The Management of People at High Risk of CVD Dr Richard Healicon Mel Varvel NHS Improvement

Introduction The challenge Meeting the challenge Click here to look inside Your opportunity to contribute

Rationale for CVD Prevention CVD is a major cause of mortality & morbidity & is a significant drain on health care resources Underlying atherosclerosis develops insidiously over many years & is usually advanced by the time symptoms occur Death from CVD often occurs suddenly & before medical care is available so that therapeutic interventions are either inapplicable or palliative Prevalence of CVD relates strongly to lifestyles & modifiable physiological & biochemical factors Risk factor modifications have been shown to reduce CVD mortality & morbidity, particularly in high risk subjects Eur Heart J (2007) 28 (19):

Management of high risk people 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

Policy Context: NHS Health Check

Policy Context: NSF for CHD 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.

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.

Existing Guidelines: JBS2 We recommend that CVD prevention in clinical practice should focus equally on (i) people with established atherosclerotic CVD, (ii) people with diabetes, and (iii) apparently healthy individuals at high risk (CVD risk of > 20% over 10 years) of developing symptomatic atherosclerotic disease. This is because they are all people at high risk of CVD. These three groups all require professional lifestyle and multifactorial risk factor management to defined lifestyle and risk factor targets. HEART Vol. 91, Supplement V, Dec 2005

Published Guidance: NICE For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk. People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records. Risk equations should be used to assess CVD risk. People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period.

Published Guidance: QOF Secondary prevention of coronary heart disease (CHD1-CHD14): –Records (Register) –Ongoing Management (Review) Cardiovascular disease: Primary prevention (PP1-PP2) –Initial diagnosis (Risk Assessment) –Ongoing Management (Lifestyle advice)

The First Step “A Journey of a thousand miles must begin with a single step” Lao Tzu, Chinese Philosopher

Meeting the Challenge Short, practical ‘how to’ guide Outlines existing guidance Includes examples of good practice Points to other sources of advice and information The Management of People at High Risk of CVD

Overview of Contents Introduction –About this guide –How to use it Background –Rationale –Policy context Establishing & Maintaining a Register –Defining & identifying those at ‘high risk’ –Creating & validating a register –Risk assessment Managing People at High Risk of CVD –Communication of risk –Management of risk factors –Follow-up: Annual review –Training & competencies –Reaching the ‘hard to reach’ –Levers/Incentives –Cost, capacity –Case studies

Purpose of Today Present the story so far Identify & share good practice Provide an opportunity to discuss issues & challenges (& reach a consensus on some) Contribute to the development of the guide –10-15 mins to debate and discuss key questions under 3 headings –Record ‘consensus’ and good practice examples (with contact details) on post-it notes and stick on relevant flip chart –We will summarise feedback at end

High CVD risk Definition-risk algorithm Creating a register –Do we have adequate codes –Exclusion codes Validating the register Examples

Management of those at high CVD risk Annual review-suggested in the NHS Health Checks document What should it include? –Recalculate risk? –Cholesterol? –Role of lifestyle interventions Examples

Management of those at high CVD risk Pharmacological –Statins –Review –monitoring Lifestyle interventions –Definition of adequate trial –‘informed dissent’ Examples