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Published byPhilip Welch Modified over 9 years ago
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CVD prevention & management: a new approach for primary care Rod Jackson School of Population Health University of Auckland New Zealand
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Why bother about CVD in 1°care? In a population of 10,000 primary care patients, every year there are about: 10 coronary & stroke deaths 1 diabetic death 1 breast cancer death 1 prostate cancer death 1 suicide every year 1 road traffic death (1 cervical cancer death every 5 years) NZHIS annual mortality statistics
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Blood pressure and CHD Law & Wald BMJ 2002;324:1570-6
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PSC.
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Reduction in stroke with combination BP lowering therapy in PROGRESS, regardless of baseline BP
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There is no such thing as hypertension
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CHD and SBP or Total cholesterol 110120130140150160170 0.5 1.0 2.0 4.0 Blood pressure Systolic blood pressure (mmHg) Risk of coronary disease 0.5 1.0 2.0 4.0 “Hyper- tension” “Hyperchol- esterolaemia” 4.05.06.07.08.0 Total cholesterol (mmol/l) Cholesterol
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Reduction in CV events with cholesterol lowering in Heart Protection Study, regardless of baseline cholesterol
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There is no such thing as hypercholesterolaemia
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Smoking and the risk of stroke Source: Bonita, 1999 Odds Ratio
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‘Diabetes’ & body mass index
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There is no such thing as obesity
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Stroke, CHD, CVD & blood glucose Asia Pacific Cohort Studies Collaboration
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HbA1c and microalbuminuria: Auckland, NZ Metcalf et al (unpublished) excl. diagnosed diabetics
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There is no such thing as non- insulin dependant diabetes
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Message Number 1: there is no such thing as hypertension or hypercholesterolaemia or obesity or type 2 diabetes and we all have CHD
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a new paradigm: ‘risk factors’ ‘CVD risk factors interact’
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Impact of multiple risk factors on CVD risk Jackson et al. Lancet 2005. 365:434-41
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Relative Risk and 95% CI 34% 25% 0%5%10%15%20% Few or no participants had a history of stroke Estimated 5 year stroke event rate Treatment Control Most or all participants had a history of stroke or TIA 1.4% 5.1% Relative Reduction in strokesAbsolute Reduction in strokes / 5 years 1.00.51.5 Absolute Effects Relative Effects ‘The bigger the CVD risk the bigger the benefit’: trials of BP lowering & stroke
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15% 5 yr risk NZ threshold for CVD risk drugs
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Message Number 2: Measure risk, not risk factors
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Estimating clinical risk: Framingham Heart Study Sex Age Diabetes Smoking BP TC HDL (LVH) Anderson et al. Am Heart J. 1991;121:293-8
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45 yr old man BP 150/90 mmHg non smoker TC 6.0 mmol/L HDLC 1.2 mmol/L new ‘diabetes’ 60 yr old man BP 150/90 mmHg smoker TC 6.0 mmol/L HDLC 1.0 mmol/L No ‘diabetes’ 5 yr CVD risk ≈ 10% 5 yr CVD risk ≈ 25% Are lipid +/or BP-lowering drugs indicated?
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Clinical risk: short-term vs life-time?
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Lifetime risk is clinically irrelevant The risk of death is 1 / person (100%) What’s clinically relevant is when it happens The lifetime CVD risk chart
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Who should we treat? Everybody - because we all have CHD BUT the intensity of treatment should be directly proportional to the clinical risk and to the costs of treatment
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Clinical risk treatment thresholds? $$$$$$$$$$$$$$$$$$$$$$$ At the clinical (absolute) risk that is affordable to individuals or populations Cheaper interventions should be initiated at lower risk levels
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risk threshold for high cost treatment SBP treatment threshold for equal Rx benefit Clinical CVD risk (% per yr) low high Patient 1 Patient 2 Patient 3 130150170 risk threshold for low cost treatment
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Treatment goals? Based on clinical risk and the ‘costs’ of lowering risk
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CVD risk threshold for drug treatment SBP target for equal Rx benefit Clinical CVD risk (% per yr) low high Patient 1 Patient 2 Patient 3 130150170 CVD risk target for treatment 155135115
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Message Number 3: Treat risk, not risk factors
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The polypill Aspirin Statin Diuretic ± ACEI ± BB ± CCB metformin?
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PREDICT: a clinical decision support system for CVD & diabetes risk assessment & management PREDICT is a computer programme that calculates CVD risk & provides E-B management recommendations
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(Please note – dates are not representative as this is a test case) Workflow: Individual Patient Tracking
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Sample Report –Group Data
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Patient populations All clinical data is made non- identifiable with encrypted NHI and sent via secure internet connection for analyses Combining information on patients Stored anonymous CVD risk profiles Practice/PHO/DHB population needs assessment & service planning
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patient-specific outcomes: hospital admissions, deaths Electronic medical record Enrolled population patient-specific CVD risk factor profiles NHI NHI (encrypted) Making new risk prediction charts
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patient-specific outcomes: hospital admissions, deaths Electronic medical record Enrolled population patient-specific CVD risk factor profiles NHI NHI (encrypted) Link with encrypted NHI Making new prediction charts
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Risk groups in first 30,878 patients from PREDICT
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Results: estimated 5-year incidence of CVD event For prior CVD 5-year risk is: 20 + 1.3*Framingham score Mean est. 5-year incidence for Hx CVD is 28.4% (95%CI 26.3 to 30.4)
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Results: events in risk groups in first 30,878 patients from PREDICT 47% 26% 63% of events occur in 21% of the people (high risk) 16% 11%
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The potential magnitude of the population evidence base One assessment per practitioner every other day for 46 weeks/year = 115 per year A practitioner can assess all appropriate patients in less than 5 years 1000 practitioners could assess more than 100,000 patients per year ‘one every other day is ok’ ‘one every other day is ok’
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Message Number 4: The next revolution in medicine will be electronic, not genomic The future is already here, its just not widely distributed It will be led by primary care
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metabolic syndrome: ‘metabollocks!’
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Relative stroke risk and usual Blood Pressure 0.5 1.0 2.0 4.0 7581879398102 diastolic blood pressure (mmHg) PSC Lancet 1995;346:1647-53 (45 prospective studies: 450,000 people 13,000 events) Relative Risk
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Relative stroke risk and usual Blood Pressure 0.5 1.0 2.0 4.0 7581879398102 diastolic blood pressure (mmHg) PSC Lancet 1995;346:1647-53 (45 prospective studies: 450,000 people 13,000 events) Relative Risk DBP > 100 mmHg DBP > 95 mmHg DBP > 90 mmHg DBP > 80 mmHg
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