Prof. Jaakko Tuomilehto Department of Public Health University of Helsinki, Department of Epidemiology and Health Promotion National Public Health Institute Helsinki, Finland; Donau-Universität Krems, Krems, Austria; Chair, Working Group on Epidemiology and Prevention European Society of Cardiology

DEVELOPED COUNTRIES Deaths in 2001 attributable to 15 leading causes Number of deaths (000s) 98% of all deaths attributable to 15 leading causes Source: WHR 2002

DEVELOPED COUNTRIES Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s)

CVD PREVENTION WORKS Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged years from 1969 to 2001 Mortality per population Start of the North Karelia Project Nationwide activity

CVD PREVENTION WORKS Japan: reduction of salt intake resulting in lower blood pressure levels and drastically reduced stroke mortality. Singapore: national programme associated with decline in NCD trends. Mauritius: changing cooking oil from palm to soy bean oil resulted in a 15% decrease in serum cholesterol in the population. Poland: sudden change in dietary fats, related to political changes - resulted in a 20% decline in heart disease mortality.

Serum cholesterol Men years mmol/l

Diastolic Blood Pressure Women Years mmHg

Smoking Prevalence Men Years %

Body-Mass Index Men Years Kg/m 2

Prevalence of HYPERGLYCEMIA in European people aged years - DECODE Previously known diabetes:4.9% Isolated fasting hyperglycemia:2.1% Isolated post-challenge hyperglycemia:1.7% Combined hyperglycemia:1.6% Impaired glucose tolerance (IGT) 11.9% TOTAL HYPERGLYCEMIA 22.2% DECODE Study Group. Lancet 1999;354:617–621

1994First Joint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention EUROASPIRE I 1998Second Joint Task Force Recommendations EUROASPIRE II 2000Joint European Societies CVD Prevention Committee 2003Third Joint Task Force Guidelines

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice The Third Joint Task Force European International European European Association Diabetes Society of Society of for the Study Federation General Hypertension Diabetes Europe Practice/Family Medicine International European European European Society of Society ofHeart Society of Behavioural AtherosclerosisNetwork Cardiology Medicine

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice What is new in these guidelines? From CHD to CVD prevention A new risk estimation model: SCORE Update / adaptations of –Priorities –Goals –Management aspects

Task force risk chart Based on Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83(1):356-62

Problems with the existing chart Based on the Framingham function which overpredicts in European populations with low or medium levels of disease incidence Thomsen et al. Int J Epidemiology, 2002, In press

Problems with the existing chart Derived from a relatively small data set; few or no events in some risk factor combinations Difficult to accommodate other risk factors such as as HDL-cholesterol Uses end points which cannot be reproduced from other data sets; therefore hard to validate Probably underestimates the importance of diabetes

The SCORE Project The Systematic COronary Risk Evaluation Project Started in 1998 under the auspices of The European Society of Cardiology Conducted and supported by: Royal College of Surgeons in Ireland EU BIOMED II programme Contract BMH National funding agencies of the component studies SCORE

SCORE objectives To assemble databases representative of typical European populations to assess the accuracy of the existing European risk system. To prepare a risk score system or systems which are optimised for coronary prevention in European clinical practice. SCORE

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

Key differences Total fatal cardiovascular risk rather than just CHD Fatal events rather than total events Charts for cholesterol and cholesterol:HDL ratio New chart shows more detail in age range No charts for those with established disease or diabetes SCORE

Better than current chart – or simply different? Current prediction – CHD – Includes nonfatal events – Uses idiosyncratic definition – Not possible to break down risk into angina and MI – Over-predicts in low/medium- risk regions – ”One size fits all” SCORE prediction – CVD (but can do CHD) – Restricted to fatal events – Uses common definition – Component risks can be calculated – Separate prediction for low risk regions – Can be customised using national mortality statistics SCORE

Priorities of Cardiovascular Disease Prevention in Clinical Practice Patients with established coronary heart disease, peripheral artery disease and cerebrovascular atherosclerotic disease Asymptomatic individuals who are at high risk of developing atherosclerotic cardiovascular disease because of: Multiple risk factors resulting in a 10 year risk of > 5% now (or if extrapolated to age 60) for developing a fatal cardiovascular event. Markedly raised levels of single risk factors: cholesterol > 8 mmol/l (320 mg/dl), LDL chol > 6 mmol/l (240 mg/dl), blood pressure > 180/110 mmHg Diabetes Type 2 and diabetes Type 1 with microalbuminuria Close relatives (first degree relatives) of Patients with early-onset atherosclerotic cardiovascular disease Asymptomatic individuals at particularly high risk Other individuals met in connection with ordinary clinical practice

Using the cardiovascular risk chart

Note that total CVD risk may be higher than indicated in the chart: - as the person approaches the next age category. - in asymptomatic subjects with pre-clinical evidence of atherosclerosis (e.g. CT scan, ultrasonography) - in subjects with a strong family history of premature CVD - in subjects with low HDL cholesterol levels, with raised triglyceride levels, with impaired glucose tolerance, and with raised levels of C-reactive protein, fibrinogen, homocysteine, apolipoprotein B or Lp(a). - in obese and sedentary subjects Using the cardiovascular risk chart Qualifiers

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice Management of risk in clinical practice Behavioural changes Dietary changes Smoking cessation Physical activity Control of arterial hypertension Management of dyslipidemias Management of diabetes Prevention in subjects with the metabolic syndrome Prophylactic drug therapy

How to achieve intensive lifestyle change in patients with disease and in high risk people? Strategies to make behavioural counselling more effective include: Develop a therapeutic alliance with the patient Gain commitments from the patient to achieve lifestyle change Ensure the patient understands the relationship between lifestyle and disease Help the patient overcome barriers to lifestyle change Involve the patient in identifying the risk factor(s) to change Design a lifestyle modification plan Use strategies to reinforce the patient’s own capacity to change Monitor progress of lifestyle change through follow-up contacts Involve other health care staff wherever possible.

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice Management of risk in clinical practice Behavioural changes Dietary changes Smoking cessation Physical activity Control of arterial hypertension Management of dyslipidemias Management of diabetes Prevention in subjects with the metabolic syndrome Prophylactic drug therapy

Goals: < 140/90 mmHg in all high risk subjects < 130/80 mmHg in patients with diabetes

Goals for CVD prevention in patients with type 2 diabetes * HbA1c * Fasting plasma glucose * Self-monitored blood glucose - fasting - postprandial * Blood pressure * Total cholesterol * LDL cholesterol < 6.1% < 6.0 mmol/l (110 mg/dl) mmol/l (70-90 mg/dl) mmol/l ( mg/dl) <130 / 80 mm Hg <4.5 mmol/l (175 mg/dl) <2.5 mmol/l (100 mg/dl)

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice Where to find more? Executive summary Eur Heart J 2003;24: Eur J Cardiovasc Prevention & Rehab 2003; 10(4):S1-S11 Pocket version Full document soon on the ESC web published later in 2003 EJCPR