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New Zealand Cardiovascular Guidelines Handbook . Cardiovascular risk assessment and diabetes screening Cardiovascular risk factor management. How to use this slide set. Contents Menu

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New zealand cardiovascular guidelines handbook l.jpg

New ZealandCardiovascularGuidelines Handbook

Cardiovascular risk assessment and diabetes screening

Cardiovascular risk factor management


How to use this slide set l.jpg
How to use this slide set

Contents Menu

To add a slide to your presentation, simply copy the slide from the contents menu by right clicking and selecting ‘copy’, then ‘paste’ into your PowerPoint presentation by selecting ‘paste’ from your edit menu.

You are free to copy slides or use the complete set. However, if you do use a slide, please use it as it is.

Page Preview

Slides have been arranged into 3 sets:

1) Overview of the revised Handbook (2009) 2) CV risk assessment and diabetes screening 3) CV risk factor management

When viewing ‘slide show’, the white tab (on left of slide) indicates the slide set that is active.

Click on tabs to return to set contents or to move between sets.

Page Notes

Background information for presenters is provided in the notes section of each slide.

Don’t forget to read this.


Contents l.jpg

Slide set 1 —Overview of the revised CVD Handbook (2009)

What’s new and important?

Slide set 2 —CV risk assessment and diabetes screening

Key implications for practice and case study 1

Slide set 3 — CV risk factor management

Key implications for practice and case study 2

Contents

10/03/2014


Slide set 1 overview of the revised cvd handbook 2009 l.jpg
Slide set 1: Overview of the revised CVD Handbook (2009)

Background

What’s new and important?

• CV risk assessment

• ‘Heart Forecast’

•Lipid targets•BP management•Diabetes and renal function•Smoking cessation

Further information

10/03/2014


Guidelines handbook l.jpg

Distils contents of full guidelines

Provides practical aids for GPs/nurses

Provides evidence to supplement:

considerations of each patient’s condition

preferences of the patient and family/whānau

Guidelines Handbook


Rationale for the 2009 guidelines handbook l.jpg

Major CVD preventive gains remain to be made

overall CVD burden is decreasing, but not in Māori, Pacific peoples and people from the Indian Subcontinent

practitioners can adopt strategies to improve patient concordance with lifestyle and medication

The 2005 handbook well received

All guidelines require reviewing and updating

Guidelines incorporate new evidence and best practice

Rationale for the 2009 Guidelines Handbook


Cvd burden is decreasing but not for all l.jpg

CHD mortality (up to 2015) is projected to decrease slightly in men and women*

But CV risk is 5% greater in Māori, and in Pacific or Indian Subcontinent peoples

For Māori, CHD mortality is projected to increase (men) or remain stable (women)

CVD burden is decreasing, but not for all

*Tobias M, et al. N Z Med J 2006; 119: U1932.


Cvd burden is increasing for m ori l.jpg
CVD burden is increasing for Māori

Average annualised count

Period

Source: Tobias M, et al. N Z Med J 2006; 119: U1932.


Cvd in primary care l.jpg
CVD in primary care

For every 10,000 primary care patients, each yearthere are about:

Source: Mortality and Demographic Data 2000, New Zealand Health Information Service, 2004.


Patient concordance l.jpg
Patient concordance

Adherence to long-term therapy for chronic illnesses averages only 50%

If adherence poor, health outcomes cannot be accurately assessed

However, low-cost strategies to improve adherence:

increase efficacy of interventions

produce significant cost savings



Since handbook publication l.jpg

Lancet reports thatlow-dose aspirin is:

of definite and substantial benefit for people with clinically manifest cardiovascular disease

not clearly justified, for prevention of disease, especially if patients are already receiving statin therapy

Source: Lancet 2009; 373: 1849-60

Since Handbook publication…


Cv risk assessment l.jpg
CV risk assessment

  • Smokers now risk-assessed 10 years earlier

  • Age bands on risk charts now show age ranges

  • Only systolic BP needed for risk calculation

  • Option of non-fasting blood levels used for TC:HDL-C ratio if fasting not possible


Cv risk assessment14 l.jpg
…CV risk assessment

  • Separate BMI charts for Māori/Pacific omitted

  • Metabolic syndrome omitted as a qualifier for a 5% risk upgrade

  • Reassess at 2 years (risk 10–15%) or 5 years (<10%)

  • Reassess after 1 year (risk >15%, or diabetes)[no change from 2005]


Cv risk assessment heart forecast l.jpg

A valuable tool in engaging patients and helping them understand lifetime CV risk, especially in younger people

Available at www.nhf.org.nz

…CV risk assessment: ‘Heart Forecast’


Cv risk factor management lipids l.jpg

Lipid targets are lower i understand lifetime CV risk, especially in younger peoplen high-risk individuals with CVD, diabetes or calculated CV risk >15%:

CV risk factor management: lipids


Cv risk factor management lipids17 l.jpg

Lipid modification with statin therapy: understand lifetime CV risk, especially in younger people

…CV risk factor management: lipids

  • Potential for muscle pain or myopathy overstated

  • Check creatine kinase if unexplained muscle pain, tenderness or weakness

* If a decision has been made to start statin therapy after 3–6 months’ lifestyle modification


Cv risk factor management bp l.jpg

Vigorous BP lowering in chronic renal disease understand lifetime CV risk, especially in younger people

Target is <125/75 mmHg in chronic renal disease and significant albuminuria

No evidence to support ACE inhibitor plus ARB combinations in chronic renal disease

CV risk factor management: BP


Cv risk factor management bp19 l.jpg

Conventional antihypertensives have similar understand lifetime CV risk, especially in younger peopleBP-lowering efficacy

β-blockers may be less effective

β-blockers and thiazides may increase diabetes

More than one drug often needed to attain optimum BP

… CV risk factor management: BP


Diabetes screening and renal function l.jpg

• HbA1 understand lifetime CV risk, especially in younger peoplec can be used if fasting blood sugar not possible (ie, no missed chances for CV risk assessment)

• If HbA1c ≥6%, then fasting blood sugar needed

Diabetes screening and renal function


Diabetes screening and renal function21 l.jpg

Renal function can be assessed with albumin:creatinine ratio (ACR) or eGFR

eGFR <60 mL/min/1.73m2 start CV risk assessment at age 35 (men) or 45 (women)

ACR and eGFR can be used to direct the management of people with diabetes and/or renal disease

…diabetes screening and renal function


Smoking cessation l.jpg

Smokers now risk-assessed 10 years earlier (aged 35+) (ACR) or eGFR

Smoking cessation guidelines revised and prominent

ABC approach should be adopted:

Ask all people if they smoke

Brief advice about stopping

Cessation support to all wishing to stop

Smoking cessation


Smoking cessation23 l.jpg

NRT approximately doubles chances of quitting (ACR) or eGFR

Oral NRT recommended if serious CV event in past 2 weeks

…smoking cessation


Further information l.jpg

www.nzgg.org.nz (ACR) or eGFR

www.oneheartmanylives.co.nz

www.pharmac.govt.nz

www.nhf.org.nz

www.bpac.org.nz

Further information


Further information25 l.jpg
…further information (ACR) or eGFR

www.nzgg.org.nz/cvdhandbook

New Zealand Guidelines Group wishes to thank those individuals and organisations who contributed to the development of this implementation resource

Funded by: Pharmac and the Ministry of Health


Slide set 2 cv risk assessment and diabetes screening l.jpg
Slide set 2: (ACR) or eGFRCV risk assessment and diabetes screening

Key implications for practiceDiabetes screeningRenal functionCase study 1Monitoring drug treatmentFurther information


General considerations l.jpg
General considerations (ACR) or eGFR

  • Identify and prioritise people at risk in your community and in your practice

  • Offer risk assessment, first, to those at greatest risk (particularly Māori men from age 35)

  • Risk assessment goes hand in hand with ongoing management

  • Ensure treatment plan reflects individual’s lifestyle: opportunities for ongoing review

  • DHBs and PHOs have resources to assist with risk assessments and ongoing training


Cv risk charts l.jpg
CV risk charts (ACR) or eGFR

  • In practice:

  • Age bands show age ranges (ie, 55–64 years)

  • No longer select age nearest to patient

  • Only systolic BP needed for risk calculation

  • Reduced ambiguity regarding age and BP

  • Update recalls (2-yearly) for CV risk 10–15%

  • Special focus on Māori, Pacific peoples, Asian and potentially very high-risk (>20%) people



Cv risk diabetes screening l.jpg
CV risk/diabetes screening (ACR) or eGFR

  • In practice:

  • No missed chances for CV risk assessment

  • Non-fasting bloods for HbA1c and TC:HDL-C

  • HbA1c ≥6%, then fasting blood sugar

  • For CV risk management, fasting bloods needed for TGs


Cv risk renal function l.jpg
CV risk/renal function (ACR) or eGFR

  • In practice:

  • Renal function assessed with ACR and eGFR

  • If eGFR <60 mL/min/1.73m2, start risk assessment at age 35 (men) or 45 (women)

  • Special focus on Māori and Pacific people

  • Māori and Pacific males often assessed too late

  • European women often assessed earlier than needed

  • ACR and eGFR guide management in diabetes and/or renal disease


Case study 1 l.jpg
Case study 1 (ACR) or eGFR

Tamati

40-year-old Māori man

Presents to practice for the first time

History

No visits to the doctor in the last 7 years

Father had MI aged 62 years

Alcohol – ‘an occasional beer’

Smoking – about 20 cigarettes per day

Examination

Weight 120 kg

BMI 35 kg/m2

Sitting BP 160/98 mmHg


Case study 133 l.jpg
…case study 1 (ACR) or eGFR

Should a CV risk assessment be carried out?

Yes, on 2 counts: Tamati is a Māori male and a smoker

What aspects of the history are important?

Age, sex, ethnicity, family history and smoking status

What bloods should be done to complete the CV risk assessment?

Fasting lipids and fasting blood glucose (consider non-fasting lips and HbA1c, if not possible)

Tamati has TC 6.3 mmol/L; TC:HDL-C ratio 6.9 fasting blood glucose 5; sitting BP 160/98 mmHg; calculated CV risk 15–20%


Case study 134 l.jpg
…case study 1 (ACR) or eGFR


Case study 135 l.jpg
…case study 1 (ACR) or eGFR

What interventions are needed?

Specific lifestyle advice for 3–6 months

Start smoking cessation therapy

If lifestyle interventions fail, consider medication

Simvastatin 20 mg/day, antihypertensive(s)

Use existing resources (eg, refer Tamati to ‘One Heart Many Lives’ programme to review 'Tamati’s story')


Case study 136 l.jpg

How frequently should CV risk assessment be considered? (ACR) or eGFR

Annually, with risk factor monitoring every 3–6 months

…case study 1


Monitoring drug treatment l.jpg
Monitoring drug treatment (ACR) or eGFR

  • Consider adverse effects of medications:

  • ACE inhibitors — angioedema, cough, hyperK+, PH

  • ARBs — hyperK+, PH

  • β-blockers — dyspnoea, ED, lethargy

  • CCBs — constipation, flushing, headache, oedema, PH

  • Statins — abdominal pain, asthenia, constipation, flatulence, headache; muscle pain, weakness, tenderness

  • Thiazides — Gout, hyperglycaemia, hypoK+, hypoNa+, PH


Further information38 l.jpg

www.nzgg.org.nz (ACR) or eGFR

www.oneheartmanylives.co.nz

www.pharmac.govt.nz

www.nhf.org.nz

www.bpac.org.nz

Further information


Further information39 l.jpg
…further information (ACR) or eGFR

www.nzgg.org.nz/cvdhandbook

New Zealand Guidelines Group wishes to thank those individuals and organisations who contributed to the development of this implementation resource

Funded by: Pharmac and the Ministry of Health


Slide set 3 cv risk factor management l.jpg
Slide set 3: (ACR) or eGFRCV risk factor management

CV risk factor managementLipid targetsBP targets in renal diseasePersonalising treatment/careMedicationsCase study 2

Further information



New lipid targets l.jpg
New lipid targets (ACR) or eGFR

For high-risk individuals with CVD, diabetes or calculated CV risk >15%:

TC <4.0 mmol/L (was actually 4.5 in 2005)

LDL-C <2.0 mmol/L (was 2.5)

  • In practice:

  • Be aware of new lipid targets

  • May require more aggressive therapy

  • Promote adherence to prescribed treatment

  • Risk factor review every 3–6 months

  • CV risk reassessed at least annually


Bp targets in renal disease l.jpg

In (ACR) or eGFRchronic renal disease with significant albuminuria (urine protein or creatinine >100 mg/mmol):

<125/75 mmHg

BP targets in renal disease

  • In practice

  • Be aware of new BP target

  • May require more aggressive therapy(eg, ACE inhibitor + calcium-channel blocker ±β-blocker ± thiazide diuretic)

  • Promote adherence to prescribed treatment

  • Yearly risk factor review + CV risk reassessment


Personalising treatment care l.jpg
Personalising treatment/care (ACR) or eGFR

Asking open-ended questions

Express empathy

Ask what the person expects from treatment?

Explain the risks and benefits of treatment (plus the risks of no treatment)

Design a treatment plan that takes account of the individual’s personal circumstances (eg, age, ethnicity, ability to undertake physical activity)

Source: National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to hypertension 2008.


Personalising treatment care45 l.jpg
…personalising treatment/care (ACR) or eGFR

Discuss use of aids (eg, medico packs)

Discuss tolerability and convenience of treatment

At each visit, ask ‘How are you managing with your medicines?’

Express encouragement and hope

Suggest where individuals can seek advice

Source: National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to hypertension 2008.


Common drug combinations l.jpg
Common drug combinations (ACR) or eGFR

In hypertension:

ACE-I or ARB plus CCB

Especially in diabetes or dyslipidaemia

ACE-I or ARB plus thiazide

Especially in heart failure or after stroke

ACE-I or ARB plus β-blocker

Recommended post-MI or in heart failure

β-blocker plus dihydropyridine CCB

Especially in CHD


Choosing appropriate drug combinations l.jpg
Choosing appropriate drug combinations (ACR) or eGFR

In hypertension:

Thiazide plus CCB

Thiazide plus β-blocker

Not recommended if glucose intolerance, metabolic syndrome, or ‘frank’ diabetes

For lipid management when high CV risk:

consider atorvastatin if simvastatin inadequate to meet target, or

consider combination of statin with ezetimibe


Monitoring drug treatment48 l.jpg
Monitoring drug treatment (ACR) or eGFR

  • Consider adverse effects of medications:

  • ACE inhibitors — angioedema, cough, hyperK+, PH

  • ARBs — hyperK+, PH

  • β-blockers — dyspnoea, ED, lethargy

  • CCBs — constipation, flushing, headache, oedema, PH

  • Statins — abdominal pain, asthenia, constipation, flatulence, headache; muscle pain, weakness, tenderness

  • Thiazides — gout, hyperglycaemia, hypoK+, hypoNa+, PH


Important contraindications l.jpg
Important contraindications (ACR) or eGFR

a Except cardioselective agents (eg, atenolol, metoprolol controlled release [CR])

b Refers to diltiazem and verapamil

c In aortic stenosis

d In uncontrolled heart failure (HF). Some β-blockers (eg, metoprolol CR) indicated in HF

e Refers to atenolol

f Before 22 weeks’ gestation

NB. The use of aspirin is not clearly justified for primary prevention of CHD events


Important cautions l.jpg
Important cautions (ACR) or eGFR

a On initiation or withdrawal of treatment

b Cardioselective agents: use cautiously and only in mild/moderate disease

c Especially diltiazem and verapamil

d Thiazides may be beneficial when combined with ACE inhibitors in type 2 diabetes


Case study 2 l.jpg
Case study 2 (ACR) or eGFR

Frank

52-year-old European male

No history of diabetes

Father died from MI aged 48 years

Ex-smoker (quit <12 months ago)

BP 148/96 mmHg

BMI 29 kg/m2

TC 6.94 mmol/L; HDL-C 0.95 mmol/L; LDL-C 4.2 mmol/L; TG 2.35 mmol/L

Frank’s risk is calculated at 24%.


Case study 252 l.jpg
…case study 2 (ACR) or eGFR

What treatments should Frank receive?

Intensive lifestyle advice (dietitian)

Simvastatin 40 mg/day (± ezetimibe)

ACE-I or ARB (± CCB)

No aspirin — not clearly justified in primary prevention

Frank needs advice about concordance — he is unhappy taking up to 4 meds. What do you do?

Explain that Frank’s current CV risk is 24%; with treatment it will be approx. 10—15% over 5 years (see later)


Case study 253 l.jpg
…case study 2 (ACR) or eGFR

How much is Frank’s risk of an MI reduced if he takes simvastatin 40 mg/day?

Approximately 30% (over the next 5 years); the risk reduction may be greater with a more potent statin (ie, atorvastatin) or higher doses

What is Frank’s absolute risk of another CV event in the next 5 years?

30% decrease from 24% = 17%


Case study 254 l.jpg

Significant treatment ‘gaps’ exist in the general population

The Bold Promise Projecta (2006): among individuals with CV risk ≥15%, only 40% were prescribed statins

GPs and PNs have a major role in ‘narrowing’ such treatment gaps

…case study 2

a Sinclair & Kerr. N Z Med J 2006; 119 (1245): U2312


Further information55 l.jpg

www.nzgg.org.nz population

www.oneheartmanylives.co.nz

www.pharmac.govt.nz

www.nhf.org.nz

www.bpac.org.nz

Further information


Further information56 l.jpg
…further information population

www.nzgg.org.nz/cvdhandbook

New Zealand Guidelines Group wishes to thank those individuals and organisations who contributed to the development of this implementation resource

Funded by: Pharmac and the Ministry of Health


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