Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Cardiovascular prevention 2015
Prof Dr Johan De Sutter
AZ Maria Middelares Gent
Universiteit Gent
Many chronic diseases are inter-related with common comorbidities
Diabetes
Cardiovascular Diseases (CVD)
Kidney Diseases (CKD)
Hypertension
Cancers
Liver Diseases
Respiratory Diseases (Asthma, COPD etc.)
Allergic Diseases
www.alliancechronicdiseases.org
Many prevalent chronic diseases share common risk factors (Indicative table)
CVD Hypertension Diabetes Cancer CKD Liver Disease
Respiratory Disease
Allergic Disease
Poor nutrition habits
x x x x x x x
Tobacco use X x x x x x
Obesity x x x x
x x x
Physical inactivity
x x x x x x x x
Alcohol consumption
x x
x x x
Environmental factors
x x x x
www.alliancechronicdiseases.org
Change in cardiovascular disease deaths 1990-2013
Cardiovascular disease deaths wordwide between 1990 and 2013 : 41% ↑
Due to
Population growth : 25% ↑
Aging of the population : 55% ↑
Despite
Age-specific CV death rate : 39% ↓
Change in cardiovascular disease deaths 1990-2013
Cardiovascular disease as death cause in Belgium (1998-2011 ICD-10)
0
5
10
15
20
25
30
35
40
45
50
1998 1999 2000 2003 2004 2005 2006 2007 2008 2009 2010 2011
men
women
%
2011 : cardiovascular disease 31%, cancer 29%, respiratory disease : 10%
Procentuele verdeling van de verschillende
hart- en vaataandoeningen Vlaams Gewest 2011
Treatment or changes in risk factors ?
Who is at very high cardiovascular risk ?
• Documented cardiovascular disease – Coronary disease (ACS, PCI, CABG,…)
– Stroke
– Peripheral arterial disease
• Diabetes type 1 or 2 with 1 or more CV risk factors and/or target organ damage
• Severe kidney disease (GFR<30 ml/min/1,73 m²)
• SCORE risk ≥ 10%
SCORE chart: 10 year risk of fatal CV disease
The risk-age concept
310
270
230
190
(mg/dl)
Who is at high cardiovascular risk
• Strongly elevated risk factor
– Familial hypercholesterolemia (LDL cholesterol ≥ 190 mg/dl)
– Severe hypertension (≥ 180/110 mmHg)
• Diabetes type 1 or 2 without CV risk factors or target organ damage
• Moderate kidney disease (GFR 30-59 ml/min/1,73m²)
• SCORE risk 5-10%
Who is at moderate/low cardiovascular risk ?
• Moderate risk : SCORE risk 1-5%
Risk can be further evaluated based on other risk factors
• HDL/triglycerids/Lp(A)/…
• Familial history of premature CV disease
• Psychosocial risk factors
• Sedentary behaviour/central obesity
• ….
• Low risk : SCORE risk < 1%
The ABC of cardiovascular prevention
Avoid tobacco
The ABC of cardiovascular prevention
Avoid tobacco Be more active
Minimum recommended:
75 min vigorous intensity/week
or
180 min moderate intensity/week
Physical activiy and cause-specific mortality
Minimum recommended:
75 min vigorous intensity/week
or
180 min moderate intensity/week
The ABC of cardiovascular prevention
Avoid tobacco Be more active
Choose good nutrition
PREDIMED study, NEJM 2013
Characteristics of a healthy diet
www.alliancechronicdiseases.org
Ezatti et al, NEJM 2013
ESC hypertension guidelines 2013
Initiation of lifestyle changes and medication
Choice of antihypertensive drugs
ESC hypertension guidelines 2013
COME STAI study
• 10.078 consecutive hypertension patients, seen by 516 general practicioners in Belgium and Luxemburg in 2013
• Medication : – 43% 1 medication
– 46% 2 or more medictions
• 55% systolic blood pressure >140 mmHg
• Treatment intensification only in 34% of patients with systolic blood pressure > 140 mmHg !
Van de Borne et al, Journal of Hypertension 2014
CTT collaborators, Lancet 2005 and 2008
CTT collaborators, Lancet 2005 and 2008
Recommended target levels
Total cholesterol (mg/dl) LDL cholesterol (mg/dl)
Low to moderate CV risk High CV risk Very high CV risk
< 190 mg/dl < 175 mg/dl < 150 mg/dl
< 115 mg/dl < 100 mg/dl < 70 mg/dl or > 50% ↓
Intervention strategies as a function of total CV risk and LDL levels
8000 CAD patients evaluated in 2012
Cardioprotective medication in patients with coronary artery disease
*: Belgium (Gent) : ACE or ARB : 45%
*
Control of risk factors in patients with coronary artery disease
Effects of cardiac rehabilitation
Duration of FU HR (95%CI)
Mortality
Cardiovascular mortality
MI (fatal/nonfatal)
CABG
PCI
Hospital readmissions
> 12 months
> 12 months
> 12 months
> 12 months
> 12 months
6-12 months
0,87 (0,75-0,99)
0,74 (0,63-0,87)
0,97 (0,82-1,15)
0,93 (0,68-1,27)
0,89 (0,66-1,19)
0,69 (0,51-0,93)
47 studies (RCT) – 10.794 patients (mostly male, middle aged and lower risk
post AMI or CABG)
Cochrane Review 2011
Controversial issues
• Risk stratification : can we improve it ?
• Statins in elderly patients ?
• Statins and diabetes ?
• Statins not for all patients ?
• Statin intolerance : how to treat it ?
How to improve the overall performance of lipid treatment guidelines ?
• Improvement of risk scores for primary prevention – More focus on age- and gender specific risk thresholds ?
– Incorporation of biomarkers (inflammation, neurohormonal markers, new lipid markers, …) ?
– Incorporation of non-invasive imaging markers (coronary calcium, intima media thickness, …) ?
– Incorporation of other risk factors (exercise capacity, BMI, waist… ) ?
• The poly pill approach
• Treatment based on results of randomized controlled trials
Age and gender specific 10-years risk thresholds ?
• 3685 adults, average age 57 years, from the Framingham Offspring Study, with no CVD at baseline
• Overall: 47% met criteria for statin therapy, based on 7,5% risk threshold
• But – 40-55 years : poor PPV for men (48%) and women (36%); 5% risk
threshold appears to have better PPV
– 66-75 years : very poor NPV (3%); 15-20% risk threshold appears to have better NPV
Navar-Boggan AM et al, JACC 2015 (in press)
Non-invasive imaging
Coronary calcifications
(CT) Intima media thickness
(Echo)
NON-INVASIVE MARKERS OF SUBCLINICAL ATHEROSCLEROSIS FOR
PREDICTING A PRIMARY CARDIOVASCULAR EVENT: A RAPID SYSTEMATIC
REVIEW
Key messages
Coronary artery calcium score provided the highest incremental
predictive value, with a CNRI ranging from 22% to 55%. The added value
of the ankle-brachial index, aortic pulse wave velocity and carotid plaque
in risk reclassification was lower than for coronary calcium (CNRI around
15%).
The clinical benefit of integrating these 4 markers into the Framingham
risk score or to SCORE was not formally assessed in studies.
Economic evaluations were only identified for one marker: coronary
artery calcium. The studies showed highly unstable results, sensitive to a
number of assumptions, and in particularly to those relating to the price
and efficacy of preventive treatments.
KCE report april 2015
Ridker et al, JACC 2015;65:942-8
Ridker et al, JACC 2015;65:942-8
Ridker et al, JACC 2015;65:942-8
Controversial issues
• Risk stratification : can we improve it ?
• Statins in elderly patients ?
• Statins and diabetes ?
• Statins not for all patients ?
• Statin intolerance : how to treat it ?
• ….
• Ideally, treatment of hypercholesterolemia for patients at risk
for CVD should start before they turn 80 years old
• No RCT evidence exists to guide statin initiation after age 80 years
• Decisions to use statins in older individuals are made individually and are not supported by high quality evidence
Controversial issues
• Risk stratification : can we improve it ?
• Statins in elderly patients ?
• Statins and diabetes ?
• Statins not for all patients ?
• Statin intolerance : how to treat it ?
• ….
Major vascular event and
prior diabetes Events (%)
Treatment Control RR (CI)
0·78 (0·69 - 0·87) 0·77 (0·73 - 0·81) 0·77 (0·74 - 0·80)
0·75 (0·64 - 0·88) 0·76 (0·72 - 0·81) 0·76 (0·73 - 0·80)
0·79 (0·67 - 0·93) 0·84 (0·76 - 0·93) 0·83 (0·77 - 0·88)
0·79 (0·72 - 0·86) 0·79 (0·76 - 0·82) 0·79 (0·77 - 0·81)
0·5 1·0 1·5
Major coronary event 776 (8·3) 979 (10·5)
2561 (7·2) 3441 (9·6) Any major coronary event 3337 (7·4) 4420 (9·8)
Stroke 407 (4·4) 501 (5·4) 933 (2·7) 1116 (3·2)
Any stroke 1340 (3·0) 1617 (3·7)
Coronary revascularization Diabetes 491 (5·2) 627 (6·7) No diabetes 2129 (6·0) 2807 (7·9) Any coronary revascularization 2620 (5·8) 3434 (7·6)
Major vascular event 1465 (15·6) 1782 (19·2) 4889 (13·7) 6212 (17·4)
Any major vascular event 6354 (14·1) 7994 (17·8)
Diabetes No diabetes
Diabetes No diabetes
Diabetes No diabetes
RR (95% CI) RR (99% CI)
Effects on MAJOR VASCULAR EVENTS, per mmol/L reduction in LDL
cholesterol, among participants with diabetes
CTT collaborators, Lancet 2005 and 2008
Statins : benefits versus new-onset diabetes
5,4 fewer CHD deaths or
nonfatal MI per 255 patients
treated for 4 years per
1 mmol/L LDL-C reduction
1 additional case of
diabetes per 255 patients
treated for 4 years
CTT collaborators, Lancet 2008 and Sattar et al, Lancet 2010
Controversial issues
• Risk stratification : can we improve it ?
• Statins in elderly patients ?
• Statins and diabetes ?
• Statins not for all patients ?
• Statin intolerance : how to treat it ?
• ….
Statins have no proven benefit for…
• Patients with heart failure and LVEF<40%
– No effect on hard CV endpoints
• Patients with aortic valve stenosis
– No effect on aortic valve stenosis progression
• Patients with severe kidney disease
– No effect on hard CV endpoints
Controversial issues
• Risk stratification : can we improve it ?
• Statins in elderly patients ?
• Statins and diabetes ?
• Statins not for all patients ?
• Statin intolerance : how to treat it ?
• ….