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new zealand cardiovascular guidelines handbook

New ZealandCardiovascularGuidelines Handbook

Cardiovascular risk assessment and diabetes screening

Cardiovascular risk factor management

how to use this slide set
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
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
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
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
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
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
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
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
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
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
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
…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
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 lipids17
Lipid modification with statin therapy:…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
Vigorous BP lowering in chronic renal disease

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
Conventional antihypertensives have similar BP-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
• HbA1c 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
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
Smokers now risk-assessed 10 years earlier (aged 35+)

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
NRT approximately doubles chances of quitting

Oral NRT recommended if serious CV event in past 2 weeks

…smoking cessation
further information
www.nzgg.org.nz

www.oneheartmanylives.co.nz

www.pharmac.govt.nz

www.nhf.org.nz

www.bpac.org.nz

Further information
further information25
…further information

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
Slide set 2: CV risk assessment and diabetes screening

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

general considerations
General considerations
  • 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
CV risk charts
  • 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
CV risk/diabetes screening
  • 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
CV risk/renal function
  • 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
Case study 1

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
…case study 1

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 135
…case study 1

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
How frequently should CV risk assessment be considered?

Annually, with risk factor monitoring every 3–6 months

…case study 1
monitoring drug treatment
Monitoring drug treatment
  • 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
www.nzgg.org.nz

www.oneheartmanylives.co.nz

www.pharmac.govt.nz

www.nhf.org.nz

www.bpac.org.nz

Further information
further information39
…further information

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
Slide set 3: CV risk factor management

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

Further information

new lipid targets
New lipid targets

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
In chronic 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
Personalising treatment/care

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
…personalising treatment/care

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
Common drug combinations

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
Choosing appropriate drug combinations

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
Monitoring drug treatment
  • 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
Important contraindications

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
Important cautions

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
Case study 2

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
…case study 2

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
…case study 2

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
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
www.nzgg.org.nz

www.oneheartmanylives.co.nz

www.pharmac.govt.nz

www.nhf.org.nz

www.bpac.org.nz

Further information
further information56
…further information

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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