CVD preventive interventions WORKSHOP Jurate Klumbiene Kaunas University of Medicine, Kaunas, Lithuania

Objectives of the workshop To broaden an understanding of the differences in the main strategies in prevention of CVD To improve skills in planning and conducting preventive activities To update knowledge concerning approaches to CVD management

Agenda of the workshop Practice profile - presentation Identification of potential interventions using population, high-risk strategies and secondary prevention of CVD – group work Group work results – presentation The main strategies of CVD prevention - lecture

Practice description I. General profile Country region – industrial (coal mines, steel factories) Urban setting – city with 200,000 inhabitants Localization – in the city centre with easy access by public transportation Type of practice - single Practice population – 2,356 individuals (638 children under 18, 472 persons over 65) Staff – 1 physician, 2 community nurses, 1 practice nurse, 1 part-time midwife Reimbursement system – public insurance, per capita Disease registers – unavailable Medical records – traditional paper forms

Practice description II. Lifestyle habits The nutrition survey conducted on a random sample of the practice population obtained the following data: total fat intake accounted for 45% of energy intake, saturated fats intake for 15 %; the average intake of cholesterol was 380 mg/day; 25 % of people consumed fruits and vegetables daily. 520 males and 356 of females are smokers. A sedentary lifestyle is common for the population.

Practice description III. Persons with risk factors for CVD 773 with hypertension 810 with high serum cholesterol 346 who are obese and 515 who are overweight 315 males and 200 women are regular smokers

Practice description IV. Patients with CVD Stroke – 35 patients History of MI – 27 patients Angina pectoris – 29 patients Atrial fibrillation – 24 patients Heart failure – 19 patients

Tasks for group work Prepare a comprehensive plan of preventive activities in the field of CVD using the following strategies: 1)Population strategy 2)High-risk strategy 3)Secondary prevention

Presentation of group work results – plenary discussion

The main strategies of CVD prevention (a lecture based on the European guidelines on cardiovascular disease prevention in clinical practise, 2007)

THE RATIONALE FOR AN ACTIVE APPROACH TO THE PREVENTION OF CARDIOVASCULAR DISEASES CVD is the major cause of premature death in most European populations. The underlying pathology is usually atherosclerosis. Death, myocardial infarction and stroke nevertheless frequently occur suddenly and before medical care is available. The mass occurrence of CVD relates strongly to life- styles and modifiable physiological factors. Risk factor modifications have been shown to reduce CVD mortality and morbidity, particularly in high-risk subjects.

CVD PRIMARY PREVENTION Population strategy - for altering, in the entire population, those lifestyle and environmental factors, and their social and economic determinants, that are the underlying causes of the mass occurrence of CVD High-risk strategy - identification of high-risk individuals and action to reduce their risk factor levels

CVD SECONDARY PREVENTION The prevention of recurrent CVD events and the progression of the disease in patients with established cardiovascular organ damage or disease.

THE PRIORITIES FOR CVD PREVENTION 1. Patients with established atherosclerotic CVD. 2.Asymptomatic individuals who are at high risk of developing CVD because of: a) multiple risk factors resulting in a 10 year risk of ≥ 5% now (or if extrapolated to age 60) for developing a fatal CVD event b) markedly raised levels of single risk factors: cholesterol ≥ 8 mmol/l, LDL cholesterol ≥ 6 mmol/l, blood pressure ≥ 180/110 mmHg c) diabetes type 2 and diabetes type 1 with micro- albuminuria 3.Close relatives (first-degree relatives) of a) patients with early onset atherosclerotic CVD b) asymptomatic individuals at particularly high risk

OBJECTIVES OF CVD PREVENTION 1. To assist those at low risk of CVD to maintain this state for their entire lives and to help those at increased total CVD risk to reduce it.

OBJECTIVES OF CVD PREVENTION 2. To achieve the characteristics of people who tend to stay healthy: -Nonsmoking -Healthy food choices -Physical activity: 30 min. of moderate activity a day -BMI < 25 kg/m 2 -BP < 140/90 mmHg -Total cholesterol < 5 mmol/l -LDL cholesterol < 3 mmol/l -Blood glucose < 6 mmol/l

OBJECTIVES OF CVD PREVENTION 3. To achieve more rigorous risk factor control over high-risk subjects, especially those with established CVD and diabetes: - BP < 130/80 mmHg if feasible - Total cholesterol < 4.5 mmol/l including those with < 4mmol/l if feasible - LDL cholesterol < 2.5 mmol/l including those with < 2mmol/l if feasible - Fasting blood glucose < 6 mmol/l

OBJECTIVES OF CVD PREVENTION 4. To consider cardioprotective drug therapy in high-risk subjects, especially those with established atherosclerotic CVD.

THE SCORE RISK ASSESSMENT SYSTEM (HeartScore, at Based on a large dataset of 12 European cohort studies Predicts fatal CVD events over a 10-year period Integrated the following risk factors: - gender - age - smoking - systolic BP - cholesterol (the cholesterol, cholesterol/HDL ratio) The threshold for being at high risk is defined as ≥ 5%

RISK CHART FOR LOW-RISK COUNTRIES

RISK CHART FOR HIGH-RISK COUNTRIES

THE DEFINITION OF HIGH TOTAL RISK FOR DEVELOPING A FATAL CARDIOVASCULAR EVENT 1. Patients with established cardiovascular disease 2. Asymptomatic subjects who have: 2.1. Multiple risk factors resulting in a 10 year risk ≥ 5% now or if extrapolated to age Markedly raised levels of single risk factors: total cholesterol ≥ 8 mmol/l, LDL cholesterol ≥ 6 mmol/l, blood pressure ≥ 180/110 mmHg 2.3.Diabetes type 2 and diabetes type 1 with microalbuminuria

CVD RISK MAY BE HIGHER THAN INDICATED IN THE CHART FOR: Sedentary or obese subjects, especially those with central obesity. Asymptomatic subjects with pre-clinical evidence of atherosclerosis (e.g. CT scan, ultrasonography). Subjects with a strong family history of premature CVD. Subjects with low HDL cholesterol or high triglycerides. Subjects with diabetes – a fivefold higher risk in women with diabetes & a threefold higher risk in men with diabetes compared with those without diabetes. The socially deprived.

THE METABOLIC SYNDROME The term refers to the combination of several factors that tend to cluster together in central obesity – hypertension, low HDL cholesterol, raised triglycerides, and raised blood glucose – to increase risk of diabetes and CVD. This implies that, if one component is identified, a systematic search for others is indicated, together with an active approach to managing all of these factors. Physical activity and weight control can radically reduce the risk of developing diabetes in those with the metabolic syndrome.

RELATIVE RISK CHART

THE MANAGEMENT OF CVD RISK IN CLINICAL PRACTICE Behavioural risk factors - stop smoking tobacco - make healthy food choices - increase physical activity Management of other risk factors - being overweight and obesity - blood pressure - plasma lipids - diabetes - metabolic syndrome

CARDIOPROTECTIVE DRUG THERAPY Aspirin for virtually everyone with established CVD and for persons with >10% SCORE risk once blood pressure has been controlled.  blockers after myocardial infarction and, in carefully titrated doses, in those with heart failure. ACE inhibitors for those with left ventricular dysfunction and in diabetic subjects with hypertension or nephropathy. Anticoagulants in those at increased risk of thromboembolic events, particularly atrial fibrillation.