cvd risk past, present & future

8/14/2019 CVD Risk Past, Present & Future

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CVDRISK

PREDICTION:

PAST,PRESENT&FUTURE

RameshSinghVeriah

CardiologyUnit

UniversityMalayaMedicalCentre(UMMC)


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AIMS

History

Whatis

risk?

Howdoesriskrelatetothemanagementof

cardiovasculardisease

(CVD)?

CalculatingCVDrisk.

Howcan

we

communicate

risk

to

patients?


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Introduction

CVDinitiallythoughtofasanatural

consequenceof

aging.

Withtimelifestylefactorsandbiochemicalas

well

as

genetic

factors

were

identified.


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SevenCountriesStudy

1958 1970,menages4059from7countries

Clearlydemonstrated

that

CVD

rates

varied

aroundtheworldandisinfluencedby

environmental

factors. Migrationfactorsappearedtohaveastrong

influence.


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FraminghamHeartStudy1961

Earliestlandmarkstudy.

Showedthat

hypertension,

high

cholesterol

andsmokingincreasedCVrisk.

Developmentof

CVD

involves

anumber

of

risk

factors.


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Cardiovascular Disease is a CommonComplex Disease

CardiovascularDisease

Adverse LipidProfile

Elevated BloodPressure

Diabetes

Obesity

Smoking Nutrition

SedentaryLifestyle

FamilyHistory


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"At least hundreds of genes areinvolved in cardiovascular disease

- Lusis AJ, 2000


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Youcan

only

predict

things

after

theyhavehappened

EugneIonesco19121994


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Whatisrisk?

Riskisthelikelihoodofbeingharmedinsomeway

Howwedefineandunderstandriskdependson

emotionalfactors

rather

than

hard

facts

ourinstinctivebias ifweunderstandthedifferencebetweenrisksandhazards basedonevidence

common

sense

Harmisnotoftenduetoasinglecausesoitbecomeshardertodefinewhatariskis

Whenwe

try

to

avoid

arisk,

we

can

change

some

part

ofthesituationthatpotentiallyresultsinexposuretoadifferentrisk


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RiskFactorAssessment

Rarelyoccurinisolation.

RatherCVD

is

aconvergence

of

anumber

of

risk

factorsthusglobalassessmentisneeded.

Combineriskfactorswithdiseasemarkerscan

proveto

be

beneficial

Importanttoidentifythemodifiableriskfactorsasitisapotentialtargetforintervention.

Whichriskfactorisanimportantpredictor,assessitatminimalcostandeasiestway.


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CVRiskPrediction:

Application Population

planning

for

public

health

messages/forums

Individual

target

more

intensive

programs

that

are

also

personalizedtomaximizethepreventionof

disease


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APerfect RiskFactor

Prevalentinthepopulation

Canbe

easily

and

safely

measured

Goodpredictivevalue

Inexpensiveto

measure


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RiskScoring

Manyriskfactorsarecorrelatedwithoneanother.

Whenconductinganinitialscreenonlyahandfulofeasilymeasuredriskfactorsareneededtomeasuretheindividualsoverallcardiacrisk.

Lowriskorhighrisk(clearlyscored)individualswillnotneedanyfurtherevaluationofadditionalriskfactorsasthiswillonlyaddtocostandnotyieldfurtherinformation.

Itis

the

intermediate

risk

individuals

that

will

warrant

furtherstratification.

Allowscosteffectivetargetingofinterventions.

CRUDE ASSESSMENT


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1. Adult Treatment Panel II. Circulation1994; 89:133363. 2. Kannel WB. J Cardiovasc Risk1994; 1: 3339.3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 85763. 4. Criqui MH et al. N Engl J Med1992; 326: 3816.

*Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD)

Includes only fatal MI and other CHD death; does not include non-fatal MI

Increased risk vs general population (%)

Original event Myocardial infarction Stroke

Myocardial infarction

Stroke

Peripheral arterial disease

57 x greater risk1

(includes death)34 x greater risk2

(includes TIA)

23 x greater risk2(includes angina andsudden death*)

9 x greater risk3

4 x greater risk4

(includes only fatal MIand other CHD death)

23 x greater risk3

(includes TIA)

CRUDEASSESSMENT

RiskofaSecondVascularEvent


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HighRiskGroup

Diabetics

Chronicrenal

failure

Thesegroupswarrantaggressivepreventive

interventions.


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RiskPredictionScores

Simpleandreliableway.

Lowcost.

FraminghamRiskScoring

HeartScore(ESC)

PROCAMAlgorithm

NewZealand

Risk

Scoring


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ImprovingRiskScoring

Calciumscoring

Multislice

CT

Echocardiography

Cardiaccatheterization

Creactiveprotein(CRP)


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WomensHealthStudy

Additionoffamilyhistory,HBA1cifdiabetic

andCRP

can

further

reclassify

women

at

intermediaterisktoeitherloworhighrisk.


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LOWERINGRISK

3complementaryapproaches

therapeutic

interventions

for

secondary

preventioninpatientswithknownCVD

identification

and

targeting

of

high

risk

individualsforprimarypreventionthrough

massscreeningorcasefinding

generalrecommendationsdisseminatedthroughoutthepopulation


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FraminghamData

Individualswhocanreduceand

minimize

risk

factor

burden

before

ageof50willsubstantiallylower

theirlifetimeriskofdevelopingCVD

Communicating risk


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Communicatingrisk

topatients

Itisdifficulttocommunicateriskanduncertainty

When

discussing

cardiovascular

disease

(CVD)

risk

with people, show them the risk prediction charts(and calculator) to help them understand their

estimated

risk

of

experiencing

a

cardiovascular

eventwithinthenext10years It is usually more helpful to discuss total CVD risk

ratherthanindividualrisksforCHD, strokeorother

events Individuals may have differing thresholds of risk

before consideringdrugtreatmenttolowerriskandthismaybeassociatedwithsocialclass


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Communicatingrisktopatients

If people want to know the benefits and risks ofinvestigations and treatments then we have to beable

to

communicate

them

effectively

The way in which health professionalscommunicate risk affects patients perception of

thatrisk

Patients should be provided with a balanced andfairassessmentoftheprosandconsofthevarious

options,

based

on

well

founded

data Use of simple visual aids and everyday analogiescanhelptoincreaseunderstandingandensurethatconsentisproperlyinformed

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