1. CHD Prevention and Risk Asssessment: Old concepts new context? Dr Paul D MacIntyre Director of Cardiology, RHH

2. Why Prevent CHD ? Premature Mortality <65yrs of age Premature Mortality <65yrs of age Avoid chronic disease Avoid chronic disease Quality of life Quality of life Economic costs Economic costs –Delay or prevent –We all die ! CVD v Cancer CVD v Cancer

3. Prevention of CHD:3 Silos 1. Low risk primary prevention 2. High risk primary prevention 3. Secondary prevention

4. Risk Factors for CVD Modifiable Modifiable –Smoking –Physical Activity –Obesity Medical Conditions Medical Conditions –Hypertension –Diabetes –Hyperlipidemia –Chronic Kidney Disease Non Modifiable Non Modifiable –Age –Sex –Family History –Socio economic status Ethnicity Relative poverty Lack of hope

6. Low Risk Primary Prevention General population at low risk of CHD General population at low risk of CHD Public Health measures to improve lifestyle Public Health measures to improve lifestyle –Smoking –Diet –Exercise Prioritise children Prioritise children –Childhood Obesity Needs both population and individual approach Needs both population and individual approach

7. Population Risk Mean Cholesterol Physical activity

8. Population risk Public Health policy Public Health policy Partnership working Partnership working –Health Services –Central government –Local authorities –Primary care –Voluntary sector Create environmental change Create environmental change –Smoking ban in public places –Plain packaging of cigarettes –Healthy eating –Environmental change to facilitate physical activity Social Determinants of Health Social Determinants of Health

9. Public Health measures Healthy Eating Food labelling Food labelling Restrictions Restrictions –Ban Junk food from public sector Engage with the food industry Engage with the food industry –Junk Tax –Fat Tax Fruit shops in public sector buildings Fruit shops in public sector buildings

10. Individual Approach

11. Smoking Stop starting and start stopping Stop starting and start stopping Young Young Programmes for low income Programmes for low income Hospital Smoking cessation services including NRT Hospital Smoking cessation services including NRT Primary care services Primary care services

12. Physical Activity –Inactivity doubles risk of CVD –Physical activity for Health Adults accumulate 30 mins of moderate intensity exercise most days of week Adults accumulate 30 mins of moderate intensity exercise most days of week Children 60 mins Children 60 mins –Physical activity for fitness 3 x 20 mins of vigorous intensity exercise per week 3 x 20 mins of vigorous intensity exercise per week –? Intensity Level required for CVD protection

13. Barriers to Exercise Master Tom MacIntyre

14. Diet Noddy’s guide Noddy’s guide –Cut the crap Accessibility Accessibility Cost Cost Convenience Convenience –Reduce portion size –Eat fruit and vegetables

15. Hospital Fruit Shop ?

16. High risk primary prevention Anticipatory care Anticipatory care Case finding Case finding High risk registers High risk registers –Structured –Opportunistic –Outreach Social deprivation Social deprivation Risk assessment Risk assessment Risk factor modification Risk factor modification

17. High risk primary prevention ?Already have the disease ?Already have the disease JBS2 guidelines JBS2 guidelines –≥ 20% 10yr risk of CVD on Framingham score –Health inequalities ASSIGN risk calculator for Scotland ASSIGN risk calculator for Scotland Prof Tunstal-Pedoe Prof Tunstal-Pedoe Social Deprivation and Family History Social Deprivation and Family History SIGN 97 SIGN 97 Health behaviour change Health behaviour change Statin and aspirin prescription Statin and aspirin prescription

18. Flower of Scotland

20. Magnificent All Blacks

25. Predict Prof Rod Jackson Prof Rod Jackson Predict Predict Absolute risk Absolute risk Unique identifier Unique identifier 90 % penetration in primary care 90 % penetration in primary care –>400,000 IT issues resolved IT issues resolved Outcome data Outcome data

26. Hope for Australia ?

27. Australian absolute cardiovascular disease risk calculator http://www.cvdcheck.org.au/ http://www.cvdcheck.org.au/

32. Secondary prevention Step change Step change –Menu based Cardiac Rehabilitation –Multidisciplinary team –Components Education Education Medical risk factor modification Medical risk factor modification Optimise pharmacological treatment Optimise pharmacological treatment Health Behaviour Change interventions Health Behaviour Change interventions –Smoking –Diet –Exercise –Stress, anxiety and depression –Does it work? –Chronic disease management

33. Secondary prevention Chronic Stable CHD Chronic Stable CHD –Primary care setting –Medical risk factor modification –Optimise treatment –Chronic disease management programmes –Health behaviour change Smoking cessation services Smoking cessation services Diet Diet Exercise referral Exercise referral Health coach model Health coach model