SIGN CHD In Scotland in the year ending 31 March 2006 over 10,300 patients died from CHD and 5,800 from cerebrovascular disease, with almost 49,000 hospital admissions for CHD and a further 22,050 for cerebrovascular disease.

Coronary Heart Disease

SIGN CHD SIGN is a collaborative network of healthcare professionals and SIGN guidelines are developed by multidisciplinary groups using a standard methodology based on a systematic review of the evidence.

SIGN levels of evidence

SIGN grades of recommendation

SIGN Coronary Heart Disease

SIGN CHD PREVENTION STABLE ANGINA ACUTE CORONARY SYNDROMES ARRHYTHMIAS CHRONIC HEART FAILURE

SIGN: Prevention

SIGN CHD: prevention Prevention of CHD - Risk Estimation Individuals with symptomatic manifestations of cardiovascular disease or diabetes should be considered at high risk (≥ 20% risk over 10 years) of cardiovascular eventsD All adults over the age of 40 who have no history of cardiovascular disease or diabetes and who are not being treated for blood pressure or lipid reduction should have their cardiovascular risk estimated at least once every five yearsD

SIGN CHD : prevention Simvastatin 40 mg/day recommended as part of the management in those patients over age 40 with a 10 year risk of CVS events of > 20%A

ASCOT-LLA/CARDS Potential events avoided and related resources saved from treating 435,000 asymptomatic individuals at high CVD risk with a statin Event Clinical benefit over 4.3 years Annual bed days saved Annual cost savings (million) Major vascular6,21717,050£5.9 All cause mortality2,303 Total8,52017,050£5.9

HPS Potential events and resources saved from treating 95,000 symptomatic individuals with a statin EventsEvents avoided Annual bed days saved Annual cost savings (million ) Major vascular9,43719,770£6.8 All cause mortality718 Total10,15519,770£6.8

Heart 2007;93: SIGN has commissioned the development of a score to include social deprivation as a risk variable. ASSIGN tends to classify more people with a positive family history and who are socially deprived as being at high risk. When used in its own host population, it abolished a large social gradient in future CVD victims not identified for preventative treatment by the Framingham score: it therefore improved social equity.

SIGN: chronic stable angina

SIGN CHD: Stable Angina Patients with left main stem disease should undergo coronary artery bypass grafting to improve coronary heart disease prognosisA Patients with triple vessel disease should be considered for coronary artery bypass grafting to improve coronary heart disease prognosis but where unsuitable be offered percutaneous coronary interventionA Patients with single or double vessel disease where optimal medical therapy fails to control symptoms should be offered percutaneous intevention or where unsuitable, be considered for coronary bypass surgeryA

SIGN: acute coronary syndromes

SIGN CHD: ACS Patients with ST elevation acute coronary syndrome should be treated immediately with primary percutaneous coronary intervention A Where primary percutaneous coronary intervention cannot be provided within 90 minutes of diagnosis, patients with ST elevation acute coronary syndrome should receive immediate thrombolytic therapy D Patients with ST elevation acute coronary syndrome within 6 hours of symptoms who fail to reperfuse following thrombolysis should be considered for rescue percutaneous coronary intervention B

SIGN CHD: ACS A ABA In addition to long term aspirin, clopidogrel therapy should be continued for three months in patients with non- ST elevation acute coronary syndromes B

SIGN: Arrhythmias

SIGN CHD: arrhythmias Patients with impaired LV ejection fraction in NYHA Class I – III after previous myocardial infarction should be considered for ICD therapyA Patients with spontaneous non-sustained ventricular tachycardia, severely depressed ejection fraction ( 0.12 sec) should be prioritized for ICD implantationB

SIGN Heart Failure

SIGN CHD : heart failure BNP should be checked prior to commencing therapy for suspected heart failure A

SIGN CHD: Heart failure Heart Failure - Interventional procedures In patients in sinus rhythm with drug refractory symptoms of heart failure due to left ventricular systolic function (LVEF 120 m/s, cardiac resynchronisation therapy (CRT) should be consideredA

SIGN CHD: Heart failure Heart Failure - Discharge planning Comprehensive discharge planning to ensure links with post discharge services should be available to all those with symptomatic heart failure. A nurse-led, home based element should be includedA Telephone follow-up by specialised heart failure nurses should be considered for patients with stable heart failure. Nurses should have the ability to alter diuretic dose, telephone schedules and recommend emergency/non-scheduled medical contactA

SIGN CHD What are the potential clinical events avoided by implementation?

SIGN CHD implementation benefits Recommendati on by guideline Mortality avoided over 5 years Events avoide d over 5 years Bed days saved per year Saving s per year (£ million) Statins – primary prevention 2,6787,22917, Statins – secondary prevention 7189,43719, Antihypertensive drugs 9502,7619, Prevention - other 7502,6725, Prevention - total5,09622,09951, Acute Coronary Syndromes guideline 8962,1762, Arrhythmia and Heart Failure guidelines 1,2322,8517, Total events7,22427,12660,

Cost (£ million) Year 1Year 6 ACS5 (5) Arrhythmias4 (5) Heart Failure7 (7) Prevention25 (27)54 (62) Total41 (44)70 (79) Estimated annual cost of implementing key recommendations by guideline

SIGN CHD The recommendations on statins and hypertension account for over 90% of the costs and the savings

SIGN CHD Over the next five years, it is estimated that over 7,200 premature deaths from CVD and over 27,000 vascular events could be avoided. This is equivalent to a 9% reduction from the current CVD mortality rate and an 8% reduction from the current CVD event rate.