Cardiovascular risk assessment

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Cardiovascular risk assessment
You can only predict things after they have
happened
Eugéne Ionesco 1912-1994
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Aims

• We will consider
• What is risk?
• How does risk relate to the management of
  cardiovascular disease (CVD)?
• How can we communicate risk to patients?

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What is risk?http//riskcomm.com

• Risk is the likelihood of being harmed in some
  way
• How we define and understand risk depends on
• emotional factors rather than hard facts
• our instinctive bias
• whether we understand the difference between
  risks and hazards
• Harm is not often due to a single cause so it
  becomes harder to define what a risk is
• When we try to avoid a risk, we can change some
  part of the situation that potentially results in
  exposure to a different risk

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Communicating riskto patients
http//www.cks.library.nhs.uk

• It is difficult to communicate risk and
  uncertainty
• When discussing cardiovascular disease (CVD) risk
  with people, show them the risk prediction charts
  (and calculator) to help them understand their
  estimated risk of experiencing a cardiovascular
  event within the next 10 years
• It is usually more helpful to discuss total CVD
  risk rather than individual risks for CHD, stroke
  or other events
• Individuals may have differing thresholds of risk
  before considering drug treatment to lower risk
  and this may be associated with social class

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Communicating risk to patientsBritish Heart
Foundation www.bhf.org.uk

• If people want to know the benefits and risks of
  investigations and treatments then we have to be
  able to communicate them effectively
• The way in which health professionals communicate
  risk affects patients perception of that risk
• Patients should be provided with a balanced and
  fair assessment of the pros and cons of the
  various options, based on well-founded data
• Use of simple visual aids and everyday analogies
  can help to increase understanding and ensure
  that consent is properly informed

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Strategies to help patients understand risks
Paling J. BMJ 20033277458

• Avoid purely descriptive terms of risk e.g. low
  risk
• Use probabilities, not percentages
• Use a consistent denominator, e.g. 1 in 100, 5 in
  100, not 1 in 100, 1 in 20
• Use absolute numbers (not relative)
• Use visual aids e.g. smiley faces available
  from www.nntonline.net

• How you say something matters
• e.g. if someone has a 10 10-year risk of CVD you
  could say
• you have a 10 chance of having a heart attack
  or stroke in the next 10 years
• you have a 90 chance of not having a heart
  attack or stroke in the next 10 years

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How to calculate CVD riskhttp//www.cks.library.n
hs.uk/

• The Joint British Societies (JBS) 2 charts (and
  calculator) are preferred over other risk
  assessment tools
• Use a consistent approach to the assessment and
  management of total CVD risk
• Cardiovascular disease risk should be managed in
  the same way in people with established disease
  and in people who are asymptomatic but at high
  total risk for CVD

• DH. National Service Framework for Coronary Heart
  Disease
• The NSF for CHD recommends that we 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 risk

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Joint British Societies (JBS) 2 charts
http//www.cks.library.nhs.uk/

• People are considered to be at high risk for
  cardiovascular disease events if they have
• a 10-year risk for CVD events greater than 20
  because of multiple risk factors or a condition
  that is known to pose a high risk for CVD events,
  e.g. established coronary heart disease, stroke
  or transient ischaemic attack, type 1 or 2
  diabetes
• People who have a single risk factor that is
  particularly abnormal are also considered to be
  at high risk
• e.g. people with blood pressure 160/100 mmHg,
  or familial dyslipidaemia
• People with 10-year CVD risk of 1020 (orange on
  the JBS 2 risk charts) are considered to be at
  moderate risk
• People with 10-year CVD risk less than 10 (green
  on the JBS 2 charts) are considered to be at low
  risk

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Summary

• Know how to use the updated Joint British tables
  (or another NSF-approved risk tool) to calculate
  a patients risk
• A patient is at high risk if their 10-year CVD
  risk exceeds 20
• Appreciate the limitations of the calculators and
  that prediction is an imprecise science
• Be aware of how you communicate risk issues to
  patients
• Communication can be helped by using visual aids