New Zealand Cardiovascular Guidelines Handbook

1. New ZealandCardiovascularGuidelines Handbook Cardiovascular risk assessment and diabetes screening Cardiovascular risk factor management

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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.

8. CVD burden is increasing for Māori Average annualised count Period Source: Tobias M, et al. N Z Med J 2006; 119: U1932.

9. 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.

10. 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

11. What the Handbook covers

12. 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…

13. 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

14. …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]

15. 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’

16. Lipid targets are lower in high-risk individuals with CVD, diabetes or calculated CV risk >15%: CV risk factor management: lipids

17. 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

18. 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

19. 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

20. • 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

21. 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

22. 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

23. NRT approximately doubles chances of quitting Oral NRT recommended if serious CV event in past 2 weeks …smoking cessation

24. www.nzgg.org.nz www.oneheartmanylives.co.nz www.pharmac.govt.nz www.nhf.org.nz www.bpac.org.nz Further information

25. …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

26. Slide set 2: CV risk assessment and diabetes screening Key implications for practiceDiabetes screeningRenal functionCase study 1Monitoring drug treatmentFurther information

27. 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

28. 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

29. New Zealand Cardiovascular Risk Charts

30. 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

31. 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

32. 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

33. …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%

34. …case study 1

35. …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')

36. How frequently should CV risk assessment be considered? Annually, with risk factor monitoring every 3–6 months …case study 1

37. 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

38. www.nzgg.org.nz www.oneheartmanylives.co.nz www.pharmac.govt.nz www.nhf.org.nz www.bpac.org.nz Further information

39. …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

40. Slide set 3: CV risk factor management CV risk factor managementLipid targetsBP targets in renal diseasePersonalising treatment/careMedicationsCase study 2 Further information

41. CV risk factor management

42. 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

43. 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

44. 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.

45. …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.

46. 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

47. 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

48. 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

49. 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

50. 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