1. The Management of People at High Risk of CVD Dr Richard Healicon Mel Varvel NHS Improvement Jan Procter-King CVD Nurse & National Trainer

2. Introduction The challenge Meeting the challenge –Set the scene (MV) –Consider key issues (MV/RH) –Practical application (JPK) Final opportunity to contribute

3. Hannah Female Aged 51 Father has type 2 diabetes aged 80 BMI 26 Mother fit and well Smoker BP 138/ 84 TC:HDL 4 Blood sugar 4.1mmol/l

4. Hannah Your result Your 10-year QRISK ® 2 score is: 5% In other words, in a crowd of 100 people like you, 5 will develop heart disease or have a stroke/TIA in the next 10 years. This is represented by the smileys. Your score has been calculated using the data you entered. Your body mass index was calculated as 28.1 kg/m 2. How does your 10-year score compare? Your score Your 10-year QRISK ® 2 score 4.8% The score of a typical person with the same age, sex, and ethnicity * 3.7% Relative risk ** 1.3 Your QHeartAge ™*** 54

5. Margaret Female Aged 69 Ex smoker of one year BMI 27 TC:HDL 3.6 TC 5.4mmol/l BP 146/78 Significant Family history of CVD Blood sugar 3.6mmol/l eGFR >90

6. Margaret Your result Your 10-year QRISK ® 2 score is: 21% In other words, in a crowd of 100 people like you, 20 will develop heart disease or have a stroke/TIA in the next 10 years. This is represented by the smileys. Your score has been calculated using the data you entered. Your body mass index was calculated as 35.2 kg/m 2. How does your 10-year score compare? Your score Your 10-year QRISK ® 2 score 19.9% The score of a typical person with the same age, sex, and ethnicity * 15.1% Relative risk ** 1.3 Your QHeartAge ™*** 73

7. Margaret Is followed up with ABPM and is diagnosed with hypertension

8. Geoff Aged 54 Smoker of 30 a day BMI 34 BP 139/82 TC 5.8mmol/l TC:HDL 4.6 Family history- father died of MI under the age of 50yrs HbA1c 41 Alcohol – 60 units a week

9. Geoff His 10-year QRISK ® 2 score is: 23%

10. He returns in one year Has stopped smoking for 11 months Taking the statin you gave him Lost a tiny bit of weight Changed his diet slightly Reduced his alcohol a little sometimes Got a new hobby

11. What do we do with him ?

12. The Challenge (10 th National Workshop): Management of people at high risk of CVD Continued confusion about whether people at high risk are eligible/stay in the programme People on statins are excluded because they will have already had a risk assessment and should be managed according to NICE guidelines People who are found to be at or above 20% risk should exit the programme irrespective of whether they have signs of disease People at or above 20% risk without disease should be placed on a high risk register and managed accordingly Work with NHS I to improve use of high risk registers and management of high risk people about to start

13. Meeting the Challenge Short, practical ‘how to’ guide Explains the problem under consideration Refers to key sources of guidance Outlines some of the key challenges Offers some potential solutions in the form of consensus statements and examples from the field Points to other sources of advice and information The Management of People at High Risk of CVD

14. In the last episode…. A long time ago in a galaxy far, far away…. –Presented existing guidance –Outlined the problem –Considered 3 key questions Who is at high risk of CVD? How do we find them? What do we do with them when we’ve found them?

15. Policy Context: The Legacy of the NSF Standard four: General practitioners and primary health care teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks. Milestone 2: Every practice should have: a systematically developed and maintained practice-based register of people with clinical evidence of CHD, occlusive vascular disease AND of people whose risk of CHD events is > 30% over ten years in place and actively used to provide structured care to those at high risk of CHD.

16. Policy Context: NSF for CHD Milestone 3: Every practice should have: a protocol describing the systematic assessment, treatment and follow-up of people at high risk of CHD, including those without evidence of existing arterial disease but whose risk of CHD events is > 30% over ten years, agreed locally and being used to provide structured care to people with CHD. Milestone 4: Every practice should have: clinical audit data no more than 12 months old available that describes all the items listed in paragraph 13 on page 4 [see CHD NSF Chapter Two]. The NSF goal: Every practice should: offer advice about each of the specified effective interventions to all of those in whom they are indicated, demonstrated by clinical audit data no more than 12 months old.

17. Existing Guidelines & Published Guidance

18. NHS Health Check The NHS Health Check programme is a systematic and integrated public health programme of vascular risk assessment and management which offers preventative checks to all those aged 40 -74 to assess their risk of vascular disease (heart disease, stroke, diabetes and kidney disease) followed by appropriate management and interventions.

19. NHS Health Check: Purpose …. to assess individual risk of coronary heart disease, stroke, diabetes and kidney disease, to communicate this risk in a way that is easy to understand, and to offer personalised advice, appropriate treatment and follow up to help individuals manage or reduce their risk- including being recalled every five years for reassessment.

20. NHS Health Check As NHS Health Check is a prevention programme, eligibility has been based on the potential to prevent vascular disease through assessment of formal risk of heart disease, stroke, diabetes and kidney disease and appropriate management of that risk. People who are already on a disease register or have been diagnosed with the following conditions are excluded from the programme on the basis that they will already be managed via existing care pathways:

21. NHS Health Check: Exclusions Coronary heart disease Chronic kidney disease (CKD stages 3-5) Diabetes (any type) or Stroke & TIA Hypertension Atrial Fibrillation Familial Hypercholesterolaemia Heart failure Peripheral Arterial Disease (PAD) or Peripheral Vascular Disease (PVD) People on statins and/ or anti-hypertensive medication and those who have been identified previously or through NHS Health Check as being at high risk of CVD

22. NHS Health Check

23. The Size of the Challenge

24. The size of the populations potentially eligible for intervention based on ≥20% CVD risk alone has been estimated to be around 23% of men and 8% of women aged 40-74 years* Some suggestion that these figures will be reduced if the QRISK score is used Exclude people with established CVD, diabetes, hypertension (disease registers), other exclusions *NSC Handbook: based on data from the Health Survey of England 2003

25. Who is at high risk of CVD? CVD vs CHD –Nearly half of all CVD deaths due to CHD –Increasing recognition that all CVD should be considered a spectrum of disorder (atherosclerotic disease) –Vascular diseases linked by a common set of risk factors Why focus on people at high risk? –People with multiple risk factors more likely to have CVD –Rate of progression of CVD & risk factors can be reduced –We can’t predict events, but we can estimate probability of CVD –Risk assessment can help us categorise & prioritise & balance costs of intervention with benefits of risk reduction –Those at greatest risk stand to benefit most

26. Who is at high risk of CVD? Definition of high risk –Risk as a continuum; treatment thresholds arbitrary –NSF staged approach; >30% risk of CHD then ≥15% (CVD risk of ≥20%) –Post NSF evidence indicates clinical benefit at lower levels –Guidelines suggest threshold of ≥20% of CVD in 10 years Which model(s) should be used to calculate risk? –Individual risk factors poor predictors –Risks multifactorial, cluster & multiply –Guidelines recommend risk assessment tools based on multiple risk factors which calculate overall risk –Framingham most widely used BUT does not include all relevant risk factors overestimates risk in UK populations –‘Younger’ models (QRISK, ASSIGN etc.) include other risk factors, e.g. socio- economic status; recognised by NICE –Decision left to NHS to meet local needs & requirements

27. Who is at high risk of CVD? Lifetime versus 10 year risk –Potential disadvantage of existing tools is influence of age –High absolute risk approach may delay intervention until later in life –New focus on lifetime risk (e.g. JBS3) “Early intervention pays long term dividends” –Other features, e.g. Heart Age, can show effect of ‘what if’ scenarios –May take a while for existing guidance (NICE) to change! http://www.jbs3risk.com/

28. How do we find them? CHD NSF Standard 4, Milestone 2 –‘Every practice should have…a systematically developed and maintained practice-based register of people with clinical evidence of CHD, occlusive vascular disease AND of people whose risk of CHD events is >30% over ten years in place and actively used to provide structured care to those at high risk of CHD’ NICE Lipid Modification –‘People aged 40–74 years who may be at high risk of CVD should be identified in primary care by estimating their CVD risk from existing medical record data. People should be prioritised in descending order of risk and offered a formal risk assessment if their estimated10-year CVD risk is 20% or more’. NHS Health Check –Formal risk assessment  treat the untreated  code(!)  exit the programme to high risk register Already being treated/ Annual Medication Review –Formal risk assessment using pre-treatment values  code (!)  high risk register Don’t forget to exclude the exclusions (those already on a disease register, e.g. CHD, Diabetes, Hypertension, etc.)

29. How do we manage those at high risk of CVD? CHD NSF stated that the interventions for people without clinical evidence of occlusive arterial disease but whose were at high risk of CHD events should include: –advice about how to stop smoking including advice on the use of nicotine replacement therapy –information about other modifiable risk factors and personalised advice about how they can be reduced (including advice about physical activity, diet, alcohol consumption, weight and diabetes) –advice and treatment to maintain blood pressure below 140/85 mm Hg

30. How do we manage those at high risk of CVD? NICE CG 67-lipid modification: –Statins –Lifestyle

31. Statins –Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or appropriate (for example, older people, people with diabetes or people in high-risk ethnic groups)

32. Lifestyle Interventions –Cardioprotective diet –Plant stanols and sterols –Physical activity –Combined interventions (diet and activity) –Weight management –Alcohol consumption –Smoking cessation

33. Initial Assessment Although there is no specific reference to follow-up or review of patients formally assessed as being at high risk of CVD, the NICE guideline indicates that as part of the risk assessment process, health professionals should: –Assess each patient’s readiness and confidence to make changes to their lifestyle, undergo treatment and/ or take medication; –Involve them in developing a shared management plan, and; –Inform them of potential future management based on current evidence and best practice.

34. Initial Assessment-for statin Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible. Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated.

35. Initial Assessment-for statin smoking status alcohol consumption blood pressure body mass index or other measure of obesity fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) fasting blood glucose renal function liver function (transaminases) thyroid-stimulating hormone (TSH) if dyslipidaemia is present.

36. Frequency of review Again, there is no specific reference to follow-up or review of patients formally assessed as being at high risk of CVD in the NICE guideline CG 67, however the CHD NSF hints at annual review: ‘As part of developing systematic and structured approaches to identifying and managing people at high risk of CHD, primary care teams should undertake an annual clinical audit that allows them to estimate the following. Priority should be given to items listed in bold:

37. Frequency of review Second step – people without clinical evidence of occlusive arterial disease but whose risk of CHD event is greater than 30% over the next ten years –the number and proportion of people aged 35 to 74 with an identified major risk factor for cardiovascular disease whose 10 year absolute risk of experiencing a major vascular event has been assessed and documented –the number and % of those identified as being at risk above threshold for active intervention whose risk has been reduced below that threshold.

39. Frequency of review NICE CG 67 Lipid modification costing template: Review of those aged 40 to 74 previously identified as high risk, not currently on statins 6 6 It is assumed that patients will be recalled every 3 years to reassess risk and discuss lipid-lowering therapy

40. What should be in an annual review? –Review, not re-assessment –Current risk algorithms are not designed to undertake ‘what if?’ scenarios. Therefore it is inappropriate to repeat the risk assessment at each subsequent review. This may change with the advent of JBS3, where ‘heart age’ may be a value that can be recalculated on the basis of changes in behaviour or risk to model potential benefits.

41. What should not be in an annual review? –A target for total or LDL cholesterol is not recommended for people who are treated with a statin for primary prevention of CVD. –Once a person has been started on a statin for primary prevention, repeat lipid measurement is unnecessary. Clinical judgement and patient preference should guide the review of drug therapy and whether to review the lipid profile. –Creatine kinase should not be routinely monitored in asymptomatic people who are being treated with a statin. – Liver function (transaminases) should be measured within 3 months of starting treatment and at 12 months, but not again unless clinically indicated.

42. However –Individual tests which contribute to an overall risk score, such as blood pressure, BMI or cholesterol, could be re-measured as a means of focussing on and monitoring the value of the test as part of a risk reduction strategy. –A cholesterol check at review would help to determine if the patient is compliant. –If the person’s CVD risk is considered to be at a level that merits intervention but they decline the offer of treatment, they should be advised that their CVD risk should be considered again in the future.

43. Funding for reviews –No specific funding for annual reviews of those at high risk of CVD –If at high CVD risk and diagnosed with a specific condition, such as hypertension, will receive funding for reviews through QOF –For those on statins, a component of the annual review will be a medication review, again funded through QOF: Medicines 12: A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines

44. Coding to support review process –There are Read codes relating to ‘at high risk of CVD’ but these are only monitoring codes which assist the practice in inviting the patient in (phone and letter invites - 9Ox0, 9Ox1, 9Ox2, 9Ox3, 9Ox4). –There is also a code (66f2) for CVD high risk review.

45. Managing High Risk Patients- in practice

46. Geoff returns in one year Smoking - Congratulate him Taking the statin – LFT (1st Year only) annual medication review BMI >30 – HbA1c or FBS BP – 134/84 ( no U and E) Opportunity to discuss lifestyle and offer any interventions

47. Questions & Next Steps Guidance document due April 2012 Look out for June issue of British Journal of Primary Care Nursing richard.healicon@improvement.nhs.uk Mel.varvel@improvement.nhs.uk Jan@etaltraining.co.uk