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Understanding new international guidelines to ... Understanding new international guidelines to tackle CV Risk: A practical model John Deanfield, MD UCL, London United Kingdom s Ho

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  • Understanding new international guidelines to tackle CV Risk:

    A practical model

    John Deanfield, MD UCL, London

    United Kingdom s

    Ho Chi Minh City, Vietnam August 7, 2014

  • JBS 2 Risk Guidelines (2005) Based on Short term (10yr) Absolute Risk

     Treat ‘risk’ not risk factors

     Focus on highest 10 year risk

     But things have changed!

  • Recent CV Guidelines

    USA: November 2013 UK: February 2014

  • ACC/AHA Guidelines

     Treat risk not Risk

    factors

     No lipid targets

    Only consider RCT

    evidence

     Target 4 groups

    - Established CVD

    - Diabetes

    - FH

    -10 yr CV risk > 7.5%November 2013

  • Elderly black man

    79yr of age

    Total cholesterol 150 mg/dl

    HDL cholesterol 40 mg/dl

    Systolic blood pressure 120 mmHg

    Not taking antihypertensive medication

    Not diabetic

    Nonsmoker

    Calculated 10-yr risk of CHD or stroke 13.7%

    Comment: Patient qualifies because he has

    a 10-yr risk of >7.5% but is >75 yr of age.

    Moderate-Intensity Statin Therapy

    Recommended

    Kearney NEJM 2014; 370: 275-278

  • New Cholesterol Guidelines to a Population-Based Sample

    Pencina NEJM 2014; 370: 1422-31

    56 million people

  • European Heart Journal 2012; 33: 1635-1701

    ESC CV Prevention Guidelines 2012

    Disenfranchises the

    young, especially women!

  • White woman with hyperlipidemia and hypertension

    46yr of age

    Total cholesterol 230 mg/dl

    HDL cholesterol 55 mg/dl

    Systolic blood pressure 150 mmHg

    Taking antihypertensive medication

    Not diabetic

    Nonsmoker

    Calculated 10-yr risk of CHD or stroke 2.0% Comment:

    Total cholesterol is high and

    blood pressure is not controlled, but

    patient has no other risk factors.

    Statin Therapy Not Recommended

    Kearney NEJM 2014; 370: 275-278

  • Non-smoking men

  • 25 yrs 40yrs 58yrs

    TC 310 mg/dl 310 mg/dl 310 mg/dl

    HDL 50 mg/dl 50 mg/dl 50 mg/dl

    TG 400 mg/dl 400 mg/dl 400 mg/dl

    LDL 180 mg/dl 180 mg/dl 180 mg/dl

    FH of CVD – – –

    BMI 25 kg/m2 25 kg/m2 25 kg/m2

    10 yr risk – 3.1% 7.5%

    Young Man comes to your

    Clinic at 25 years

    “Waiting for dyslipidemic

    patients to reach middle age

    before starting therapy is a

    failure of prevention”

    Hazen 2014

  • Joint British Societies (JBS)3:

    March 26th 2014

    Early intervention pays long term dividends

    Investing in Your Arteries!

  • JBS3 : What’s different?

    “Investing in Your Arteries”

     Personalised, lifetime approach to CVD prevention

     New CVD risk calculator with understandable

    risk metrics linked to interventions .Demonstrate

    the potential for benefit on a person’s risk over their

    lifetime.

     Provides CV risk management guidance for the

    whole range of people.

    Empower individuals to take control of their

    CVD health by promoting lifestyle changes,

    not just drugs

    Heart March 2014 and www.jbs3risk.com

  • Established CVD or

    Familial Hypercholesterolaemia

    Diabetes age >40 years

    Chronic Kidney Disease

    Lifestyle and drug therapy

    as recommended in JBS3

    10 year CVD risk score ABOVE current NICE threshold*:

    Lifestyle + Drug therapy

    BELOW current NICE threshold*

    Examine JBS3 ‘lifetime metrics’

    Heart age

    Projected CVD risk

    To inform discussion on risk

    modification by:

    Lifestyle changes

    Drug therapy when indicated

    Ongoing research on

    implementation and impact of

    JBS3 recommendations and

    risk calculator

    *Current NICE Guidance www.nice.org.uk

    NO YES

    Use JBS3 risk calculator

    JBS3 CVD Risk Approach

    www.jbs3risk.com

    http://www.nice.org.uk/

  • JBS3 CVD Risk Calculator 35 year old female: adverse risk factors

    Heart March 2014 and www.jbs3risk.com

  • Heart March 2014 and www.jbs3risk.com

  • JBS3 : Start of a new Process

     Changes interactions

    in primary care

     Personalised approach

     Empowers lifestyle

     Not just a statin

    conversation!

    Implementation and Evaluation challenges!

  • JBS3: Patient Pull

    Patient friendly app Send programme with

    individual data

  • Health Checks JBS3

    • Understanding • Behaviour • Risk factors • CV events

    Next Steps: Formal

    Evaluation in Primary care

  • Lifetime CVD Risk Management

    JBS3 platform applicable to other NCDs

    such as dementia which share risk factors

  • BP (1990-92) Gottesman JAMA Neurol 2014; 1646: E1-10

  • CV disease is preventable

    “Life-long Rx likely to be cost-effective and

    often cost saving” Circulation 2011;124:967-990

  • Joint British Societies (JBS)3:

    March 26th 2014

    Strategy to communicate CV risk to rest of us as well as opportunities for lifetime

    benefit

    Management of High short term Risk

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