SHA24/029001

Gulf Heart Association 10 Saudi Heart Association 24 14 February 2013

Global CVD Risk Assessment1. What is your approach?

2. What should be your approach?

Ian Graham SCORE, HeartScore, SURF, JTF5 Professor of Cardiovascular Medicine, Trinity College, Dublin

I am privileged to be here Peace be upon you ‫السلم عليكم‬

Marie-Therese Cooney -Work Alexandra Dudina -Work Tora Leong -Work Ian Graham -Credit My heartfelt thanks

GHA10/SHA24 Global CVD Risk Assessment 1 What is your approach?

1. The Fifth Joint European Task Force on Prevention 2. Principles of total risk assessment 3. Options 4. SCORE and HeartScore 5. New developments 6. Conclusions

GHA10/SHA24 Global CVD Risk Assessment 2 What should be your approach?

1.

2.

3.

4.

5.

6.

Risk in KSA Cultural considerations Is SCORE relevant or applicable?

SCORE KSA? Interactice case studies Conclusions

Prediction is very difficult, especially if it’s about the future Nils Bohr

I am sure that you are very good at risk estimation‌.

Assessing Risk Outline • • • • 1.

2.

3.

4.

The Fifth Joint European Task Force on Prevention The concept of total risk Risk estimation systems New initiatives in risk estimation:High and low risk countries Risk in the young and old Adding new risk markers HDL cholesterol & BMI

•

Conclusions

2012 Joint European Guidelines on cardiovascular disease prevention in clinical practice

:

Partner Societies The 5th Joint European Societies’ Task Force on Cardiovascular Disease Prevention in Clinical Practice European Society of Cardiologue (ESC) European Association for Cardiovascular Prevention & Rehabilitation (EAPCR) European Society of Hypertensoin (ESH) International Society of Behavioural Medicine (ISBM) European Heart Network (EHN)

European Society of General Practice/ Family Medicine (ESGP/FM/Wonca)

European Artherosclerosis Society (EAS)

European Association for the Study of Diabetes (EASD) Internatonal Diabetes Federation Europe (IDF-Europe) European Stroke Organization (ESO)

The 5th Joint Task Force of the European Society of Cardiology and other Societies on CVD Prevention in Clinical Practice Chairperson Joep Perk (Sweden).

Chapter coordinators Guy De Backer (Belgium), Helmut Gohlke (Germany), Ian Graham (Ireland), Željko Reiner (Croatia), Monique Verschuren (Netherlands).

Chapter writers Christian Albus (Germany), Pascale Benlian (France), Gudrun Boysen (Denmark), Renata Cifkova (Czech Republic), Christi Deaton (UK), Shah Ebrahim (UK), Miles Fisher (UK), Giuseppe Germano (Italy), Richard Hobbs (UK), Alessandro Mezzani (Italy), Eva Prescott (Denmark), Lars Ryden (Sweden), Jose Luis Zamorano (Spain), Faiez Zannad (France).

Other contributors Arno Hoes (Netherlands), Sehnaz Karadeniz (Turkey), (Sweden), Martin Scherer (Germany), Mikko Syvänne (Finland), Wilma JM Scholte Op Reimer (Netherlands), Christiaan Vrints (Belgium), David Wood (UK).

Guidelines on Prevention

Research

SCORE,HeartScore Evidence based reviews

Guidelines 94,98,03,07,12 EuroAspire SURF

Audit

Implementation PIC Nat. Co-ord EuroAction

5th Joint task Force on the prevention of CVD in clinical practice

Why stress assessment of total CVD risk ?

• Multiple risk factors usually contribute to the atherosclerosis that causes CVD • These risk factors interact, sometimes multiplicatively • Thus the aim should be to reduce total risk; if a target cannot be reached with one risk factor, total risk can still be reduced by trying harder with others.

• There is no reason to suppose that this principle does not apply to all countries

Table 1

Impact of combinations of risk factors on 10 year risk of CVD deathWho gets the statin?

SEX

AGE

CHOL

BP

SMOK RISK %

F

60

8

120

NO

?

F

60

7

140

YES

?

M

60

6

160

NO

?

M

60

5

180

YES

?

Table 1

Impact of combinations of risk factors on 10 year risk of CVD deathWho gets the statin?

SEX

AGE

CHOL

BP

SMOK RISK %

F

60

8

120

NO

2

F

60

7

140

YES

5

M

60

6

160

NO

8

M

60

5

180

YES

21

How do I assess CVD risk quickly and easily? • Those with~known CVD ~ diabetes or impaired renal fuction, ~ very high levels of individual risk factors are already at INCREASED CVD RISK and need management of all risk factors For all other people, the SCORE- or other- risk charts- can be used to estimate total risk—this is critically important because many people have mildly raised levels of several risk factors that, in combination, can result in unexpectedly high levels of total CVD risk

Priorities: New: 4 categories of risk:

Risk assessment- Options •

Clinical judgement- very efficient, not always reliable

•

FRAMINGHAM (Previous European and current UK guidelines)small data set (c 5K, now 8K) from one US town, but meticulous long-term follow-up. THANK YOU! ASSIGN Scottish data, includes impact of social deprivation Q RISK Large UK data set, not random sample with much missing data PROCAM Moderate size, single city SCORE (Systematic Coronary Risk Evaluation)- Large (205K), representative (10 population samples) but rather few variables and uses total CVD mortality as the end point WHO/ISH Different from other systems- not based on prospective data- RRs applied to global burden of diseases study REYNOLDS Based on randomised control trials- Woman’s Health Study, Physician’s Health Study

• • • • • •

Assessing cardiovascular risk • Cooney MT, Dudina AL, Graham IM. Value and limitations of existing scores for the assessment of cardiovascular risk: A review for clinicians.

JACC 2009;54:1209-27 • Cooney MT, Dudina A, d’Agostino R, Graham IM. Cardiovascular risk estimation systems in primary prevention. Do they differ? Do they make a difference? Can we see the future?

Circulation 2010;122:300-10

The SCORE database 12 European cohort studies – Some with multiple component cohorts – Mainly population studies In round figures: • 205,000 persons • 3 million person-years of observation • Over 7,000 fatal cardiovascular events

10 year risk of fatal CVD in high risk regions

10 year risk of fatal CVD in low risk regions

SCORE & HeartScore- update & new initiatives

1.Low and high risk countriesThe problem: Secular changes in CVD mortality mean that any risk assessment system may under- or overestimate risk

How are low and high risk countries defined?

No data < 30 30-50 50-70 70-100 100-150 150-200 > 200

Age standardised CHD mortality rates (under 65) in men & women

Cardiovascular Disease â&#x20AC;&#x201C; The Scope of the Problem

Cerebro vascular Diseas Ischaemic Heart Disease

World Heart Organisation, World Health Report,

Low and high risk countries • Cut point chosen: 2008 CVD + diabetes mortality age 45-74: 220/100,000 men, 160,100/000 women • Low risk: Andorra, Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, The Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland, United Kingdom • High risk: All others • Very high risk: (>500/100,000 for men and >250/100/000 for women): Armenia, Azerbaijan, Belarus, Bulgaria, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Macedonia FYR, Moldova, Russia, Ukraine, Uzbekistan

Are the SCORE charts suitable for use in other areas?

• Probably, if the country has similar mortality to the countries from which the high and low risk charts were derived Alternatives: • Recalibrate SCORE. Requires: Up to date risk factor prevalences and mortality data.

Examples: Belgium, Netherlands, Sweden, Poland, Czech Republic, Slovakia, Greece, Spain • Derive a new risk estimation system.

Requires: Local cohort data.

Examples: Norway, Finland

SCORE & HeartScore- update & new initiatives

2.Risk in the youngThe problem: A low absolute risk may conceal a very high relative or lifetime risk

10 year risk of fatal CVD in high risk regions

Risk and age: we considered• • • • • •

Absolute risk Relative risk Attributable risk Risk age (heart age, cardiovascular age) Risk advancement periods Lifetime risk

35

Relative risk chart â&#x20AC;˘

This chart may be used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication.

Non-smoker 180 3 Systolic blood pressure (mmHg)

3 160 2 3 140 1 2 120 1 1 4

5

Smoker

4 3 2 1

5 4 2 2

6 4 3 2

6 4 3 2

7 5 3 2

8 6 4 3

10 7 5 3

12 8 6 4

6

7

8

4

5

6

7

8

Cholesterol (mmol/L)

Please note that this chart shows RELATIVE not absolute risk. The risks are RELATIVE to 1 in the bottom left. Thus a person in the top right hand box has a risk that is 12 times higher than a person in the bottom left.

Risk in the young • Is the relative risk chart sufficient?

Consider• Attributable risk • Years of life lost or gained • Risk age • Risk advancement periods • Of these, we suggest that risk age is the easiest to understand

Risk Age Definition: â&#x20AC;&#x17E;The age of a person with a given burden of risk factors compared with the age of a person with the same risk but who has fewer risk factors.â&#x20AC;&#x153; Synonyms: Heart age, cardiovascular age It may have a critically important advantages in that it may be independent of end-point used (fatal or non-fatal) and country 38

A 40 year old man man who smokes and has a high BP and cholesterol may have a â&#x20AC;&#x153;risk ageâ&#x20AC;? of 65 years

39

SCORE & HeartScore- update & new initiatives

2.1 Risk in the older peopleThe problem: Current risk estimation systems assume that risk factors function similarly at all ages. This is wrong.

Prospective Studies Collaboration â&#x20AC;&#x201C; Effect of total cholesterol level on CVD mortality in different age groups

Age Group

Hazard Ratio (95%CI) for 1mmol/l lower total cholesterol

80-89

0.85 (0.82 to 0.89)

70-79

0.82 (0.80 to 0.85)

60-69

0.72 (0.69 to 0.74)

50-59

0.58 (0.56 to 0.61)

40-49

0.44 (0.42 to 0.48)

Prospective Studies Collaboration Lancet 2007

Risk in older persons • Current risk estimation systems assume constant beta coefficients regardless of age • We have re-examined this assumption in collaboration with the Norwegian CONOR investigators • We find that SCORE, and probably all current risk systems, over-estimate risk in older persons.

• Future systems should ideally use very large cohorts to allow risk estimates to be calculated in 5 or 10 year age groups

SCORE O.P. Chart Cf SCORE High risk age 65: 2-47%, median c. 22% vs 6%

WOMEN Non-Smoker Smoker 180 12 12 13 13 14 19 19 20 160 10 11 11 12 12 16 17 18 140 9 9 10 10 11 14 15 16 120 8 8 8 9 9 12 13 14

21 19 16 14

22 20 17 15

180 160 140 120

6 5 4 4

10 9 8 7

10 9 8 7

11 10 8 7

180 160 140 120

3 2 2 2 4

3 3 3 3 4 4 5 2 2 3 3 4 4 4 2 2 2 2 3 3 4 2 2 2 2 3 3 3 5 6 7 8 4 5 6 Total Cholesterol (mmol/l)

5 4 4 3 7

5 5 4 3 8

6 5 4 4

6 5 5 4

6 6 5 4

7 6 5 4

9 8 7 6

9 8 7 6

MEN Age 75

70

65

Non-Smoker 180 17 18 20 22 160 15 16 17 19 140 13 14 15 17 120 11 12 13 15 180 160 140 120

9 8 7 6

10 9 8 7

180 160 140 120

5 4 4 3 4

5 6 7 8 9 9 10 5 5 6 7 7 8 9 4 4 5 6 6 7 8 4 4 4 5 6 6 7 5 6 7 8 4 5 6 Total Cholesterol (mmol/l)

11 10 8 7

12 11 9 8

24 21 19 16

Smoker 28 30 32 25 26 29 22 23 25 19 21 22

35 31 28 25

39 35 31 27

14 12 10 9

16 14 12 10

21 18 16 14

23 20 18 16

17 15 13 11

19 16 14 13

12 13 10 11 9 10 8 9 7 8

mpareow risk rCegions, assumed HDL 1.2mmol/l for

SCORE & HeartScore- update & new initiatives

3. Adding in new risk markers The question: How much do we gain?

Interheart: the relative contribution of each of the 9 risk factors to the 90% PAR

Yusuf et al, Lancet 2004

Multiple biomarkers for the prediction of first major cardiovascular events and death Wang TJ, Gona P, Larsen MG et al New Engl J Med 2006;335:2631-9 • Framingham offspring study. N=3209, 7.4 yr FU, 207 deaths, 169 major CVD events • Assessed the effect of adding CRP, BNP, NNP, aldosterone, renin, fibrinogen, D-dimer, P-A inhibitor type1, homocysteine and urine albumin:creatinine ratio to the conventional risk factors • Results: • ROC (C statistic) 0.76 for conventional risk factors 0.77 when all new factors added WOW! But this does not mean that new factors may not be useful in re-classifying subjects close to an intervention threshold The take-home message may be to try harder with conventional risk factors if a new marker is markedly elevated

JTF5 2012 on other biomarkers of risk • Have only limited value when added to SCORE • HS CRP may be used to refine risk assessment in persons with an unusual or moderate CVD risk profile (IIB, Weak) • HS CRP should not be measured in asymptomatic low risk people o assess risk (IIIB, Strong) • Essentially similar advice for fibrinogen and homocysteine

SCORE & HeartScore- update & new initiatives

4. HDL cholesterol & BMI The question: How much do they add to risk estimation?

From Dr Marie-Therese Cooneyâ&#x20AC;&#x2122;s and Dr Alexandra Dudinas doctoral theses

HDL Cholesterol • Strong inverse association between HDL and risk – Both genders, all ages, including older women – Remains independent after adjustment – At all levels of total CV risk

CVD Mortality Rate Relative Risks Compared to the lowest total Chol Quartile and the highest HDL quartile

10.0 9.2 9.0 8.0 6.5

7.0

6.7

6.0 Relative Risk

4.6

5.0

3.1

4.0

4.7

3.0

3.0

1.4

2.0 1.0

4.0

3.2 2.2

3.5

1.3 1.0

HDL1 1.5

2.1

HDL2 HDL3

0.0 TOT1

TOT2 Total Cholesterol

HDL4 TOT3

TOT4

HDL

HDL = 0.8mmol/l

HDL = 1.4mmol/l

HDL = 1.0mmol/l

HDL = 1.8mmol/l

Chart for Women from high risk countries Non-Smoker

Without HDL: HDL 0.8:

4.6

HDL 1.0:

3.8

HDL 1.4:

2.5

HDL 1.8:

1.7

2.4

Systolic Blood Pressure (mmHg)

180 160 140 120

7 5 4 3

7 5 4 3

8 6 4 3

8 6 5 4

Age

Smoker

9 14 14 7 65 10 11 5 8 8 4 6 6

15 12 9 7

16 12 9 7

17 13 10 8

180 160 140 120

3 2 2 1

3 3 2 1

4 3 2 2

4 3 2 2

4 6 7 3 60 5 5 2 4 4 2 3 3

7 5 4 3

8 6 4 3

8 6 5 4

180 160 140 120

2 1 1 1

2 1 1 1

2 2 1 1

2 2 1 1

2 4 4 2 55 3 3 1 2 2 1 2 2

4 3 2 2

4 3 2 2

5 4 3 2

180 160 140 120

1 1 0 0

1 1 0 0

1 1 1 0

1 1 1 0

1 1 2 1 50 1 1 1 1 1 0 1 1

2 1 1 1

2 1 1 1

2 2 1 1

180 160 140 120

0 0 0 0 4

0 0 0 0 0 0 1 1 0 0 0 0 40 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 6 7 8 4 5 6 7 Total Cholesterol (mmol/l)

1 0 0 0 8

Without HDL: 5.7

HDL 0.8: 10.2 HDL 1.0:

8.5

HDL 1.4:

5.9

HDL 1.8:

4.0

SCORE BMI An increase in BMI from 20 to 30 is associated with• 0.75 (0.4) mmol/L increase in cholesterol • 0.2 mmol/L decrease in HDL chol • 15 (11) mmHg increase in blood pressure • A doubling of cardiovascular mortality; more marked in the young and not evident in older women From Dr Alexandra Dudina’s MD thesis

Assessing Risk: How far can we go?

Conclusions 1.

2.

3.

4.

5.

6.

7.

8.

All current guidelines on CVD prevention recommend total risk assessment Current risk estimation systems do not differ greatly in their performance They can be re-calibrated for different populations- but systems based on local cohort data are the ideal Developments in risk estimation in younger and older persons New risk markers add little to risk estimation overall, although they may be useful in re-classifying subjects close to an intervention threshold. They also signal a need to try harder with conventional risk factors HDL cholesterol can refine risk estimation CIMT and other imaging techniques are diagnostic tests that can refine risk estimation in those at intermediate risk The real challenge is to USE risk estimation systems rather than to try to make more complex and sophisticated systems

Thank you End of part 1

Gulf Heart Association 10 Saudi Heart Association 24 14 February 2013

Global CVD Risk Assessment1. What is your approach?

2. What should be your approach?

Ian Graham SCORE, HeartScore, SURF, JTF5 Professor of Cardiovascular Medicine, Trinity College, Dublin

GHA10/SHA24 Global CVD Risk Assessment 2 What should be your approach?

1.

2.

3.

4.

5.

6.

Risk in KSA Cultural considerations Is SCORE relevant or applicable?

SCORE KSA? Interactive case studies Conclusions

CVD- the size of the problem • Current life expectancy 65 (45-80) yrs • 1900- <10% deaths due to CVD • 1970- biggest cause of death in developed countries • Falling in developed countries, rising fast in developing ones • 2000- biggest cause of death worldwide • 1996- 15,000,000 deaths • 2020- 25,000,000 deaths (Source WHO)

CVD risk in Saudi Arabia: What might one wish to know?

CVD Risk in Saudi Arabia: what information would one like?

1. Population distribution and demographics- age, gender, education, social class 2. Causes of death and disability and secular trends 3. Nutritional and lifestyle data 4. Risk factor distributions and secular trends 5. Is a risk estimation system possible? (re-calibration/new system) 6. Awareness that a high tech therapeutic approach is politically more popular than a long-term preventive approach 7. Audit of risk factor management- for example, SURF-KSA?

Risk in KSA

Changing Arabia & the Middle East

Cardiovascular Disease â&#x20AC;&#x201C; The Scope of the Problem

Cerebro vascular Disease Ischaemic Heart Disease

World Heart Organisation, World Health Report,

The prevalence of cardiovascular risk factors in the Middle East: a systematic review Motlagh B, O’Donnell M, Yusuf S. EJCPR 2009,26:268-80

• • • • •

Cohort studies from 1980 1000+ participants 51 studies n=267,537 from:Saudi Arabia ,Kuwait, Oman, Qatar, Lebanon, Iran, Iraq, Israel, Gaza & the West Bank, Syria, Egypt, Yemen, United Arab Emirates, Turkey, Bahrain

The prevalence of cardiovascular risk factors in the Middle East: a systematic review Motlagh B, O’Donnell M, Yusuf S. EJCPR 2009,26:268-80 • Obesity (BMI 30+) 24.5% • Diabetes (3 definitions, 2 WHO 1985 & 1999) 10.5% • Hypertension (>140/90, >160/95 in 3) 21.7% • Smoking 15.6% • Increased cholesterol (variable definitions): ~Men 7% (Saudi) - 42.2% (Kuwait) ~Women 6% (Turkey) – 33.3% (Kuwait) High prev of raised cholesterol in Kuwait, Oman Low HDL cholesterol in Turkey, Oman, Saudi Arabia

Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.

Yusuf et al.Lancet 2004;364:937-52

â&#x20AC;˘ Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, fruit and vegetable consumption, alcohol, regular physical activity & psycho-social factors account for most of the risk of myocardial infarction in both sexes and at all ages & in all regions â&#x20AC;˘ Nevertheless, even though the odds ratios are fairly constant, risk factor prevalences vary widely

Risk Factor prevalences in INTERHEART (%).

Overall adjusted for age, sex & smoking Middle East

SMOKING FRUIT & VEG CONSUMPTION EXERCISE ALCOHOL HYPERTENSION 23.4 DIABETES ABDOMINAL OBESITY LIPIDS PSYCHOSOCIAL

Overall

45.5 7.3 4.2 1.0 9.2

36.4 12.9 25.5 13.9

15.5 25.9 70.5 41.6

12.3 33.7 54.1 28.8

Cultural considerations

Risk in KSA- cultural considerations.

Please teach the EACPR • Knowledge and understanding of CVD as a major health problem and of the concepts of risk and prevention- at national and individual levels • Nutritional practices and knowledge and attitude to overweight and exercise • Climate and infrastructure: is exercise promotion realistic?

Are the SCORE charts suitable for use in other areas?

• Probably, if the country has similar mortality to the countries from which the high and low risk charts were derived Alternatives: • Recalibrate SCORE. Requires: Up to date risk factor prevalences and mortality data.

Examples: Belgium, Netherlands, Sweden, Poland, Czech Republic, Slovakia, Greece, Spain • Derive a new risk estimation system.

Requires: Local cohort data.

Examples: Norway, Finland

What risk estimation system would be optimal for KSA? • The ideal would be a risk system derived from a large, representative cohort of KSA subjects • This is very challenging- population demographics, certainty regarding causes of death, difficulties in following up subjects • WHO risk charts are available for the area- but are based on uncertain and untested methodology • Recalibration of an existing system such as SCORE may be a realistic option. Requires upto-date mortality data and risk factor prevalences

Interactive case histories (and see the ESCs Guideline Learning Tool )

Hyperlipidaemic Octogenarian JL is an 82 year old who has mild and non specific chest discomfort.

You measure her blood cholesterol and then wish that you had not because it turns out to be 12 mmol/L. What will you do?

Hyperlipidmaemic octogenarian • Tough one. Most of us would probably give a statin • Randomised controlled trials don’t help much at this age • But, the further you get into your 80’s, the less time you have to benefit from a statin, so the case is not strong

Clustering Risks JD Is a 54 year old who comes to see you with moderate chest tightness after walking for 10 minutes. His father died of a myocardial infarction, he is unemployed, and smokes 20 cigarettes a day.

Blood Pressure 150/100.

Cholesterol 5.8mmol/L. LDL Cholesterol 3.6mmol/L. HDL Cholesterol 0.7 mmol/L. Triglycerides 3.2 mmol/L. What is his 10year risk of death from CVD? Should he have an exercise electro-cardiogram?

How aggressively should his risk factors be managed?

SCORE Risk 11% Qualifiers: •Low HDL •High Trigs •Family Hx •Low SES •Symptoms •BUT-SHOULD THE CHART BE USED?

Clustering risks • If you believe that he has true angina, he is already at high risk and the risk chart should not be used. His “chart” risk is high at c.11%. Five extra factors (angina, family hx, unemployed, low HDL, high triglycerides) make his risk of death far higher, and his risk of having CAD almost 100% • 3 min + ex ecg- angio now! Normal ex ecg- don’t believe it.

• Treat to Chol <4, LDL chol <1.8 BP <140/90and detailed programme re. cigs, exercise, weight. Discuss lifestyle diary- “fitness for life” • But do we have the time or the skills?

Female Dilemma MW is a 60 year old housewife.

Cholesterol 8.2mmol/L Triglycerides 1.1 mmol/L Blood pressure 120/76.

She has never smoked.

How would you advise her?

Female dilemma SCORE Risk 2% No Qualifiers Impressive Cholesterol, mod BP but lack of other risks results in low total CVD risk

• First, exclude secondary hyperlipidaemia (especially hypothyroidism) • Check for other risk factors (qualifiers) such as HDL, Triglycerides, Glucose (risk may be higher than shown on SCORE chart) • Next negotiate an intensive, long term lifestyle approach • With statins in reserve!

Impact of combinations of risk factors on 10 year risk of CVD death- who gets the statin?

SEX

AGE

CHOL

BP

SMOKE RISK %

F

60

8

120

NO

?

F

60

7

140

YES

?

M

60

6

160

NO

?

M

60

5

180

YES

?

Impact of combinations of risk factors on 10 year risk of CVD death- who gets the statin?

SEX

AGE

CHOL

BP

SMOKE RISK %

F

60

8

120

NO

2

F

60

7

140

YES

5

M

60

6

160

NO

8

M

60

5

180

YES

21

Hmmm P O’S attended your local hospital recently with weight loss and polyuria and was found to be diabetic.

50 Years old Blood Pressure 160/96 Non Smoker Cholesterol 6 mmol/L. He was told that this level of cholesterol is “OK for his age” Do you agree with this advice?

Hmm. • This 50 yr old male with a BP of 160 and a chol of 6 is at HIGH risk because of his diabetes.

• What is “normal”? Chol of 6 may not be statistically abnormal, but in terms of “desirable for health” is very abnormal in this man • Thus the word “normal” requires definitionwhat does your local lab mean? On what evidence did they define a “normal range”?

• Treat as “high” or “very high” risk

Mr. Xâ&#x20AC;&#x2122;s Syndrome Mr. X comes into you with a sore toe. He is 165 cm tall and has a waist circumference of 112cm Blood pressure: 162/96mmHg Blood sugar: 8.4 mmol/L fasting Apart from the toe, he feels fine.

What next?

Syndrome X

â&#x20AC;˘ Add smoking, driving a taxi, inactivity and alcohol and you have Dublin man, Munster man, Glasgow man, Warsaw man, Kiev man

Systematic search for other risk factors reveals: Blood pressure: 162/96mmHg Total Cholesterol: 5mmol/l HDL Cholesterol: 0.8mmol/l Triglycerides: 2.5mmol/l 2 hour postprandial glucose: 10mmol/l

SCORE Risk = 2% But the SCORE charts do not accommodate the metabolic syndrome and its components •Central Obesity •Impaired glucose tolerance •Low HDL •Moderately elevated triglycerides

How hard to try?

Your colleague is aged 40, has a strong family history of coronary disease, has xanthelasma and turns out to have familial hypercholesterolaemia.

Total cholesterol 12.6 mmol/L. LDL cholesterol 7.8mol/L. HDL cholesterol 1.0mmol/L. Triglycerides of 1.9mmol/L. Blood pressure is 140/100. Non Smoker You decide on a target cholesterol level of under 5 mmol/L. While both you and your colleague know this may or may not be possible to achieve,what options are available to you?

How hard to try?

• All those with familial hyperlipidaemia will have atherosclerotic disease in middle age • In this case, full dose statins will be required, probably with ezetemibe, careful dietary advice, and a long-term fitness programme • Other options include the addition of an ion exchange resin, a fibrate or nicotinic acid.

Discuss side effects • Attack any other risk factors, especially BP, to reduce global risk

GHA10/SHA24 Global CVD Risk Assessment: Conclusions 1.

2.

3.

4.

5.

CVD is the biggest cause of death in Europe and KSA The case for prevention is established Risk factors are the same but the prevalence differs The principle of total CVD risk estimation is universal But we need to learn more about both risk factor prevalences and cultural attitudes in KSA 6. At present it looks as if a recalibrated risk chart such as SCORE may help in promoting risk estimation in KSA 7. Interactive case histories (and the GLT) may be more effective than didactic talks in influencing physician behaviour

Thank you