Transcript PowerPoint-presentatie - Fonds Gesundes O\u0308sterreich

Prof. Jaakko Tuomilehto
Department of Public Health
University of Helsinki,
Department of Epidemiology and Health Promotion
National Public Health Institute
Helsinki, Finland;
Donau-Universität Krems, Krems, Austria;
Chair, Working Group on Epidemiology and Prevention
European Society of Cardiology
DEVELOPED COUNTRIES
Deaths in 2001 attributable to 15 leading causes
Cardiovascular diseases
Malignant neoplasms
Injuries
Respiratory diseases
Digestive diseases
Respiratory infections
Neuropsychiatric disorders
Diabetes mellitus
98% of all deaths
attributable to
15 leading causes
Diseases of the genitourinary system
Perinatal conditions
Tuberculosis
Nutritional/endocrine disorders
Other neoplasms
Congenital abnormalities
Musculoskeletal diseases
0
1000
2000
3000
Number of deaths (000s)
4000
5000
6000
7000
Source: WHR 2002
DEVELOPED COUNTRIES
Deaths in 2000 attributable to selected leading risk factors
Blood pressure
Tobacco
Cholesterol
High Body Mass Index
Low fruit and vegetable intake
Physical inactivity
Alcohol
Urban air pollution
Lead exposure
Occupational carcinogens
Illicit drugs
Unsafe sex
Occupational particulates
Occupational risk factors for injury
0
500
1000
1500
2000
Number of deaths (000s)
2500
3000
CVD PREVENTION WORKS
Start of the North
Nationwide activity
Karelia Project
Age-adjusted
mortality rates of
coronary heart
disease in North
Karelia and the
whole of Finland
among males
aged 35-64 years
from 1969 to
2001
700
600
500
400
300
Mortality per
100 000
population
200
100
70
75
80
85
Year
90
95
2000
Percntdecline
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CVD PREVENTION WORKS
• Japan: reduction of salt intake resulting in
lower blood pressure levels and drastically
reduced stroke mortality.
• Singapore: national programme associated
with decline in NCD trends.
• Mauritius: changing cooking oil from palm to
soy bean oil resulted in a 15% decrease in
serum cholesterol in the population.
• Poland: sudden change in dietary fats,
related to political changes - resulted in a
20% decline in heart disease mortality.
Serum cholesterol
Men 30-59 years
mmol/l
mmol/l
7,5
7
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu Province
Lapland
6,5
6
5,5
5
1972
1977
1982
1987
1992
1997
2002
Diastolic Blood Pressure
Women 30-59 Years
mmHg
95
90
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu Province
Lapland
85
80
75
1972
1977
1982
1987
1992
1997
2002
Smoking Prevalence
Men 30-59 Years
%
60
50
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu Province
Lapland
40
30
20
10
0
1972
1977
1982
1987
1992
1997
2002
Body-Mass Index
Men 30-59 Years
Kg/m2
30
29
North Karelia
28
Kuopio
Turku/Loimaa
27
Helsinki/Vanta
a
Oulu Province
26
Lapland
25
1972
1977
1982
1987
1992
1997
2002
Prevalence of HYPERGLYCEMIA in European
people aged 30 - 92 years - DECODE
•
•
•
•
•
Previously known diabetes:
Isolated fasting hyperglycemia:
Isolated post-challenge hyperglycemia:
Combined hyperglycemia:
Impaired glucose tolerance (IGT)
• TOTAL HYPERGLYCEMIA
DECODE Study Group. Lancet 1999;354:617–621
4.9%
2.1%
1.7%
1.6%
11.9%
22.2%
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 Guidelines
European Guidelines on Cardiovascular
Disease Prevention in Clinical Practice
The Third Joint Task Force
European
Association
for the Study
Diabetes
International
Society of
Behavioural
Medicine
International
Diabetes
Federation
Europe
European
Society of
General
Practice/Family
Medicine
European
Society of
Atherosclerosis
European
Society of
Hypertension
European
Heart
Network
European
Society of
Cardiology
European Guidelines on
Cardiovascular Disease
Prevention in Clinical Practice
What is new in these guidelines?
• From CHD to CVD prevention
• A new risk estimation model: SCORE
• Update / adaptations of
– Priorities
– Goals
– Management aspects
10-Year risk of
coronary heart disease
Wom en
Non-smok er
Task force
risk chart
Men
Smoker
Age
Non-smok er
Smoker
180
160
70
140
120
180
160
60
140
120
Over 40%
20% to 40%
10% to 20%
5% to 10%
Und er 5%
180
160
50
140
120
10-year risk
180
Based on Anderson KM, Wilson PW,
Odell PM, Kannel WB. An updated
coronary risk profile. A statement for
health professionals. Circulation
1991;83(1):356-62
160
40
140
120
180
160
30
140
120
4
5
6
7
8
4
5
6
7
8
4
5
Cholesterol mmol
6
7
8
4
5
6
7
8
150 200 250 300
mg/dl
Problems with the existing chart
• Based on the Framingham function which overpredicts in
European populations with low or medium levels of
disease incidence
Thomsen et al. Int J Epidemiology, 2002, In press
Problems with the existing chart
• Derived from a relatively small data set; few or no events
in some risk factor combinations
• Difficult to accommodate other risk factors such as as
HDL-cholesterol
• Uses end points which cannot be reproduced from other
data sets; therefore hard to validate
• Probably underestimates the importance of diabetes
SCORE
The SCORE Project
The Systematic COronary Risk Evaluation Project
Started in 1998 under the auspices of
The European Society of Cardiology
Conducted and supported by:
• Royal College of Surgeons in Ireland
• EU BIOMED II programme
Contract BMH4-98-3186
• National funding agencies of the component studies
SCORE
SCORE objectives
To assemble databases representative of typical
European populations to assess the accuracy of the
existing European risk system.
To prepare a risk score system or systems which are
optimised for coronary prevention in European clinical
practice.
SCORE
The SCORE database
12 European cohort studies
– Mainly population studies
– Some with multiple component cohorts
In round figures:
• A quarter of a million persons
• 3 million person-years of observation
• Over 7,000 fatal cardiovascular events
SCORE
Key differences
• Total fatal cardiovascular risk rather than just
CHD
• Fatal events rather than total events
• Charts for cholesterol and cholesterol:HDL
ratio
• New chart shows more detail in 50-65 age range
• No charts for those with established disease or
diabetes
SCORE
Better than current chart
– or simply different?
Current prediction
–
–
–
–
–
–
CHD
Includes nonfatal events
Uses idiosyncratic definition
Not possible to break down risk
into angina and MI
Over-predicts in low/mediumrisk regions
”One size fits all”
SCORE prediction
–
–
–
–
–
–
CVD (but can do CHD)
Restricted to fatal events
Uses common definition
Component risks can be calculated
Separate prediction for low risk
regions
Can be customised using national
mortality statistics
Priorities of Cardiovascular Disease
Prevention in Clinical Practice
•
•
•
•
Patients with established coronary heart disease, peripheral
artery disease and cerebrovascular atherosclerotic disease
Asymptomatic individuals who are at high risk of developing
atherosclerotic cardiovascular disease because of:
 Multiple risk factors resulting in a 10 year risk of > 5% now (or if
extrapolated to age 60) for developing a fatal cardiovascular event.
 Markedly raised levels of single risk factors: cholesterol
> 8 mmol/l (320 mg/dl), LDL chol > 6 mmol/l (240 mg/dl), blood
pressure > 180/110 mmHg
 Diabetes Type 2 and diabetes Type 1 with microalbuminuria
Close relatives (first degree relatives) of
 Patients with early-onset atherosclerotic cardiovascular disease
 Asymptomatic individuals at particularly high risk
Other individuals met in connection with ordinary clinical practice
Using the cardiovascular risk chart
Using the cardiovascular risk chart
Qualifiers
Note that total CVD risk may be higher than indicated in the chart:
- as the person approaches the next age category.
- in asymptomatic subjects with pre-clinical evidence of
atherosclerosis (e.g. CT scan, ultrasonography)
- in subjects with a strong family history of premature CVD
- in subjects with low HDL cholesterol levels, with raised
triglyceride levels, with impaired glucose tolerance, and
with raised levels of C-reactive protein, fibrinogen,
homocysteine, apolipoprotein B or Lp(a).
- in obese and sedentary subjects
European Guidelines on
Cardiovascular Disease
Prevention in Clinical Practice
Management of risk in clinical practice
•
•
•
•
•
•
•
•
•
Behavioural changes
Dietary changes
Smoking cessation
Physical activity
Control of arterial hypertension
Management of dyslipidemias
Management of diabetes
Prevention in subjects with the metabolic syndrome
Prophylactic drug therapy
How to achieve intensive lifestyle change in
patients with disease and in high risk people?
Strategies to make behavioural counselling more effective
include:
• Develop a therapeutic alliance with the patient
• Gain commitments from the patient to achieve lifestyle change
• Ensure the patient understands the relationship between
lifestyle and disease
• Help the patient overcome barriers to lifestyle change
• Involve the patient in identifying the risk factor(s) to change
• Design a lifestyle modification plan
• Use strategies to reinforce the patient’s own capacity to change
• Monitor progress of lifestyle change through follow-up contacts
• Involve other health care staff wherever possible.
European Guidelines on
Cardiovascular Disease
Prevention in Clinical Practice
Management of risk in clinical practice
•
•
•
•
•
•
•
•
•
Behavioural changes
Dietary changes
Smoking cessation
Physical activity
Control of arterial hypertension
Management of dyslipidemias
Management of diabetes
Prevention in subjects with the metabolic syndrome
Prophylactic drug therapy
Guide to Blood Pressure Management
Estimate absolute fatal CVD risk* using the SCORE Chart
Use initial office blood pressure# to estimate risk of fatal CVD
BP
< 140/90
mmHg
Maintain
lifestyle
advice
and annual
follow-up
Absolute risk of fatal
CVD < 5%
and no target
organ damage
DBP 90-109 mmHg
and/or
SBP 140-179 mmHg
Absolute risk of fatal
CVD < 5%
and target
organ damage
DBP  90 mmHg
and/or
SBP 140 mmHg
Absolute risk of fatal
CVD > 5%
and
DBP  90 mmHg
and/or
SBP 140 mmHg
DBP > 110 mmHg
and/or
SBP > 180 mmHg
Lifestyle advice for
several months
with repeat BP
measurements
Lifestyle advice and
drug therapy#
Lifestyle advice and
drug therapy#
Lifestyle advice and
drug therapy#
promptly and
independently of
total risk
DBP
90-94
and/or
SBP 140-149
mmHg
DBP
> 95
and/or
SBP > 150
mmHg
Reinforce
lifestyle
advice;
drug therapy
if preferred
by patient
Drug#
therapy and
reinforce
lifestyle
advice
Goals:
< 140/90 mmHg in all high risk subjects
< 130/80 mmHg in patients with diabetes
*High fatal CVD risk > 5% over 10 years or will exceed 5% if projected to age 60 years.
This corresponds to the formerly used 20% absolute risk of a composite of coronary heart disease
events.
#
Consider causes of secondary hypertension. If appropriate, refer to a specialist.
CAUTION: Patients with normal or high normal pressure (130-139/85-89 mmHg) may
qualify for antihypertensive treatment if they have a history of stroke, CHD, or diabetes.
Goals for CVD prevention in
patients with type 2 diabetes
* HbA1c
* Fasting plasma glucose
* Self-monitored blood glucose
- fasting
- postprandial
* Blood pressure
* Total cholesterol
* LDL cholesterol
< 6.1%
< 6.0 mmol/l (110 mg/dl)
4.0-5.0 mmol/l (70-90 mg/dl)
4.0-7.5 mmol/l (70-135 mg/dl)
<130 / 80 mm Hg
<4.5 mmol/l (175 mg/dl)
<2.5 mmol/l (100 mg/dl)
European Guidelines on
Cardiovascular Disease
Prevention in Clinical Practice
Where to find more?
• Executive summary
Eur Heart J 2003;24:1601-1610
Eur J Cardiovasc Prevention & Rehab 2003;
10(4):S1-S11
• Pocket version
• Full document
soon on the ESC web
published later in 2003 EJCPR