CHD Prevention and Risk Asssessment:

Old concepts new context?

Dr Paul D MacIntyre

Director of Cardiology, RHH

Why Prevent CHD ?

Premature Mortality <65yrs of age Avoid chronic disease

Quality of life Economic costs

– Delay or prevent– We all die !

CVD v Cancer

Prevention of CHD:3 Silos

1. Low risk primary prevention2. High risk primary prevention3. Secondary prevention

Risk Factors for CVD

Modifiable– Smoking– Physical Activity– Obesity

Medical Conditions– Hypertension– Diabetes– Hyperlipidemia– Chronic Kidney

Disease

Non Modifiable– Age– Sex– Family History– Socio economic

status Ethnicity Relative poverty Lack of hope

Low Risk Primary Prevention General population at low risk of CHD Public Health measures to improve

lifestyle– Smoking – Diet– Exercise

Prioritise children– Childhood Obesity

Needs both population and individual approach

Population Risk

Mean Cholesterol Physical

activity

Population risk

Public Health policy Partnership working

– Health Services– Central government– Local authorities – Primary care– Voluntary sector

Create environmental change – Smoking ban in public places– Plain packaging of cigarettes – Healthy eating– Environmental change to facilitate physical activity

Social Determinants of Health

Public Health measuresHealthy Eating

Food labelling Restrictions

– Ban Junk food from public sector Engage with the food industry

– Junk Tax– Fat Tax

Fruit shops in public sector buildings

Individual Approach

Smoking

Stop starting and start stopping Young Programmes for low income Hospital Smoking cessation services

including NRT Primary care services

Physical Activity

– Inactivity doubles risk of CVD– Physical activity for Health

Adults accumulate 30 mins of moderate intensity exercise most days of week

Children 60 mins– Physical activity for fitness

3 x 20 mins of vigorous intensity exercise per week

– ? Intensity Level required for CVD protection

Barriers to Exercise

Master Tom MacIntyre

Diet

Noddy’s guide– Cut the crap

Accessibility Cost Convenience

– Reduce portion size– Eat fruit and vegetables

Hospital Fruit Shop ?

High risk primary prevention Anticipatory care Case finding High risk registers

– Structured – Opportunistic– Outreach

Social deprivation Risk assessment Risk factor modification

High risk primary prevention

?Already have the disease JBS2 guidelines

– ≥ 20% 10yr risk of CVD on Framingham score

– Health inequalities ASSIGN risk calculator for Scotland Prof Tunstal-Pedoe Social Deprivation and Family History SIGN 97 Health behaviour change Statin and aspirin prescription

Flower of Scotland

Magnificent All Blacks

Predict

Prof Rod Jackson Predict Absolute risk Unique identifier 90 % penetration in primary care

– >400,000 IT issues resolved Outcome data

Hope for Australia ?

Australian absolute cardiovascular disease risk calculator

http://www.cvdcheck.org.au/

Secondary prevention

Step change– Menu based Cardiac Rehabilitation– Multidisciplinary team– Components

Education Medical risk factor modification Optimise pharmacological treatment Health Behaviour Change interventions

– Smoking– Diet – Exercise– Stress, anxiety and depression

– Does it work?– Chronic disease management

Secondary prevention

Chronic Stable CHD– Primary care setting– Medical risk factor modification– Optimise treatment– Chronic disease management programmes– Health behaviour change

Smoking cessation services Diet Exercise referral Health coach model