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Absolute Cardiovascular Disease Risk Scoring
- What You Need to Know
Professor Kim Greaves BSc, MBBS, MD, FRCP (UK), FRACP.
Consultant Cardiologist, Director of Cardiac Research Sunshine Coast University Hospital
Griffith University
2
• In Australia there are 150,000 deaths per year• In 2016….
What is the Burden of CVD?
3. Stroke: 10,451 deaths
1. Coronary Heart Disease: 19,077 deaths
2. Dementia and Alzheimers: 13,126 deaths
4. Lung cancer: 8410 deathsCardiovascular Disease –
Biggest KillerDeaths in Australia, AIHW 2016
Economic Costs
• Australia spent $160 billion on health 2015-16
• $11 billion spent on cardiovascular disease
• Most expensive disease group • 7% overall health budget
3
Disease Expenditure in Australia 2015-16, AIHW 2019
Economic Costs
• Cost acutely per ACS: $22,000• Cost acutely for stroke: $27,000• Estimated $7.1 billion could be saved • Use of preventative pharmacotherapy
alone
4
The economics costs of heart attack and chest pain (Acute Coronary Syndrome)’. Access Economics 2012Economic impact of stroke. National stroke foundation. Deloitte Access Economics 2013Cobiac L, 2012 BMC Public Health
Cardiovascular Disease
• Majority of these deaths are preventable
• Huge opportunity for CVD prevention
• 52 countries • 15,152 MIs and 14,882 controls• Relationship between risk factors and MI• Population attributable fraction
Evidence that Cardiovascular Disease is Preventable
Yusuf Lancet 2004
Risk of acute myocardial infarction associated with exposure to multiple risk factors
Population attributable fraction:80% of all MIs could have been avoided if there was no smoking, lipids, HT, DM, obesity
Interheart Study, Yusuf et al Lancet 2004
Risk of acute myocardial infarction associated with potentially protective risk factors
Avoiding smoking and adopting healthy lifestyle reduces risk by 75%
Interheart Study, Yusuf et al Lancet 2004
Prevention of CVD is a National Health Priority
Australian Health Ministers’ Advisory Council, 2017, National Strategic Framework for Chronic Conditions. Australian Government. Canberra
Combined Risk
• Rather than treating individual risk factors• Overall effect of multiple individual risk factors• Combined together • Create a more accurate picture or score• Individuals overall future risk of having a heart attack or stroke
Risk of acute myocardial infarction associated with exposure to multiple risk factors
Interheart Study, Yusuf et al Lancet 2004
OR: 13
Absolute Cardiovascular Disease Risk Score Assessments• National Vascular Disease Prevention Alliance
• 45 years or over • 35 years or over & Aboriginal or Torres Strait
Islander• Without history of cardiovascular disease
➜ Absolute Cardiovascular Disease Risk checked• Calculate likelihood of heart attack, stroke,
vascular disease in next 5 years
Framingham Risk Equation
• N=5573 free of CVD• 30-74 years• Follow up 4-12 years
Anderson Am H J 1990
Anderson Am H J 1990
• Age• Gender• Systolic BP• Smoking• Total chol/HDL ratio• Diabetes• ECG LVH
FRE: Advantages and Disadvantages• Last century• Another country• No FH, obesity, SE status• No AF• <74 yrs• Indigenous• Patients on meds• Overestimate risk
• Most thoroughly tested• Tested against Australian
study performed well• FRE equivalent or better
predictive abilities than other risk scores
• High risk• Over 15% (1:7) chance of getting
heart attack, stroke, vascular disease in next 5 years
• Moderate risk• 10-15% (1:10) chance in next 5
years• Low risk
• Less than 10% in next 5 years
20
Absolute Cardiovascular Disease Risk
Low: less than 10% risk of CVD within the next 5 years
• Diabetes >60years• Diabetes microalbuminuria• Moderate or severe kidney
disease• Very high cholesterol or FH• Very high blood pressure
High: greater than 15% risk of CVD within the next 5 years
Moderate: 10-15% risk of CVD within the next 5 years
Review absolute risk in 2 years
Conduct formal absolute risk assessment
Continue with lifestyle intervention Review absolute risk
6-12 months
Consider treating for BP and lipid lowering therapyReview absolute risk 6-12
months
Risk++
What is the Evidence Interventions Work?
ASCOT-LLA Study
• 19,342 hypertensive patients• 40-79 yrs & ³3 other CVD risk factors• 10,305 into statin study• 10mg atorvastatin or placebo• Follow up 5 years for non-fatal MI
and fatal CHD• Stopped trial after 3 years
• 100 events in atorvastatin group• 154 events placebo
P Sever Lancet 2003
ASCOT-LLA STUDY
Dual therapy: anti-hypertensive and statin therapy
Absolute Cardiovascular Disease Risk What is the uptake of absolute
cardiovascular disease risk assessment?
• N=9564 from 2011-2012 Australian Health Measures Survey
• Calculated ACVDR scores• Information on medications taken• Proportions on guideline-recommended
therapy• Estimates for the Australian population
Banks MJA 2016
• There are 7.3M Australians between 45-74 years
• 1.45M of these are at high CVD risk (20%) • 811,000 people no prior CVD • 634,000 people prior CVD
Pharmacological treatment of ACVD risk in Australia
Banks E MJA 2016
20%
35%
47%
29%
45%
24%
No prior CVD
• 970,000 at high ACVD risk (13% of population aged 45-74 yrs) • Not receiving guideline-recommended therapies
Banks E MJA 2016
ACVD Risk Of Patients Presenting With ACS and their Pharmacological Treatment
• Assessed the ACVD risk score• Patients presenting with ACS• 12 months• 520 patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No Prior CVD, high risk Prior CVD
ACVD Risk Of Patients Presenting With ACS on Pharmacological Therapy
No therapy 48%
Single therapy 30%
Dual therapy 22%
Triple therapy 57%
Dual therapy 28%
Single therapy 8%
No therapy 7%N = 112 N = 177
Why is there such Poor ACVD risk
assessment uptake?
Barriers EnablersNo incentives Financial opportunities
Time constraints Clear guidelines
Not useful/no value
Too many guidelines
Don’t know how to use
Don’t know how to proceed after risk assessmentDon't think about it
Low patient compliance
EURIKA study Eur J Prev Cardiol 2011Graham et al ESC 2006Sposito Curr Med Res Opinion 2009
Absolute Cardiovascular Risk Assessment In General Practice: A General Practitioner survey of assessment practices, knowledge attitude and beliefs, and barriers and enablers to assessment
Greaves K 2019
• 111 GPs• ACVD risk assessment rates
• Categorized: • high assessors (³ 80%), • moderate assessors (60-79%)• low assessors(£59%)
• Association between assessment rates and factors related to • Practitioner demographics/characteristics• GP knowledge/beliefs, patients, organization and structure
Results
Male 53%
Age >45yrs 43%
Aware of concept of CVD risk 96%
Unaware that CVD risk should be assessed in all eligible patients 11%
Used Australian CVD risk calculator 71%
Used own clinical judgement, didn’t use any score, or didn’t know
9%
Time spent explaining what score means 0-4 mins 28%
5-9 mins 48%
10-15 mins 15%
Group Assessment rates
High assessors (³ 80%) 45%
Moderate assessors (60-79%) 25%
Low assessors (£59%) 23%
Very low (<19%)* 10%
Very high (100%) 17%
Results
* did not assess risk, treated risk factors individually, or were unsure who an eligible patient was.
Higher assessors
Lower assessors
GP Factors Patient Factors
• Older Age
• Knowledge of CVD risk and the ACVD risk score calculator
• Time
• Patient knowledge
• Patient motivation
Interventions
Importance of Surveillance
• Surveillance system is essential to:• To quantify the magnitude and distribution
of a disease• To monitor effectiveness of prevention
strategies• To inform public health policy and planning
38
• Australia’s majority provider of health analytics software• 28/31 PHNs• Monthly reporting on
• 15 million patients
39
PATCAT (Practice Aggregation Tool)
• Product of PenCS• Reporting tool for population
health analysis • Possible surveillance tool for
ACVD risk over a population
40
GP
CAT4
GP GP GP GP
CAT4CAT4 CAT4 CAT4
PATCAT
de-identified data
Study Objectives
• To evaluate PAT CAT as a surveillance system for monitoring
• Levels of absolute CVD risk and treatment within population
41
Conclusions1. CVD is a serious health problem but largely preventable
2. Absolute CVD risk assessment indicates an individual’s overall CVD risk
3. Patients should be offered lifestyle modification and pharmacological treatment according to their ACVD risk
4. Current ACVD assessment rates are low
5. A large proportion of people are at high or moderate CVD risk and remain untreated
6. Many of these will go on to have adverse cardiovascular events within 5 years
KEEP CALM
AND
CARRY ONSCREENING
Calcium Scoring
• 969 patients all on statins• Adding evolocumab• Evaluate effect of on plaque composition• 76 weeks of treatment• Coronary IVUS• Measure plaque composition
No Prior CVDHigh ACVD Risk
Incomplete/No pharmacotherapy
2015 2020 2025 2030 2035
50
25
75
100
Prior CVDHigh ACVD Risk
Incomplete/No pharmacotherapy
Proportion of population
at high ACVD risknot on therapy (%)
Date (years)
Proportion of Patients at high ACVD risk, with and without prior CVD, not on guideline-recommended therapy
0
Intervention
New Incentive payments
Yes7%
No93%
Proportion of SCHHS staff had ACVDR checked
(eligible N = 648/1200)
93% did not have their ACVDR checked
Staff Health Measures Survey October 2015
Other6%
Was not aware I
needed one83%
Haven't had time5%
Not relevant to me4%
I prefer not to know1%
Knowing my risk is not important to
me1%
SCHHS staff reasons for not having ACVD assessed
N = 455
ACS screened for inclusionn = 722
No Prior CVDn = 350(66%)
36% Prior CVD(n=177)
Excludedn = 185 (26%)
Type 1 MIn = 527 (73%)
32% High ACVD Risk
(n=112)
Small is beautiful…..
High ACVDR Score and Untreated in General Practice using CAT4
53
Demographic Patients
Total in practice 3823
High ACVDRS + no prior CVD + no meds 77
No meds AND
Diabetes + age >60 years 14
Diabetes + Microalbumin >15 8
Chronic kidney disease 26
Familial hypercholesterolaemia 0
BP >160/110 No filter
Cholesterol >7.5 No filter
Total High CVD Risk on no medications 125
Automatic high CVD Risk
• N = 8491 without CVD• 30-74 yrs age• Followed up since 1968, ‘71, ’84• Follow up for CVD over 12 yrs
• CHD, stroke, PAD, HF.
• 1174 participants had a CVD event
Exercise• Meta-analysis• 22 studies, 1M participants• Low and moderate intensity
exercise• All cause mortality
J Woodcock Int J Epidemiol 2011
2.5 hrs/week = 19% relative
reduction all cause mortality
Smoking Cessation
• Meta-analysis• 25 prospective cohort studies• 500,000 patients• Aged > 60 yrs• CV mortality
Mons BMJ 2015
Diet• 7447 patients high CVD risk• MACE and death from CVD
outcomes• HR 0.69 (0.53-0.91) favouring
Med diet with nuts• HR 0.72 (0.54-0.95) favouring
Med diet plus with extra virgin olive oil (EVOO)
Estruch NEJM 2018
Diet• PURE study• 135,335 individuals • 18 countries• 7 year follow up• mortality
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
P trend
% S from carbohydrate
46% 55% 61% 68% 77%
Hazard ratio (mortality)
- 1.07 1.06 1.17 1.28 0.0001
% S from total fat
11% 18% 24% 29% 35%
Hazard ratio (mortality)
- 0.90 0.81 0.80 0.77 <0.0001
% S from total protein
11% 13% 15% 17% 20%
Hazard ratio (mortality)
- 1.05 0.92 0.85 0.88 0.0030
Omega 3 Fatty acids – where are we now?
• Some confusion as whether beneficial• Early data 2000’s suggested benefit; based on observational studies
• 2006 meta-analysis of 48 randomised controlled trials and 26 cohort studies.
• 26 observational cohort studies alone suggested that omega 3 reduced total mortality.
• Pooled results from the 48 randomised controlled trials showed no benefit• Included both primary and secondary prevention patients. BMJ, Hooper L 2006
Omega 3 Fatty Acids
• Cochrane review published July 2018• 79 trials, 112,000 participants• effects of greater omega-3 intake versus lower or no omega-3 intake
for heart and circulatory disease • No benefit
PAT CAT: proportions of ACVDR in a GP population
64
Conclusion• Evidence not strong for omega 3 FFA to have beneficial effects
• Unlikely in primary prevention• Possibly in secondary prevention if TG are high
• Dose, type of n-3 FA ie highly purified, effects are uncertain• Supplements not recommended routinely• Heart Foundation recommends eating fish 2-3x per week
Contents of today’s talk1. Burden of cardiovascular disease2. Economic costs of CVD3. ‘Cumulative Risk’ – what’s the the evidence?4. The ACVD risk score and the Framingham Risk Equation5. Using the ACVD risk calculator and how to proceed after6. Evidence for drug interventions in preventing CVD7. Current uptake of ACVD risk assessment, barriers and enablers8. Surveillance of ACVD risk
• 35yrs• Smoker• Overweight• BP 139/90• Doesn’t know cholesterol• Not diabetic
Do Heart Age Calculators Help?• Can improve communication of risk to people when used in
conjunction to risk scores• Heart age can be used to convey and motivate people to change their
lifestyle even when overall absolute risk in next 5 years is low• Caution if used to inform drug-treatment decisions –
• Mass medicalization• Absolute risk is more relevant• Low absolute risk vs elevated heart age
Bonner et al; BMC Cardiovasc Dis 2018