Absolute Cardiovascular Disease Risk Scoring

- What You Need to Know

Professor Kim Greaves BSc, MBBS, MD, FRCP (UK), FRACP.

Consultant Cardiologist, Director of Cardiac Research Sunshine Coast University Hospital

Griffith University

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• In Australia there are 150,000 deaths per year• In 2016….

What is the Burden of CVD?

3. Stroke: 10,451 deaths

1. Coronary Heart Disease: 19,077 deaths

2. Dementia and Alzheimers: 13,126 deaths

4. Lung cancer: 8410 deathsCardiovascular Disease –

Biggest KillerDeaths in Australia, AIHW 2016

Economic Costs

• Australia spent $160 billion on health 2015-16

• $11 billion spent on cardiovascular disease

• Most expensive disease group • 7% overall health budget

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Disease Expenditure in Australia 2015-16, AIHW 2019

Economic Costs

• Cost acutely per ACS: $22,000• Cost acutely for stroke: $27,000• Estimated $7.1 billion could be saved • Use of preventative pharmacotherapy

alone

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The economics costs of heart attack and chest pain (Acute Coronary Syndrome)’. Access Economics 2012Economic impact of stroke. National stroke foundation. Deloitte Access Economics 2013Cobiac L, 2012 BMC Public Health

Cardiovascular Disease

• Majority of these deaths are preventable

• Huge opportunity for CVD prevention

• 52 countries • 15,152 MIs and 14,882 controls• Relationship between risk factors and MI• Population attributable fraction

Evidence that Cardiovascular Disease is Preventable

Yusuf Lancet 2004

Risk of acute myocardial infarction associated with exposure to multiple risk factors

Population attributable fraction:80% of all MIs could have been avoided if there was no smoking, lipids, HT, DM, obesity

Interheart Study, Yusuf et al Lancet 2004

Risk of acute myocardial infarction associated with potentially protective risk factors

Avoiding smoking and adopting healthy lifestyle reduces risk by 75%

Interheart Study, Yusuf et al Lancet 2004

Prevention of CVD is a National Health Priority

Australian Health Ministers’ Advisory Council, 2017, National Strategic Framework for Chronic Conditions. Australian Government. Canberra

Combined Risk

• Rather than treating individual risk factors• Overall effect of multiple individual risk factors• Combined together • Create a more accurate picture or score• Individuals overall future risk of having a heart attack or stroke

Risk of acute myocardial infarction associated with exposure to multiple risk factors

Interheart Study, Yusuf et al Lancet 2004

OR: 13

Absolute Cardiovascular Disease Risk Score Assessments• National Vascular Disease Prevention Alliance

• 45 years or over • 35 years or over & Aboriginal or Torres Strait

Islander• Without history of cardiovascular disease

➜ Absolute Cardiovascular Disease Risk checked• Calculate likelihood of heart attack, stroke,

vascular disease in next 5 years

Framingham Risk Equation

• N=5573 free of CVD• 30-74 years• Follow up 4-12 years

Anderson Am H J 1990

Anderson Am H J 1990

• Age• Gender• Systolic BP• Smoking• Total chol/HDL ratio• Diabetes• ECG LVH

FRE: Advantages and Disadvantages• Last century• Another country• No FH, obesity, SE status• No AF• <74 yrs• Indigenous• Patients on meds• Overestimate risk

• Most thoroughly tested• Tested against Australian

study performed well• FRE equivalent or better

predictive abilities than other risk scores

• High risk• Over 15% (1:7) chance of getting

heart attack, stroke, vascular disease in next 5 years

• Moderate risk• 10-15% (1:10) chance in next 5

years• Low risk

• Less than 10% in next 5 years

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Absolute Cardiovascular Disease Risk

Low: less than 10% risk of CVD within the next 5 years

• Diabetes >60years• Diabetes microalbuminuria• Moderate or severe kidney

disease• Very high cholesterol or FH• Very high blood pressure

High: greater than 15% risk of CVD within the next 5 years

Moderate: 10-15% risk of CVD within the next 5 years

Review absolute risk in 2 years

Conduct formal absolute risk assessment

Continue with lifestyle intervention Review absolute risk

6-12 months

Consider treating for BP and lipid lowering therapyReview absolute risk 6-12

months

Risk++

What is the Evidence Interventions Work?

ASCOT-LLA Study

• 19,342 hypertensive patients• 40-79 yrs & ³3 other CVD risk factors• 10,305 into statin study• 10mg atorvastatin or placebo• Follow up 5 years for non-fatal MI

and fatal CHD• Stopped trial after 3 years

• 100 events in atorvastatin group• 154 events placebo

P Sever Lancet 2003

ASCOT-LLA STUDY

Dual therapy: anti-hypertensive and statin therapy

Absolute Cardiovascular Disease Risk What is the uptake of absolute

cardiovascular disease risk assessment?

• N=9564 from 2011-2012 Australian Health Measures Survey

• Calculated ACVDR scores• Information on medications taken• Proportions on guideline-recommended

therapy• Estimates for the Australian population

Banks MJA 2016

• There are 7.3M Australians between 45-74 years

• 1.45M of these are at high CVD risk (20%) • 811,000 people no prior CVD • 634,000 people prior CVD

Pharmacological treatment of ACVD risk in Australia

Banks E MJA 2016

20%

35%

47%

29%

45%

24%

No prior CVD

• 970,000 at high ACVD risk (13% of population aged 45-74 yrs) • Not receiving guideline-recommended therapies

Banks E MJA 2016

ACVD Risk Of Patients Presenting With ACS and their Pharmacological Treatment

• Assessed the ACVD risk score• Patients presenting with ACS• 12 months• 520 patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No Prior CVD, high risk Prior CVD

ACVD Risk Of Patients Presenting With ACS on Pharmacological Therapy

No therapy 48%

Single therapy 30%

Dual therapy 22%

Triple therapy 57%

Dual therapy 28%

Single therapy 8%

No therapy 7%N = 112 N = 177

Why is there such Poor ACVD risk

assessment uptake?

Barriers EnablersNo incentives Financial opportunities

Time constraints Clear guidelines

Not useful/no value

Too many guidelines

Don’t know how to use

Don’t know how to proceed after risk assessmentDon't think about it

Low patient compliance

EURIKA study Eur J Prev Cardiol 2011Graham et al ESC 2006Sposito Curr Med Res Opinion 2009

Absolute Cardiovascular Risk Assessment In General Practice: A General Practitioner survey of assessment practices, knowledge attitude and beliefs, and barriers and enablers to assessment

Greaves K 2019

• 111 GPs• ACVD risk assessment rates

• Categorized: • high assessors (³ 80%), • moderate assessors (60-79%)• low assessors(£59%)

• Association between assessment rates and factors related to • Practitioner demographics/characteristics• GP knowledge/beliefs, patients, organization and structure

Results

Male 53%

Age >45yrs 43%

Aware of concept of CVD risk 96%

Unaware that CVD risk should be assessed in all eligible patients 11%

Used Australian CVD risk calculator 71%

Used own clinical judgement, didn’t use any score, or didn’t know

9%

Time spent explaining what score means 0-4 mins 28%

5-9 mins 48%

10-15 mins 15%

Group Assessment rates

High assessors (³ 80%) 45%

Moderate assessors (60-79%) 25%

Low assessors (£59%) 23%

Very low (<19%)* 10%

Very high (100%) 17%

Results

* did not assess risk, treated risk factors individually, or were unsure who an eligible patient was.

Higher assessors

Lower assessors

GP Factors Patient Factors

• Older Age

• Knowledge of CVD risk and the ACVD risk score calculator

• Time

• Patient knowledge

• Patient motivation

Interventions

Importance of Surveillance

• Surveillance system is essential to:• To quantify the magnitude and distribution

of a disease• To monitor effectiveness of prevention

strategies• To inform public health policy and planning

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• Australia’s majority provider of health analytics software• 28/31 PHNs• Monthly reporting on

• 15 million patients

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PATCAT (Practice Aggregation Tool)

• Product of PenCS• Reporting tool for population

health analysis • Possible surveillance tool for

ACVD risk over a population

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GP

CAT4

GP GP GP GP

CAT4CAT4 CAT4 CAT4

PATCAT

de-identified data

Study Objectives

• To evaluate PAT CAT as a surveillance system for monitoring

• Levels of absolute CVD risk and treatment within population

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Conclusions1. CVD is a serious health problem but largely preventable

2. Absolute CVD risk assessment indicates an individual’s overall CVD risk

3. Patients should be offered lifestyle modification and pharmacological treatment according to their ACVD risk

4. Current ACVD assessment rates are low

5. A large proportion of people are at high or moderate CVD risk and remain untreated

6. Many of these will go on to have adverse cardiovascular events within 5 years

KEEP CALM

AND

CARRY ONSCREENING

Calcium Scoring

• 969 patients all on statins• Adding evolocumab• Evaluate effect of on plaque composition• 76 weeks of treatment• Coronary IVUS• Measure plaque composition

No Prior CVDHigh ACVD Risk

Incomplete/No pharmacotherapy

2015 2020 2025 2030 2035

50

25

75

100

Prior CVDHigh ACVD Risk

Incomplete/No pharmacotherapy

Proportion of population

at high ACVD risknot on therapy (%)

Date (years)

Proportion of Patients at high ACVD risk, with and without prior CVD, not on guideline-recommended therapy

0

Intervention

New Incentive payments

Yes7%

No93%

Proportion of SCHHS staff had ACVDR checked

(eligible N = 648/1200)

93% did not have their ACVDR checked

Staff Health Measures Survey October 2015

Other6%

Was not aware I

needed one83%

Haven't had time5%

Not relevant to me4%

I prefer not to know1%

Knowing my risk is not important to

me1%

SCHHS staff reasons for not having ACVD assessed

N = 455

ACS screened for inclusionn = 722

No Prior CVDn = 350(66%)

36% Prior CVD(n=177)

Excludedn = 185 (26%)

Type 1 MIn = 527 (73%)

32% High ACVD Risk

(n=112)

Small is beautiful…..

High ACVDR Score and Untreated in General Practice using CAT4

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Demographic Patients

Total in practice 3823

High ACVDRS + no prior CVD + no meds 77

No meds AND

Diabetes + age >60 years 14

Diabetes + Microalbumin >15 8

Chronic kidney disease 26

Familial hypercholesterolaemia 0

BP >160/110 No filter

Cholesterol >7.5 No filter

Total High CVD Risk on no medications 125

Automatic high CVD Risk

• N = 8491 without CVD• 30-74 yrs age• Followed up since 1968, ‘71, ’84• Follow up for CVD over 12 yrs

• CHD, stroke, PAD, HF.

• 1174 participants had a CVD event

Exercise• Meta-analysis• 22 studies, 1M participants• Low and moderate intensity

exercise• All cause mortality

J Woodcock Int J Epidemiol 2011

2.5 hrs/week = 19% relative

reduction all cause mortality

Smoking Cessation

• Meta-analysis• 25 prospective cohort studies• 500,000 patients• Aged > 60 yrs• CV mortality

Mons BMJ 2015

Diet• 7447 patients high CVD risk• MACE and death from CVD

outcomes• HR 0.69 (0.53-0.91) favouring

Med diet with nuts• HR 0.72 (0.54-0.95) favouring

Med diet plus with extra virgin olive oil (EVOO)

Estruch NEJM 2018

Diet• PURE study• 135,335 individuals • 18 countries• 7 year follow up• mortality

Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

P trend

% S from carbohydrate

46% 55% 61% 68% 77%

Hazard ratio (mortality)

- 1.07 1.06 1.17 1.28 0.0001

% S from total fat

11% 18% 24% 29% 35%

Hazard ratio (mortality)

- 0.90 0.81 0.80 0.77 <0.0001

% S from total protein

11% 13% 15% 17% 20%

Hazard ratio (mortality)

- 1.05 0.92 0.85 0.88 0.0030

Omega 3 Fatty acids – where are we now?

• Some confusion as whether beneficial• Early data 2000’s suggested benefit; based on observational studies

• 2006 meta-analysis of 48 randomised controlled trials and 26 cohort studies.

• 26 observational cohort studies alone suggested that omega 3 reduced total mortality.

• Pooled results from the 48 randomised controlled trials showed no benefit• Included both primary and secondary prevention patients. BMJ, Hooper L 2006

Omega 3 Fatty Acids

• Cochrane review published July 2018• 79 trials, 112,000 participants• effects of greater omega-3 intake versus lower or no omega-3 intake

for heart and circulatory disease • No benefit

PAT CAT: proportions of ACVDR in a GP population

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Conclusion• Evidence not strong for omega 3 FFA to have beneficial effects

• Unlikely in primary prevention• Possibly in secondary prevention if TG are high

• Dose, type of n-3 FA ie highly purified, effects are uncertain• Supplements not recommended routinely• Heart Foundation recommends eating fish 2-3x per week

Contents of today’s talk1. Burden of cardiovascular disease2. Economic costs of CVD3. ‘Cumulative Risk’ – what’s the the evidence?4. The ACVD risk score and the Framingham Risk Equation5. Using the ACVD risk calculator and how to proceed after6. Evidence for drug interventions in preventing CVD7. Current uptake of ACVD risk assessment, barriers and enablers8. Surveillance of ACVD risk

• 35yrs• Smoker• Overweight• BP 139/90• Doesn’t know cholesterol• Not diabetic

Do Heart Age Calculators Help?• Can improve communication of risk to people when used in

conjunction to risk scores• Heart age can be used to convey and motivate people to change their

lifestyle even when overall absolute risk in next 5 years is low• Caution if used to inform drug-treatment decisions –

• Mass medicalization• Absolute risk is more relevant• Low absolute risk vs elevated heart age

Bonner et al; BMC Cardiovasc Dis 2018