Global Cardiac Risk Management

Anthony Battad CD, MD, MSc., MPH, FRCPCDirector // DirecteurAmbulatory Care, St. Boniface Hospital // Soins ambulatoire, Hôpital St. BonifaceMedical Director //Directeur médicalMaster of Physician Assistant Studies // Mâitre d’études assitants-médicineUniversity of Manitoba // Université du Manitoba

abattad@sbgh.mb.ca

Disclosure

• Conference expenses paid for by University of Manitoba• No financial conflicts to disclose

• Understand the global impact of atherosclerotic disease

• Name the major risk factors implicated in atherosclerotic disease

• Recall the important targets for atherosclerotic risk factors

• Implement a global strategy for the prevention and treatment of atherosclerotic disease

Objectives

• 64 year old male. Previously well (no PMHx)• No family history of premature HD• Non-smoker; Minimal ETOH use• Took his blood pressure at Walmart

• 162/80• In the office:

• 156/78 (BP Tru)• Remainder of exam is unremarkable

Case # 1

• 56 year old female• On a routine physical: LDL = 5, HDL = 1.02, TG = 2.4• No previous medical history• FHx: (+) for HD on father’s side• BMI = 29• BP = 146/56

Case # 2

• 55 year old male in for “executive physical”• FHx: (+) for MI (father at 52, mother at 56)• Smoker 12 pk-yrs; 8 – 10 drinks / week• High stress job

Case # 3

• Not every person at high risk will develop disease• Not every person at low risk will be event free

• Estimating the lifetime risk of CV disease can be difficult• Most risk factor calculators underestimate or overestimate the risk

• Risk factor treatment to accepted targets have inherent risks

• Which asymptomatic patients do you target for screening?

Global Risk Management: The Challenge

• 2013: 15.3 million deaths annually1

• Lifetime risk of CVD: 20 % – 49 % and 32 % ♂ ♀2

• One half to one third of all CVD attributable to CHD/CAD• Over 90% of all CHD events occur in patients with at least one risk factor

• The “Big 3” modifiable risk factors:• Dyslipidemia• Hypertension• Diabetes

Some facts to consider

1The Farr Institute of Health Informatics Research, 20132Jones, L., Framingham Study, 1999

Hypertension Dyslipidemia Diabetes

Smoking

• > 10 % CV deaths worldwide, 30 % North America• Pathophysiology:

• Vasoconstriction HTN• Hypercoagulability clot formation• Endothelial dysfunction vascular instability

• Single most effective intervention

A few words about smoking

Some more facts…

• 75 000 Canadians/year suffer an MI and 50 000/year suffer stroke

• 75% of stroke victims survive first event• 33% of patients under the age of 65

• Hospitalized MI has 8% mortality• 1 in 2 MI patients are under the age of 65

• ~ $19 billion/year cost to Canadian economy

Why is risk assessment and treatment needed?

Who Cares !!!!

To identify individuals at sufficient risk so appropriate global intervention can be given

LDL < 2

BP < 130/80

BMI < 26

A1C < 6 Excercise

Smoking Cessation

It is NOT unique to any one population

3 Step Approach to Global Risk Management

• Screening: Who and When

• Stratify to Risk Group:• High, Medium, Low

• Treat according to risk• Specific, easy targets

Screening: Who and When

• Males ≥ 40 / Females ≥ 50 (or post-menopausal)

• All adults: DM, HTN, smoker, evidence of atherosclerosis, FHx of premature CAD, abdominal obesity

• When: PHE, routine office visit, even acute unrelated illness

• Screen with full lipid profile, FBG

Figure 1

Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032)

Canadian Caridovascular Society, 2012

Figure 2

Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032)

Canadian Caridovascular Society, 2012

Figure 3

Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032)

Canadian Caridovascular Society, 2012

Stratify to a Risk Group

• High Risk: FRS > 19% • or DM, proven CAD, PVD, CVD

• Medium Risk: FRS 10% - 19%

• Low Risk: FRS: < 10%

Patient Screened

High Risk:•LDL < 2 mmol/L•BP < 130/80•FBG ≤ 7

Framingham Risk PointsAge, Tchol, Smoking, BP, HDL

Medium Risk:•LDL < 3.5•BP <130/80•FBG ≤ 7

Low Risk:•LDL < 5•BP and FBG as above

Metabolic Syndrome•WC > 102 cm male/ 88 cm female•TG ≥ 1.7 mmol/L•HDL ≤ 1 mmol/L male/ 1.3 female•BP ≥ 130/85•FBG 6.2 – 7.0 mmol/L

DM or CAD/Surrogates?

No Yes

Figure 4

Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032)

Canadian Caridovascular Society, 2012

Targets: Summary

• Lipid Profile:• Risk: < 2 mmol/L and TC/HDL ratio < 4• Risk: < 3.5 mmol/L (ratio < 5)• Risk: < 5 mmol/L (ratio < 6)

• Fasting Blood Glucose:• < 7 mmol/L (or < 6 if tolerated)

Population SBP > DBP >

Diabetes 130 80

High risk (TOD or CV risk factors) 140 90

Low risk (no TOD or CV risk factors)

160 100

Very elderly* (≥80 yrs.) 160 NA

Usual blood pressure threshold values for initiation of pharmacological treatment

TOD = target organ damage.

CHEP, 2015

Population SBP < DBP <

Diabetes 130 80

All others < 80 yrs. (including CKD)

140 90

Very elderly (≥ 80 yrs.) 150 NA

Treatment consists of health behaviour ±pharmacological management

Recommended Treatment Targets

In patients with coronary artery disease be cautious when lowering blood pressureif diastolic blood pressures are < 60mmHg

CHEP, 2015

FAQ’s

• What is the role of hs-CRP?• What about Lipoproteins?• What is the role of homocysteine?• Who needs a Graduated Exercise Stress Test?• Who needs referral to a “Specialist?”

• Tool for further risk stratification

• Useful for low to moderate risk patients

• Good predictor of CVD events

• Should we do this test regularly?

High sensitivity C-reactive protein (hs – CRP)

• Provide a more accurate number of “atherogenic” particles• Elevated apo B100 elevated LDL or VLDL

• Lp (a) levels causative for CVD• Measured in special cases• Not routinely used yet

Lipoproteins

• No role in the diagnosis of CAD in the absence of clinical findings

• No predictive value

• May lead to unnecessary invasive work-up

Stress Testing

• Complex or difficult to manage• Not at target despite maximal meds• Excess medication side-effects

• Development of symptons consistent with CVD• Angina• TIA

• Patient’s request

When to Refer

• 64 year old male. Previously well (no PMHx)• No family history of premature HD• Non-smoker; Minimal ETOH use• Took his blood pressure at Walmart

• 162/80• In the office:

• 156/78 (BP Tru)• Remainder of exam is unremarkable

Case # 1

• 56 year old female• On a routine physical: LDL = 5, HDL = 1.02, TG = 2.4• No previous medical history• FHx: (+) for HD on father’s side• BMI = 29• BP = 146/56

Case # 2

• 55 year old male in for “executive physical”• FHx: (+) for MI (father at 52, mother at 56)• Smoker 12 pk-yrs; 8 – 10 drinks / week• High stress job

Case # 3

• Screen patients at any given opportunity• Burden of CVD is high

• Once one traditional risk factor is diagnosed, manage the other risk factors simultaneously

• Use a risk calculator to determine risk

• Don’t forget about lifestyle modifications

• Smoking cessation is the single most important intervention

Take Away Points

Thank you….Questions?