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Risk estimation and the prevention of cardiovascular disease SIGN 97. Key messages. Prevention - a journey not a destination Moving from CHD to CVD Risk estimation essential Reinforcement of lifestyle messages Significant changes need to be taken on board.

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Risk estimation and the prevention of cardiovascular disease sign 97 l.jpg

Risk estimation and the prevention of cardiovascular disease SIGN 97

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Key messages

  • Prevention - a journey not a destination

  • Moving from CHD to CVD

  • Risk estimation essential

  • Reinforcement of lifestyle messages

  • Significant changes need to be taken on board

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RISK ESTIMATIONThe basis of all rational prevention strategies

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CVD PreventionRisk estimation

  • Multifactorial

  • Reducing the interventional level to 20% CVD risk in the next 10years

  • The problem of social deprivation

  • The potential of a new risk scoring tool: ASSIGN 20

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CVD Prevention


Diet, exercise, alcohol and smoking remain fundamental!

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Lifestyle modification (1)

  • Diets low in total and saturated fats should be recommended for all for the reduction of CVD risk. (A)

  • regular physical activity of at least moderate intensity (eg makes a person slightly out of breath) is recommended for the whole populationunless contraindicated by condition . (B)

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Lifestyle modification (2)

  • In patients with no evidence of CHD , light to moderate alcohol consumption may be protective against coronary events. (B)

  • All people who smoke should be advised to stop and offered support to facilitate this in order to minimise cardiovascular and general health risks. (B)

  • Motivational interviewing should be considered in patients with cardiovascular disease who require to change health behaviours including diet, exercise, alcohol and compliance with treatment. (B)

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CVD Prevention


Lower is better!

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Blood pressure lowering (1)

  • Individuals with BP greater than 160/100 mm Hg should have drug treatment and specific lifestyle advice to lower their BP and risk of CVD. (A)

  • Individuals with established CVD, who also have chronic renal disease or diabetes with complications, or target end organ damage may be considered for treatment at the lower threshold of systolic >130 mm Hg and /or diastolic >80 mm Hg. (A)

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Blood pressure lowering (2)

  • Asymptomatic individuals with sustained systolic BP >140 mm Hg systolic and /or diastolic BP > 90 mm Hg and whose 10 year risk of CVD is calculated to be:

    • ≥20% should be considered for BP lowering therapy

    • <20% should continue with lifestyle strategies and have their BP and total risk reassessed annually (A)

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Lipid lowering

  • All adults over the age of 40 years who are assessed as having a ten year risk of a first CV event ≥ 20% should be considered for treatment with simvastatin 40 mg/day following an informed discussion of risks and benefits. (A)

  • All patients with established CVD should be considered for more intensive statin therapy following informed discussion. (B)

    There is no grade A evidence for treating any population to a target TC level

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Statins = largest prescribing cost in UK. Statin bill in Lothian = £8.4M (2006)….

Report on Prescribing Pressures in Primary Care 2007-2008. NHS Lothian

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Population 787,504

40-74 years 312,097

Eligible for statin

  • 2o prevn ~15,100

  • 1o prevn ~62,000

  • Total ~77,100

    Receiving statin

  • Total ~62,000

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What does this mean for NHS Lothian?

  • Around 62,000 patients receiving statin in 2006

  • Around 15,000 additional people eligible for statin using new guidance

    • SIGN approach: majority adequately treated with simva

    • JBS-2 targets: many will require atorvastatin

  • Annual cost of treating people newly eligible for statin estimated to range from:

    • £0.7M (simva)

    • to £3.5M (atorva)

  • May be potential to “switch statins” for those already on atorvastatin

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  • SIGN97 provides a summary of the best evidence to date

  • Evidence does not support “treating to target” (but QOF has target of <5mmol/L)

  • In Lothian up to 80% of people eligible may already be receiving statins (NB limitations of using prescribing data)

  • Implementing SIGN97 in Lothian should be affordable (using generic statins)

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Implementing the SIGNCVD guidelines

Maximise your learning time

Key messages for your colleagues

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Key messages & beyond (1)

  • ASSIGN 20 has major implications for primary care, especially practices in deprived areas - is its likely impact deliverable with current resources?

  • Simva. 40 for all at risk will require increased prescribing resources.

  • Screening all those over 40 for CVD risk every 5years - this will be extremely challenging given current practice resources?

  • How can we take on board motivational interviewing within existing resources?

  • How can we train and supervise people effectively in what should be a widely used practice technique to bring about positive change?

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Key messages & beyond (2)

  • A gradualist approach is required which is multi professional and realistic about the difficulties in relation to practice, resource and capacity.

  • All colleagues, including secondary care, should be encouraged to take part in learning events which ideally should be in protected time.

  • Follow up within practices to ensure practice change should be the responsibility of individual CHPs and MCNs.