Transcript Document

The Management of People at
High Risk of CVD
Dr Richard Healicon
Mel Varvel
NHS Improvement
Jan Procter-King
CVD Nurse & National Trainer
Introduction
• The challenge
• Meeting the challenge
– Set the scene (MV)
– Consider key issues (MV/RH)
– Practical application (JPK)
• Final opportunity to contribute
Hannah
• Female
• Aged 51
• Father has type 2 diabetes
aged 80
• BMI 26
• Mother fit and well
• Smoker
• BP 138/ 84
• TC:HDL 4
• Blood sugar 4.1mmol/l
Hannah
• Your result
• Your 10-year QRISK®2 score is: 5%
• In other words, in a crowd of 100 people like you, 5 will
develop heart disease or have a stroke/TIA in the next 10
years. This is represented by the smileys.
• Your score has been calculated using the data you entered.
• Your body mass index was calculated as 28.1 kg/m2.
• How does your 10-year score compare?
• Your score Your 10-year QRISK®2 score 4.8% The score of
a typical person with the same age, sex, and ethnicity* 3.7%
Relative risk** 1.3 Your QHeartAge™*** 54
Margaret
•
•
•
•
•
•
•
•
Female
Aged 69
Ex smoker of one year
BMI 27
TC:HDL 3.6
TC 5.4mmol/l
BP 146/78
Significant Family history of
CVD
• Blood sugar 3.6mmol/l
• eGFR >90
Margaret
• Your result
• Your 10-year QRISK®2 score is: 21%
• In other words, in a crowd of 100 people like you, 20 will
develop heart disease or have a stroke/TIA in the next 10
years. This is represented by the smileys.
• Your score has been calculated using the data you entered.
• Your body mass index was calculated as 35.2 kg/m2.
• How does your 10-year score compare?
• Your score Your 10-year QRISK®2 score 19.9% The score
of a typical person with the same age, sex, and ethnicity*
15.1% Relative risk** 1.3 Your QHeartAge™*** 73
Margaret
• Is followed up
with ABPM and is
diagnosed with
hypertension
Geoff
•
•
•
•
•
•
•
Aged 54
Smoker of 30 a day
BMI 34
BP 139/82
TC 5.8mmol/l
TC:HDL 4.6
Family history- father died of
MI under the age of 50yrs
• HbA1c 41
• Alcohol – 60 units a week
Geoff
• His 10-year QRISK®2 score is: 23%
He returns in one year
• Has stopped smoking for 11
months
• Taking the statin you gave him
• Lost a tiny bit of weight
• Changed his diet slightly
• Reduced his alcohol a little
sometimes
• Got a new hobby
What do we do with him ?
The Challenge (10th National Workshop):
Management of people at high risk of CVD
Continued confusion about whether people at high risk are eligible/stay in the
programme
People on statins are excluded because they will have already had a risk
assessment and should be managed according to NICE guidelines
People who are found to be at or above 20% risk should exit the programme
irrespective of whether they have signs of disease
People at or above 20% risk without disease should be placed on a high risk
register and managed accordingly
Work with NHS I to improve use of high risk registers and management of high
risk people about to start
Meeting the Challenge
• Short, practical ‘how to’ guide
• Explains the problem under
consideration
• Refers to key sources of guidance
• Outlines some of the key
challenges
• Offers some potential solutions in
the form of consensus statements
and examples from the field
• Points to other sources of advice
and information
In the last episode….
• A long time ago in a galaxy far, far away….
– Presented existing guidance
– Outlined the problem
– Considered 3 key questions
• Who is at high risk of CVD?
• How do we find them?
• What do we do with them when we’ve found them?
Policy Context:
The Legacy of the NSF
•
Standard four: General practitioners and
primary health care teams should identify all
people at significant risk of cardiovascular
disease but who have not yet developed
symptoms and offer them appropriate
advice and treatment to reduce their risks.
•
Milestone 2:
Every practice should have:
a systematically developed and maintained
practice-based register of people with
clinical evidence of CHD, occlusive vascular
disease AND of people whose risk of CHD
events is > 30% over ten years in place and
actively used to provide structured care to
those at high risk of CHD.
Policy Context: NSF for CHD
•
•
•
Milestone 3:
Every practice should have:
a protocol describing the systematic assessment, treatment and follow-up of
people at high risk of CHD, including those without evidence of existing
arterial disease but whose risk of CHD events is > 30% over ten years, agreed
locally and being used to provide structured care to people with CHD.
Milestone 4: Every practice should have:
clinical audit data no more than 12 months old available that describes all
the items listed in paragraph 13 on page 4 [see CHD NSF Chapter Two].
The NSF goal: Every practice should:
offer advice about each of the specified effective interventions to all of those
in whom they are indicated, demonstrated by clinical audit data no more than
12 months old.
Existing Guidelines &
Published Guidance
NHS Health Check
• The NHS Health Check programme is a
systematic and integrated public health
programme of vascular risk assessment and
management which offers preventative checks to
all those aged 40 -74 to assess their risk of
vascular disease (heart disease, stroke, diabetes
and kidney disease) followed by appropriate
management and interventions.
NHS Health Check: Purpose
• …. to assess individual risk of coronary
heart disease, stroke, diabetes and kidney
disease, to communicate this risk in a way
that is easy to understand, and to offer
personalised advice, appropriate treatment
and follow up to help individuals manage or
reduce their risk- including being recalled
every five years for reassessment.
NHS Health Check
• As NHS Health Check is a prevention programme,
eligibility has been based on the potential to
prevent vascular disease through assessment of
formal risk of heart disease, stroke, diabetes and
kidney disease and appropriate management of
that risk.
• People who are already on a disease register or
have been diagnosed with the following conditions
are excluded from the programme on the basis that
they will already be managed via existing care
pathways:
NHS Health Check: Exclusions
• Coronary heart disease
• Chronic kidney disease
(CKD stages 3-5)
• Diabetes (any type) or
• Stroke & TIA
• Hypertension
• Atrial Fibrillation
• Familial
Hypercholesterolaemia
• Heart failure
• Peripheral Arterial
Disease (PAD) or
Peripheral Vascular
Disease (PVD)
People on statins and/ or anti-hypertensive medication and
those who have been identified previously or through NHS
Health Check as being at high risk of CVD
NHS Health Check
The Size of the Challenge
The Size of the Challenge
• The size of the populations potentially eligible for
intervention based on ≥20% CVD risk alone has
been estimated to be around 23% of men and 8%
of women aged 40-74 years*
• Some suggestion that these figures will be reduced
if the QRISK score is used
• Exclude people with established CVD, diabetes,
hypertension (disease registers), other exclusions
*NSC Handbook: based on data from the Health Survey of England 2003
Who is at high risk of CVD?
• CVD vs CHD
– Nearly half of all CVD deaths due to CHD
– Increasing recognition that all CVD should be considered a
spectrum of disorder (atherosclerotic disease)
– Vascular diseases linked by a common set of risk factors
• Why focus on people at high risk?
–
–
–
–
People with multiple risk factors more likely to have CVD
Rate of progression of CVD & risk factors can be reduced
We can’t predict events, but we can estimate probability of CVD
Risk assessment can help us categorise & prioritise & balance
costs of intervention with benefits of risk reduction
– Those at greatest risk stand to benefit most
Who is at high risk of CVD?
• Definition of high risk
–
–
–
–
Risk as a continuum; treatment thresholds arbitrary
NSF staged approach; >30% risk of CHD then ≥15% (CVD risk of ≥20%)
Post NSF evidence indicates clinical benefit at lower levels
Guidelines suggest threshold of ≥20% of CVD in 10 years
• Which model(s) should be used to calculate risk?
– Individual risk factors poor predictors
– Risks multifactorial, cluster & multiply
– Guidelines recommend risk assessment tools based on multiple risk factors which
calculate overall risk
– Framingham most widely used BUT
• does not include all relevant risk factors
• overestimates risk in UK populations
– ‘Younger’ models (QRISK, ASSIGN etc.) include other risk factors, e.g. socioeconomic status; recognised by NICE
– Decision left to NHS to meet local needs & requirements
Who is at high risk of CVD?
• Lifetime versus 10 year risk
– Potential disadvantage of
existing tools is influence of
age
– High absolute risk approach
may delay intervention until
later in life
– New focus on lifetime risk
(e.g. JBS3) “Early intervention
pays long term dividends”
– Other features, e.g. Heart Age,
can show effect of ‘what if’
scenarios
– May take a while for existing
guidance (NICE) to change!
http://www.jbs3risk.com/
How do we find them?
•
CHD NSF Standard 4, Milestone 2
– ‘Every practice should have…a systematically developed and maintained practice-based
register of people with clinical evidence of CHD, occlusive vascular disease AND of
people whose risk of CHD events is >30% over ten years in place and actively used to
provide structured care to those at high risk of CHD’
•
NICE Lipid Modification
– ‘People aged 40–74 years who may be at high risk of CVD should be identified in
primary care by estimating their CVD risk from existing medical record data. People
should be prioritised in descending order of risk and offered a formal risk assessment if
their estimated10-year CVD risk is 20% or more’.
•
NHS Health Check
– Formal risk assessment treat the untreated  code(!)  exit the programme to high risk
register
•
Already being treated/ Annual Medication Review
– Formal risk assessment using pre-treatment values code (!)  high risk register
•
Don’t forget to exclude the exclusions (those already on a disease register, e.g.
CHD, Diabetes, Hypertension, etc.)
How do we manage those at high risk of CVD?
CHD NSF stated that the interventions for people without clinical
evidence of occlusive arterial disease but whose were at high risk
of CHD events should include:
– advice about how to stop smoking including advice on the use of
nicotine replacement therapy
– information about other modifiable risk factors and personalised
advice about how they can be reduced (including advice about
physical activity, diet, alcohol consumption, weight and diabetes)
– advice and treatment to maintain blood pressure below 140/85 mm
Hg
How do we manage those at high risk of CVD?
NICE CG 67-lipid modification:
– Statins
– Lifestyle
Statins
– Statin therapy is recommended as part of the management strategy
for the primary prevention of CVD for adults who have a 20% or
greater 10-year risk of developing CVD. This level of risk should
be estimated using an appropriate risk calculator, or by clinical
assessment for people for whom an appropriate risk calculator is
not available or appropriate (for example, older people, people
with diabetes or people in high-risk ethnic groups)
Lifestyle Interventions
–
–
–
–
–
–
–
Cardioprotective diet
Plant stanols and sterols
Physical activity
Combined interventions (diet and activity)
Weight management
Alcohol consumption
Smoking cessation
Initial Assessment
Although there is no specific reference to follow-up or
review of patients formally assessed as being at high risk
of CVD, the NICE guideline indicates that as part of the
risk assessment process, health professionals should:
– Assess each patient’s readiness and confidence to make changes to
their lifestyle, undergo treatment and/ or take medication;
– Involve them in developing a shared management plan, and;
– Inform them of potential future management based on current
evidence and best practice.
Initial Assessment-for statin
Before offering lipid modification therapy for primary
prevention, all other modifiable CVD risk factors
should be considered and their management optimised
if possible. Baseline blood tests and clinical assessment
should be performed, and comorbidities and secondary
causes of dyslipidaemia should be treated.
Initial Assessment-for statin
•
•
•
•
•
•
•
•
•
smoking status
alcohol consumption
blood pressure
body mass index or other measure of obesity
fasting total cholesterol, LDL cholesterol, HDL cholesterol and
triglycerides (if fasting levels are not already available)
fasting blood glucose
renal function
liver function (transaminases)
thyroid-stimulating hormone (TSH) if dyslipidaemia is present.
Frequency of review
Again, there is no specific reference to follow-up or review of
patients formally assessed as being at high risk of CVD in the
NICE guideline CG 67, however the CHD NSF hints at annual
review:
‘As part of developing systematic and structured approaches to
identifying and managing people at high risk of CHD, primary care
teams should undertake an annual clinical audit that allows them to
estimate the following. Priority should be given to items listed in
bold:
Frequency of review
Second step – people without clinical evidence of occlusive
arterial disease but whose risk of CHD event is greater than
30% over the next ten years
– the number and proportion of people aged 35 to 74 with an
identified major risk factor for cardiovascular disease whose 10
year absolute risk of experiencing a major vascular event has been
assessed and documented
– the number and % of those identified as being at risk above
threshold for active intervention whose risk has been reduced
below that threshold.
Frequency of review
NICE CG 67 Lipid modification costing template:
Review of those aged 40 to 74 previously identified as high risk,
not currently on statins6
6It
is assumed that patients will be recalled every 3 years to
reassess risk and discuss lipid-lowering therapy
What should be in an annual review?
– Review, not re-assessment
– Current risk algorithms are not designed to undertake ‘what if?’
scenarios. Therefore it is inappropriate to repeat the risk assessment at
each subsequent review. This may change with the advent of JBS3,
where ‘heart age’ may be a value that can be recalculated on the basis
of changes in behaviour or risk to model potential benefits.
What should not be in an annual review?
– A target for total or LDL cholesterol is not recommended for people
who are treated with a statin for primary prevention of CVD.
– Once a person has been started on a statin for primary prevention,
repeat lipid measurement is unnecessary. Clinical judgement and
patient preference should guide the review of drug therapy and whether
to review the lipid profile.
– Creatine kinase should not be routinely monitored in asymptomatic
people who are being treated with a statin.
– Liver function (transaminases) should be measured within 3 months of
starting treatment and at 12 months, but not again unless clinically
indicated.
However
– Individual tests which contribute to an overall risk score, such as blood
pressure, BMI or cholesterol, could be re-measured as a means of
focussing on and monitoring the value of the test as part of a risk
reduction strategy.
– A cholesterol check at review would help to determine if the patient is
compliant.
– If the person’s CVD risk is considered to be at a level that merits
intervention but they decline the offer of treatment, they should be
advised that their CVD risk should be considered again in the future.
Funding for reviews
– No specific funding for annual reviews of those at high risk of
CVD
– If at high CVD risk and diagnosed with a specific condition, such
as hypertension, will receive funding for reviews through QOF
– For those on statins, a component of the annual review will be a
medication review, again funded through QOF:
Medicines 12: A medication review is recorded in the notes in the
preceding 15 months for all patients being prescribed repeat
medicines
Coding to support review process
– There are Read codes relating to ‘at high risk of CVD’ but these
are only monitoring codes which assist the practice in inviting the
patient in (phone and letter invites - 9Ox0, 9Ox1, 9Ox2, 9Ox3,
9Ox4).
– There is also a code (66f2) for CVD high risk review.
Managing High Risk Patientsin practice
Geoff returns in one year
• Smoking - Congratulate him
• Taking the statin – LFT (1st Year
only) annual medication review
• BMI >30 – HbA1c or FBS
• BP – 134/84 ( no U and E)
• Opportunity to discuss lifestyle
and offer any interventions
Questions & Next Steps
• Guidance document due April 2012
• Look out for June issue of British Journal of
Primary Care Nursing
• [email protected]
• [email protected]
• [email protected]