CVD prevention & management: a new

approach for primary care

Rod JacksonSchool of Population Health

University of AucklandNew Zealand

CVD prevention & management: a new

approach for primary care

Rod JacksonSchool of Population Health

University of AucklandNew Zealand

Why bother about CVD in 1°care?Why bother about CVD in 1°care?

In a population of 10,000 primary care patients, every year there are about:

• 10 coronary & stroke deaths• 1 diabetic death• 1 breast cancer death• 1 prostate cancer death• 1 suicide every year• 1 road traffic death• (1 cervical cancer death every 5 years)

NZHIS annual mortality statistics

Blood pressure and CHDBlood pressure and CHD

Law & Wald BMJ 2002;324:1570-6

PSC.

Reduction in stroke with combination BP lowering therapy in PROGRESS, regardless of

baseline BP

Reduction in stroke with combination BP lowering therapy in PROGRESS, regardless of

baseline BP

There is no such thing as hypertension

There is no such thing as hypertension

16 20 24 28 32 36

0.5

1.0

2.0

4.0

CHD and SBP or Total cholesterolCHD and SBP or Total cholesterol

110 120 130 140 150 160 170

0.5

1.0

2.0

4.0

Blood pressure

Systolic blood pressure (mmHg)

Risk of coronary disease

0.5

1.0

2.0

4.0

“Hyper-tension”

“Hyperchol-

esterolaemia”

4.0 5.0 6.0 7.0 8.0

Total cholesterol (mmol/l)

Cholesterol

Reduction in CV events with cholesterol lowering in Heart Protection Study, regardless of baseline

cholesterol

Reduction in CV events with cholesterol lowering in Heart Protection Study, regardless of baseline

cholesterol

There is no such thing as hypercholesterolaemia

There is no such thing as hypercholesterolaemia

Smoking and the risk of stroke

Smoking and the risk of stroke

7.2

12

3.54

0

2

4

6

8

Reference Passive Ex-smoker Active Active

Source: Bonita, 1999

Odds Ratio

‘Diabetes’ & body mass index‘Diabetes’ & body mass index

There is no such thing as obesity

There is no such thing as obesity

Stroke, CHD, CVD & blood glucose Stroke, CHD, CVD & blood glucose

Total stroke

4.5 5.0 5.5 6.0 6.5 7.0 7.5

4.0

2.0

1.0

0.5

Hazard ratio & 95% CI

4.5 5.0 5.5 6.0 6.5 7.0 7.5

4.0

2.0

1.0

0.54.5 5.0 5.5 6.0 6.5 7.0 7.5

4.0

2.0

1.0

0.5

Total ischaemic heart diseaseCardiovascular death

Usual fasting glucose (mmol/l)Asia Pacific Cohort Studies Collaboration

HbA1c and microalbuminuria: Auckland, NZ

HbA1c and microalbuminuria: Auckland, NZ

Metcalf et al (unpublished)excl. diagnosed diabetics

There is no such thing as non-insulin dependant

diabetes

There is no such thing as non-insulin dependant

diabetes

Message Number 1:

there is no such thing as hypertension

or hypercholesterolaemia or obesity or type 2

diabetes

Message Number 1:

there is no such thing as hypertension

or hypercholesterolaemia or obesity or type 2

diabetes

and we all have CHDand we all have CHDQuickTime™ and a

TIFF (Uncompressed) decompressorare needed to see this picture.

a new paradigm:

‘risk factors’

‘CVD risk factors interact’

Impact of multiple risk factors on CVD risk

Impact of multiple risk factors on CVD risk

Jackson et al. Lancet 2005. 365:434-41

Relative Risk and 95% CI

34%

25%

0% 5% 10% 15% 20%

Few or no participantshad a history of stroke

Estimated 5 year stroke event rate

TreatmentControl

Most or all participantshad a history ofstroke or TIA

1.4%

5.1%

Relative Reduction in strokesAbsolute Reduction in strokes / 5 years

1.00.5 1.5

Absolute Effects Relative Effects

‘The bigger the CVD risk the bigger the benefit’: trials of BP lowering &

stroke

‘The bigger the CVD risk the bigger the benefit’: trials of BP lowering &

stroke

15% 5 yr risk

NZ threshold for CVD risk drugsNZ threshold for CVD risk drugs

Message Number 2:Message Number 2:

Measure risk, not risk factors

Estimating clinical risk:Framingham Heart Study

•Sex•Age•Diabetes•Smoking•BP•TC•HDL•(LVH)

Anderson et al. Am Heart J. 1991;121:293-8

45 yr old manBP 150/90 mmHg non smokerTC 6.0 mmol/LHDLC 1.2 mmol/Lnew ‘diabetes’

60 yr old manBP 150/90 mmHgsmokerTC 6.0 mmol/LHDLC 1.0 mmol/LNo ‘diabetes’

5 yr CVD risk ≈ 10%

5 yr CVD risk ≈ 25%

Are lipid +/or BP-lowering drugs indicated?

Are lipid +/or BP-lowering drugs indicated?

Clinical risk:

short-term vs life-time?

Clinical risk:

short-term vs life-time?

Lifetime risk is clinically irrelevant

The risk of death is 1 / person (100%)

What’s clinically relevant is when it happens

The lifetime CVD risk chart

Who should we treat?

Everybody - because we all have CHD

BUT the intensity of treatment should be directly proportional to the clinical risk and to the costs

of treatment QuickTime™ and a

TIFF (Uncompressed) decompressorare needed to see this picture.

Clinical risk treatment thresholds?

Clinical risk treatment thresholds?

$$$$$$$$$$$$$$$$$$$$$$$

At the clinical (absolute) risk that is affordable to individuals

or populationsCheaper interventions should be initiated at lower risk levels

risk threshold for high cost treatment

SBP treatment threshold for equal Rx benefit

Clinical CVD risk (% per yr)

low high

high

Patient 1 Patient 2 Patient 3

130 150 170

risk threshold for low cost treatment

Treatment goals?Treatment goals?

Based on clinical risk and the ‘costs’ of

lowering risk

CVD risk threshold for drug treatment

SBP target for equal Rx benefit

Clinical CVD risk (% per yr)

low high

high

Patient 1 Patient 2 Patient 3

130 150 170

CVD risk target for treatment

155135115

Message Number 3:Message Number 3:

Treat risk, not risk factors

The polypillThe polypill

Aspirin

Statin

Diuretic ± ACEI ± BB ± CCB

metformin?

PREDICT: a clinical decision support system for CVD & diabetes

risk assessment & management

PREDICT: a clinical decision support system for CVD & diabetes

risk assessment & management

PREDICT is a computer programme that calculates CVD risk & provides E-B management recommendations

(Please note – dates are not representative as this is a test case)

Workflow: Individual Patient TrackingWorkflow: Individual Patient Tracking

Sample Report –Group DataSample Report –Group Data

Patient populations

All clinical data is made non-

identifiable with encrypted NHI and sent via

secure internet connection for

analyses

Combining information on patients Combining information on patients

Stored anonymous

CVD risk profiles

Practice/PHO/DHB population needs assessment & service planning

patient-specific outcomes: hospital admissions, deaths

Electronic medical recordEnrolled

population

patient-specific CVD risk factor profiles

NHI

NHI (encrypted)

Making new risk prediction chartsMaking new risk prediction charts

patient-specific outcomes: hospital admissions, deaths

Electronic medical record

Enrolled population

patient-specific CVD risk factor profiles

NHI

NHI (encrypted)

Link with encrypted NHI

Making new prediction chartsMaking new prediction charts

Risk groups in first 30,878 patients from PREDICT

Risk groups in first 30,878 patients from PREDICT

Results: estimated 5-year incidence of CVD event

For prior CVD 5-year risk is: 20 + 1.3*Framingham score Mean est. 5-year incidence for Hx CVD is 28.4% (95%CI 26.3 to 30.4)

Results: events in risk groups in first 30,878 patients from PREDICT

Results: events in risk groups in first 30,878 patients from PREDICT

47%

26%

63% of events occur in 21% of the people (high risk)

16%

11%

The potential magnitude of the population

evidence base

The potential magnitude of the population

evidence base

• One assessment per practitioner every other day for 46 weeks/year = 115 per year

• A practitioner can assess all appropriate patients in less than 5 years

• 1000 practitioners could assess more than 100,000 patients per year

‘one every other day is ok’‘one every other day is ok’

Message Number 4:

The next revolution in medicine will be electronic, not genomic

Message Number 4:

The next revolution in medicine will be electronic, not genomic

The future is already here, its just not widely distributed

It will be led by primary care

metabolic syndrome:

‘metabollocks!’

metabolic syndrome:

‘metabollocks!’

Relative stroke risk and usual Blood PressureRelative stroke risk and usual Blood Pressure

0.5

1.0

2.0

4.0

75 81 87 93 98 102diastolic blood pressure (mmHg)

PSC Lancet 1995;346:1647-53

(45 prospective studies: 450,000 people 13,000 events)Relative Risk

Relative stroke risk and usual Blood PressureRelative stroke risk and usual Blood Pressure

0.5

1.0

2.0

4.0

75 81 87 93 98 102diastolic blood pressure (mmHg)

PSC Lancet 1995;346:1647-53

(45 prospective studies: 450,000 people 13,000 events)

Relative Risk

DBP > 100 mmHg

DBP > 95 mmHg

DBP > 90 mmHgDBP > 80 mmHg