New Zealand Cardiovascular Guidelines Handbook

1
New ZealandCardiovascularGuidelines Handbook

• Cardiovascular risk assessment and diabetes
  screening
• Cardiovascular risk factor management

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Contents

• Slide set 1 Overview of the revised CVD
  Handbook (2009)
• Whats 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

12/12/2009
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Slide set 1 Overview of the revised CVD Handbook
(2009)
Background Whats new and important? CV risk
assessment Heart Forecast Lipid
targets BP management Diabetes and renal
function Smoking cessation Further information
12/12/2009
5
Guidelines Handbook

• Distils contents of full guidelines
• Provides practical aids for GPs/nurses
• Provides evidence to supplement
• considerations of each patients condition
• preferences of the patient and family/whanau

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Rationale for the 2009 Guidelines Handbook

• Major CVD preventive gains remain to be made
• overall CVD burden is decreasing, but not in
  Maori, 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

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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 Maori, and in
  Pacific or Indian Subcontinent peoples
• For Maori, CHD mortality is projected to increase
  (men) or remain stable (women)

Tobias M, et al. N Z Med J 2006 119 U1932.
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CVD burden is increasing for Maori
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 year
  there 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

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What the Handbook covers
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Since Handbook publication

• Lancet reports that low-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

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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
  TCHDL-C ratio if fasting not possible

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CV risk assessment

• Separate BMI charts for Maori/Pacific omitted
• Metabolic syndrome omitted as a qualifier for a
  5 risk upgrade
• Reassess at 2 years (risk 1015) or 5 years
  (lt10)
• Reassess after 1 year (risk gt15, or diabetes)
  no change from 2005

15
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

16
CV risk factor management lipids

• Lipid targets are lower in high-risk individuals
  with CVD, diabetes or calculated CV risk gt15

17
CV risk factor management lipids

• Lipid modification with statin therapy

• 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 36 months lifestyle modification
18
CV risk factor management BP

• Vigorous BP lowering in chronic renal disease
• Target is lt125/75 mmHg in chronic renal disease
  and significant albuminuria
• No evidence to support ACE inhibitor plus ARB
  combinations in chronic renal disease

19
CV risk factor management BP

• Conventional antihypertensives have similar
  BP-lowering efficacy
• ß-blockers may be less effective
• ß-blockers and thiazides may increase diabetes
• More than one drug often needed to attain optimum
  BP

20
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

21
diabetes screening and renal function

• Renal function can be assessed with
  albumincreatinine ratio (ACR) or eGFR
• eGFR lt60 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

22
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

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smoking cessation

• NRT approximately doubles chances of quitting
• Oral NRT recommended if serious CV event in past
  2 weeks

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Further information

• www.nzgg.org.nz
• www.oneheartmanylives.co.nz
• www.pharmac.govt.nz
• www.nhf.org.nz
• www.bpac.org.nz

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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
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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 Maori men from age
  35)
• Risk assessment goes hand in hand with ongoing
  management
• Ensure treatment plan reflects individuals
  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, 5564 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 1015
• Special focus on Maori, Pacific peoples, Asian
  and potentially very high-risk (gt20) people

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New Zealand Cardiovascular Risk Charts
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CV risk/diabetes screening

• In practice
• No missed chances for CV risk assessment
• Non-fasting bloods for HbA1c and TCHDL-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 lt60 mL/min/1.73m2, start risk assessment
  at age 35 (men) or 45 (women)
• Special focus on Maori and Pacific people
• Maori 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

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Case study 1

• Tamati
• 40-year-old Maori 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

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case study 1

• Should a CV risk assessment be carried out?
• Yes, on 2 counts Tamati is a Maori 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 TCHDL-C ratio 6.9
  fasting blood glucose 5 sitting BP 160/98 mmHg
  calculated CV risk 1520

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case study 1
35
case study 1

• What interventions are needed?
• Specific lifestyle advice for 36 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 'Tamatis
  story')

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case study 1

• How frequently should CV risk assessment be
  considered?
• Annually, with risk factor monitoring every 36
  months

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Monitoring drug treatment

• Consider adverse effects of medications
• ACE inhibitors angioedema, cough, hyperK, PH
• ARBs hyperK, PH
• ß-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

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Further information

• www.nzgg.org.nz
• www.oneheartmanylives.co.nz
• www.pharmac.govt.nz
• www.nhf.org.nz
• www.bpac.org.nz

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 gt15
• TC lt4.0 mmol/L (was actually 4.5 in 2005)
• LDL-C lt2.0 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 36 months
• CV risk reassessed at least annually

43
BP targets in renal disease

• In chronic renal disease with significant
  albuminuria (urine protein or creatinine gt100
  mg/mmol)
• lt125/75 mmHg

• In practice
• Be aware of new BP target
• May require more aggressive therapy(eg, ACE
  inhibitor calcium-channel blocker ß-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
  individuals 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.
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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 ß-blocker
• Recommended post-MI or in heart failure
• ß-blocker plus dihydropyridine CCB
• Especially in CHD

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Choosing appropriate drug combinations

• In hypertension
• Thiazide plus CCB
• Thiazide plus ß-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
• ß-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

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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 ß-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
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Case study 2

• Frank
• 52-year-old European male
• No history of diabetes
• Father died from MI aged 48 years
• Ex-smoker (quit lt12 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
• Franks risk is calculated at 24.

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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 Franks current CV risk is 24 with
  treatment it will be approx. 1015 over 5 years
  (see later)

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case study 2

• How much is Franks 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 Franks absolute risk of another CV event
  in the next 5 years?
• 30 decrease from 24 17

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case study 2

• 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

a Sinclair Kerr. N Z Med J 2006 119 (1245)
U2312
55
Further information

• www.nzgg.org.nz
• www.oneheartmanylives.co.nz
• www.pharmac.govt.nz
• www.nhf.org.nz
• www.bpac.org.nz

56
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