Transcript CVD preventive interventions Jūratė Klumbienė

CVD preventive interventions
WORKSHOP
Jurate Klumbiene
Kaunas University of Medicine, Kaunas, Lithuania
Objectives of the workshop
• To broaden an understanding of the
differences in the main strategies in prevention
of CVD
• To improve skills in planning and conducting
preventive activities
• To update knowledge concerning approaches
to CVD management
Agenda of the workshop
• Practice profile - presentation
• Identification of potential interventions
using population, high-risk strategies and
secondary prevention of CVD – group work
• Group work results – presentation
• The main strategies of CVD prevention lecture
Practice description
I. General profile
• Country region – industrial (coal mines, steel
factories)
• Urban setting – city with 200,000 inhabitants
• Localization – in the city centre with easy access by
public transportation
• Type of practice - single
• Practice population – 2,356 individuals (638 children
under 18, 472 persons over 65)
• Staff – 1 physician, 2 community nurses, 1 practice
nurse, 1 part-time midwife
• Reimbursement system – public insurance, per
capita
• Disease registers – unavailable
• Medical records – traditional paper forms
Practice description
II. Lifestyle habits
• The nutrition survey conducted on a random
sample of the practice population obtained the
following data: total fat intake accounted for 45%
of energy intake, saturated fats intake for 15 %;
the average intake of cholesterol was 380
mg/day; 25 % of people consumed fruits and
vegetables daily.
• 520 males and 356 of females are smokers.
• A sedentary lifestyle is common for the
population.
Practice description
III. Persons with risk factors for CVD
• 773 with hypertension
• 810 with high serum cholesterol
• 346 who are obese and 515 who are
overweight
• 315 males and 200 women are regular
smokers
Practice description
IV. Patients with CVD
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Stroke – 35 patients
History of MI – 27 patients
Angina pectoris – 29 patients
Atrial fibrillation – 24 patients
Heart failure – 19 patients
Tasks for group work
Prepare a comprehensive plan of preventive
activities in the field of CVD using the following
strategies:
1) Population strategy
2) High-risk strategy
3) Secondary prevention
Presentation of group work results
–
plenary discussion
The main strategies of CVD
prevention
(a lecture based on the European
guidelines on cardiovascular disease
prevention in clinical practise, 2007)
THE RATIONALE FOR AN ACTIVE APPROACH TO
THE PREVENTION OF CARDIOVASCULAR DISEASES
• CVD is the major cause of premature death in most
European populations .
• The underlying pathology is usually atherosclerosis.
• Death, myocardial infarction and stroke nevertheless
frequently occur suddenly and before medical care
is available.
• The mass occurrence of CVD relates strongly to lifestyles and modifiable physiological factors.
• Risk factor modifications have been shown to
reduce CVD mortality and morbidity, particularly in
high-risk subjects.
CVD PRIMARY PREVENTION
Population strategy - for altering, in the
entire population, those lifestyle and
environmental factors, and their social and
economic determinants, that are the
underlying causes of the mass occurrence
of CVD
High-risk strategy - identification of high-risk
individuals and action to reduce their risk
factor levels
CVD SECONDARY PREVENTION
The prevention of recurrent CVD
events and the progression of the
disease in patients with established
cardiovascular organ damage or
disease.
THE PRIORITIES FOR CVD PREVENTION
1. Patients with established atherosclerotic CVD.
2. Asymptomatic individuals who are at high risk of
developing CVD because of:
a) multiple risk factors resulting in a 10 year risk of ≥
5% now (or if extrapolated to age 60) for developing a
fatal CVD event
b) markedly raised levels of single risk factors:
cholesterol ≥ 8 mmol/l, LDL cholesterol ≥ 6 mmol/l, blood
pressure ≥ 180/110 mmHg
c) diabetes type 2 and diabetes type 1 with microalbuminuria
3. Close relatives (first-degree relatives) of
a) patients with early onset atherosclerotic CVD
b) asymptomatic individuals at particularly high risk
OBJECTIVES OF CVD PREVENTION
1. To assist those at low risk of CVD to
maintain this state for their entire lives and to
help those at increased total CVD risk to
reduce it.
OBJECTIVES OF CVD PREVENTION
2. To achieve the characteristics of people who
tend to stay healthy:
-Nonsmoking
-Healthy food choices
-Physical activity: 30 min. of moderate activity a day
-BMI < 25 kg/m2
-BP < 140/90 mmHg
-Total cholesterol < 5 mmol/l
-LDL cholesterol < 3 mmol/l
-Blood glucose < 6 mmol/l
OBJECTIVES OF CVD PREVENTION
3. To achieve more rigorous risk factor control
over high-risk subjects, especially those with
established CVD and diabetes:
- BP < 130/80 mmHg if feasible
- Total cholesterol < 4.5 mmol/l including those with <
4mmol/l if feasible
- LDL cholesterol < 2.5 mmol/l including those with <
2mmol/l if feasible
- Fasting blood glucose < 6 mmol/l
OBJECTIVES OF CVD PREVENTION
4. To consider cardioprotective drug therapy
in high-risk subjects, especially those with
established atherosclerotic CVD.
THE SCORE RISK ASSESSMENT
SYSTEM
(HeartScore, at www.escardio.org)
• Based on a large dataset of 12 European cohort
studies
• Predicts fatal CVD events over a 10-year period
• Integrated the following risk factors:
- gender
- age
- smoking
- systolic BP
- cholesterol (the cholesterol, cholesterol/HDL ratio)
• The threshold for being at high risk is defined as ≥
5%
RISK CHART FOR LOW-RISK COUNTRIES
RISK CHART FOR HIGH-RISK COUNTRIES
THE DEFINITION OF HIGH TOTAL RISK FOR
DEVELOPING A FATAL CARDIOVASCULAR
EVENT
1. Patients with established cardiovascular disease
2. Asymptomatic subjects who have:
2.1. Multiple risk factors resulting in a 10 year
risk
≥ 5% now or if extrapolated to age 60
2.2. Markedly raised levels of single risk factors:
total cholesterol ≥ 8 mmol/l,
LDL cholesterol ≥ 6 mmol/l,
blood pressure ≥ 180/110 mmHg
2.3.Diabetes type 2 and diabetes type 1 with
microalbuminuria
CVD RISK MAY BE HIGHER THAN INDICATED IN THE
CHART FOR:
• Sedentary or obese subjects, especially those with
central obesity.
• Asymptomatic subjects with pre-clinical evidence of
atherosclerosis (e.g. CT scan, ultrasonography).
• Subjects with a strong family history of premature
CVD.
• Subjects with low HDL cholesterol or high
triglycerides.
• Subjects with diabetes – a fivefold higher risk in
women with diabetes & a threefold higher risk in
men with diabetes compared with those without
diabetes.
• The socially deprived.
THE METABOLIC SYNDROME
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The term refers to the combination of several
factors that tend to cluster together in central
obesity – hypertension, low HDL cholesterol,
raised triglycerides, and raised blood glucose – to
increase risk of diabetes and CVD.
This implies that, if one component is identified,
a systematic search for others is indicated,
together with an active approach to managing all
of these factors.
Physical activity and weight control can radically
reduce the risk of developing diabetes in those
with the metabolic syndrome.
RELATIVE RISK CHART
THE MANAGEMENT OF CVD RISK IN
CLINICAL PRACTICE
• Behavioural risk factors
- stop smoking tobacco
- make healthy food choices
- increase physical activity
• Management of other risk factors
- being overweight and obesity
- blood pressure
- plasma lipids
- diabetes
- metabolic syndrome
CARDIOPROTECTIVE DRUG THERAPY
•
Aspirin for virtually everyone with established CVD
and for persons with >10% SCORE risk once
blood pressure has been controlled.
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 blockers after myocardial infarction and, in
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carefully titrated doses, in those with heart failure.
ACE inhibitors for 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.