CVD risk estimation and prevention: An overview of SIGN 97

Annual prevalence of CVD  4.2% men  3% women

Cardiovascular Disease (CVD) includes….  Cerebrovascular disease  Coronary heart disease  Peripheral vascular disease

Clinical risk assessment-history  Age  Sex  Family history  Smoking  Alcohol  Diet  Physical activity  Socioeconomic status

Clinical risk assessment - measurements  Blood pressure  BMI/waist circumference  Cholesterol  Glucose  Renal function

Risk scoring systems  Framingham - set up in the US in the 1970s  ASSIGN – set up by SIGN to reduce differences in socio-economic risk.  QRISK2  JBS score

Diet  Reduction of total and saturated dietary fat.  Less than 6g of dietary salt per day.  Two 140g portions of fish per week one of which should be fatty fish.  Increased intake of fruit and vegetable.

Alcohol  Brief multi-contact intervention.  Information about recommended daily limits  Low to moderate alcohol consumption is cardio-protective.

Other specific recommendations  Physical activity – moderate intensity.  Active smoking- dose related risk and should be advised to stop and supported in this, especially young and low socio-economic status.  Passive smoking- increases risk of CVD and should be minimised.

Antiplatelets with established CVD  Aspirin 75mg/day of clear benefit in CHD.  Clopidogrel can be used.  Individuals with history of stroke or TIA in sinus rhythm should be considered for aspirin + dipyridamole (or) clopidogrel.

Antiplatelets without established CVD  In asymptomatic individuals with CVD risk >20% in ten years.  In hypertensives with CVD risk > 20% in 10 years.  In DM, aspirin if over 50 years of age and in younger diabetics with increased CVD risk

Lipid lowering in established CVD Patients with established CVD should be considered for intensive statin therapy.

Lipid lowering without established CVD Recommended if age > 40 years CVD risk > 20% in 10 years

Lipid lowering  Reducing LDL by 1.6 mmol/L halves CHD events after 2 years with standard statin doses.  Existing total cholesterol target of < 5mmol/L for established CVD is regarded as the minimum standard of care(NHS Scotland)  Elderly- age alone not a reason. Assess 10 year CVD risk, life expectancy and quality of life.

Lipid lowering  DM - drug therapy shows statistically significant reduction of relative risk of various endpoints including all cause mortality and fatal/nonfatal MI.  Familial hypercholesterolemia- treat irrespective of risk calculation as cholesterol usually > 8. Might need ezetimibe + statin combination.

Lipid lowering  Individuals with hypertriglyceridemia (>1.7mmol/L) and/or low HDL(<1mmol/L in men, <1.2mmol/L in women), consider fibrates and nicotinic acid.  Statins are drug of choice in diabetics with combined dyslipidemia and elevated LDL.  Statins and fibrates together- combined dyslipidemia.(caution with statin and gemfibrozil together).

BP with established CVD  Treat if BP > 140/90mmHg  Individuals with DM or chronic renal disease or target organ damage, treat if BP > 130/80mmHg

BP without established CVD  If BP > 160/100, drug therapy  If CVD risk > 20% over 10 years, treat if BP > 140/90  If CVD risk < 20%, lifestyle change and reassess 3-5 years.

Psychological stress Depression Lack of social support Social isolation