mg/24 hr (NiQuitin®)
Gum (2 mg, 4 mg)
Nasal spray (0.5 mg per puff)
Inhalation cartridge (10 mg cartridge plus
mouthpiece)
Lozenges (1 mg, 2 mg, 4 mg)
Sublingual tablets (2 mg)
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Decide on a quit date - the date you intend to
stop smoking.
Start taking the tablets one week before the
quit date. Start on 0.5 mg daily for three
days. Then 0.5 mg twice daily on days four to
seven. Then, 1 mg twice daily for 11 weeks.
Take each dose with a full glass of water,
preferably after eating.
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One tablet (150 mg) each day for six days.
Then increase to one tablet twice a day
Aim to stop smoking completely on day eight
of treatment.
Continue the tablets for a further seven
weeks
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A, 48 year old male
Clinic reading 142/92
Home readings 136/86
CV risk 6%
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B, 52 year old white female
Home readings 136/86
LVH
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C, 48 year old white male,
Clinic reading 162/106
ABPM 136/86
CV risk 25%
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D, 48 year old black male,
Clinic reading 162/106
ABPM 136/86
CV risk 25 %
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E 50 year old black male
Home readings 155/98
On amlodipine
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F, 65 year old Asian female
Home readings 152/96
On ramipril and felodipine
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G, 55 year old black female
New patient taking diclofenac for knees for
the last year. Feels well
BP 184/114
ECG LVH
+ blood on urine dip
Fundoscopy normal/abnormal