CVD prevention &

management: a new
approach for primary care

Rod Jackson
School of Population Health
University of Auckland
New Zealand
 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 CHD

Law & Wald BMJ 2002;324:1570-6

PSC.
Reduction in stroke with combination BP lowering
therapy in PROGRESS, regardless of baseline BP
There is no such thing as
hypertension
 CHD and SBP or Total cholesterol
Blood pressure Cholesterol

4.0 4.0
Risk of coronary disease

4.0

2.0 2.0

2.0

“Hyperchol-
1.0 “Hyper- 1.0
esterolaemia”
1.0
tension”

0.5

0.5 0.5 16 20 24

110 120 130 140 150 160 170 4.0 5.0 6.0 7.0 8.0

Systolic blood pressure (mmHg) Total cholesterol (mmol/l)

Reduction in CV events with cholesterol lowering in Heart
Protection Study, regardless of baseline cholesterol
There is no such thing as
hypercholesterolaemia
 Smoking and the risk of stroke
8

6 7.2
Odds Ratio

4
2 3.5
2
1
0
Reference Passive Ex-smoker Active Active

Source: Bonita, 1999

‘Diabetes’ & body mass index
There is no such thing as
obesity
 Stroke, CHD, CVD & blood glucose
Total stroke Total ischaemic Cardiovascular death
4.0 4.0 heart disease 4.0
Hazard ratio & 95% CI

2.0 2.0 2.0

1.0 1.0 1.0

0.5 0.5 0.5

4.5 5.0 5.5 6.0 6.5 7.0 7.5 4.5 5.0 5.5 6.0 6.5 7.0 7.5 4.5 5.0 5.5 6.0 6.5 7.0 7.5

Usual fasting glucose mmol/l)

(

Asia Pacific Cohort Studies Collaboration

 HbA1c and microalbuminuria: Auckland, NZ

excl. diagnosed diabetics Metcalf et al (unpublished)

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

and we all have CHD

QuickTime™ and a
TIFF (U ncompressed) decompressor
are needed to see this picture.
 a new paradigm:
‘risk factors’

‘CVD risk factors interact’

Impact of multiple risk factors on CVD risk

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

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

Absolute Effects Relative Effects

Absolute Reduction in strokes / 5 years Relative Reduction in strokes

Few or no
participants 1.4% 34%
had a history of
stroke

Most or all
participants 5.1% 25%
had a history of
stroke or TIA

Treatment
0% 5% 10% 15% 20% 0.5 1.0 1.5
Control
Estimated 5 year stroke event rate Relative Risk and 95% CI
NZ threshold for CVD risk drugs

15% 5 yr risk
 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

Are lipid +/or BP-lowering drugs indicated?

60 yr old man
BP 150/90 mmHg
45 yr old man
smoker
BP 150/90 mmHg
TC 6.0 mmol/L
non smoker
HDLC 1.0 mmol/L
TC 6.0 mmol/L
No ‘diabetes’
HDLC 1.2 mmol/L
new ‘diabetes’
5 yr CVD risk ≈ 25%
5 yr CVD risk ≈ 10%
 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 (U ncompressed) decompressor
are needed to see this picture.
Clinical risk treatment thresholds?

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

At the clinical (absolute) risk that is

affordable to individuals or populations
Cheaper interventions should be initiated at
lower risk levels
 high
Clinical CVD risk (% per yr)
risk threshold for high cost treatment

risk threshold for low cost treatment

Patient 1 Patient 2 Patient 3

low 130 150 170 high

SBP treatment threshold for equal Rx benefit
 Treatment goals?

Based on clinical risk and the

‘costs’ of lowering risk
 high
CVD risk target for treatment
Clinical CVD risk (% per yr)

CVD risk threshold for drug treatment

Patient 1 Patient 2 Patient 3

low 115 130 135 150 155 170 high

SBP target for equal Rx benefit
 Message Number 3:

Treat risk, not risk factors

 The polypill
Statin

Aspirin
metformin?

Diuretic ± ACEI ± BB ± CCB

 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
 Workflow: Individual Patient Tracking

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

Sample Report –Group Data
 Combining information on patients

Patient All clinical data is

populations made non- Stored
identifiable with anonymous
encrypted NHI CVD risk
and sent via profiles
secure internet
connection for
analyses

Practice/PHO/DHB
population needs
assessment & service
planning
 Making new risk prediction charts

Electronic medical record

Enrolled
population

NHI

NHI (encrypted)

patient-specific patient-specific CVD

outcomes: hospital
risk factor profiles
admissions, deaths
 Making new prediction charts

Electronic medical record

Enrolled
population

NHI

NHI (encrypted)

patient-specific patient-specific CVD

outcomes: hospital
risk factor profiles
admissions, deaths
Link with
encrypted NHI
Risk groups in first 30,878 patients from
PREDICT

Hx CVD
12%

Risk 15+%
9% Risk <10%
68%

Risk 10-<15%
11%
 Results: estimated 5-year incidence
of CVD event

Mean est. 5-year incidence for Hx CVD is 28.4% (95%CI 26.3 to 30.4)
For prior CVD 5-year risk is: 20 + 1.3*Framingham score
 Results: events in risk groups in first
30,878 patients from PREDICT
Hx CVD
12%

47%
Risk 15+%
9% 16% Risk <10%
68%

11% 26%
Risk 10-<15%
11%

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

 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’

 Message Number 4:

The next revolution in medicine will be

electronic, not genomic

It will be led by primary care

The future is already here, its just not

widely distributed
metabolic syndrome:

‘metabollocks!’
Relative stroke risk and usual Blood Pressure
(45 prospective studies: 450,000 people 13,000 events)

4.0
Relative Risk

2.0

1.0

0.5

75 81 87 93 98 102
diastolic blood pressure (mmHg)
PSC Lancet 1995;346:1647-53
Relative stroke risk and usual Blood Pressure
(45 prospective studies: 450,000 people 13,000 events)

4.0
Relative Risk

2.0 DBP > 100 mmHg

DBP > 95 mmHg

1.0
DBP > 90 mmHg
DBP > 80 mmHg
0.5

75 81 87 93 98 102
diastolic blood pressure (mmHg)
PSC Lancet 1995;346:1647-53