Joint British Societies' guidelines on the prevention of cardiovascular disease in clinical practice continued

Guidelines for asymptomatic people at high risk (CVD risk ≥20% over 10 years) of developing CVD

Blood pressure

• Healthy individuals with systolic BP ≥160 mmHg and/or diastolic BP ≥100 mmHg should receive lifestyle advice and drug(s) therapy if BP is sustained at these levels on repeat measurements regardless of the level of absolute CVD risk
  • treatment targets are systolic <140 mmHg and diastolic <85 mmHg
• Healthy individuals with systolic BP 140–159 mmHg and/or diastolic BP 90–99 mmHg and:
  • CVD risk ≥20% or target organ damage or diabetes: lifestyle advice and drug(s) therapy if BP is sustained at these levels on repeat measurements
  • CVD risk <20% and no target organ damage and no diabetes: lifestyle advice, monitor blood pressure and reassess CVD risk annually
  • healthy individuals with systolic <140 mmHg and diastolic <85 mmHg: lifestyle advice and reassess in 5 years

Cholesterol

• Healthy individuals with familial hypercholesterolaemia or other inherited dyslipidaemia should receive lifestyle advice and drug(s) therapy
• Healthy individuals with CVD risk ≥20% and:
  • total cholesterol >4.0 mmol/l and LDL cholesterol >2.0 mmol/l: lifestyle advice and drug(s) therapy if cholesterol is sustained at these levels on repeat measurements
  • total cholesterol <4.0 mmol/l and LDL cholesterol <2.0 mmol/l: lifestyle advice and reassess annually
• Healthy individuals with CVD risk <20%, and no cardiovascular complications and no diabetes should receive lifestyle advice and be reassessed in 5 years

Cardioprotective drug therapy

• Aspirin (75 mg) in individuals >50 years whose hypertension, if present, is controlled to audit standard (systolic <150 mmHg and diastolic <90 mmHg)

Screening of first degree blood relatives

• Screen close relatives if familial hypercholesterolaemia or other inherited dyslipidaemia is suspected

Guidelines for patients with diabetes mellitus

• Optimal targets for patients with diabetes:
  • glycaemic control HbA_1c <6.5%
  • fasting plasma glucose ≤6.0 mmol/l
  • blood pressure <130/80 mmHg
  • total cholesterol <4.0 mmol/l or a 25% reduction
  • LDL cholesterol <2.0 mmol/l or a 30% reduction
• ACE inhibitors/angiotensin-II receptor blockers
  • prescribe for patients with renal dysfunction and microalbuminuria
• Cholesterol lowering therapy (statins)
  • prescribe for all people ≥40 years with type 1 or 2 diabetes
  • for patients 18–39 years with type 1 or 2 diabetes and who have at least one of the following:
    • retinopathy
    • nephropathy
    • poor glycaemic control (HbA_1c >9%)
    • elevated blood pressure
    • requiring drug therapy
    • total cholesterol >6 mmol/l
    • features of metabolic syndrome
    • family history of premature CVD

Joint British Societies' guidelines on the prevention of cardiovascular disease in clinical practice continued

How to use the CVD risk prediction charts for prevention of CVD

• These charts are for estimating CVD risk (non-fatal myocardial infarction and stroke, coronary and stroke death and new angina pectoris) for individuals who have not already developed coronary heart disease (CHD) or other major atherosclerotic disease. They are an aid to making clinical decisions about how intensively to intervene on lifestyle and whether to use antihypertensive, lipid lowering, and antiplatelet medication, but should not replace clinical judgement

• The use of these charts is not appropriate for patients who have existing atherosclerotic disease or are at higher risk for other medical reasons. Examples are:
  • CHD or other major atherosclerotic disease
  • familial hypercholesterolaemia or other inherited dyslipidaemias
  • renal dysfunction including diabetic nephropathy
  • type 1 and 2 diabetes mellitus

• The charts should not be used to decide whether to introduce antihypertensive medication when blood pressure is persistently at or above 160/100 mm Hg or when target organ damage caused by hypertension is present. In both cases antihypertensive medication is recommended regardless of CVD risk. Similarly the charts should not be used to decide whether to introduce lipid lowering medication when the ratio of serum total to HDL cholesterol exceeds 6. Such medication is generally indicated with such a ratio regardless of estimated CVD risk

• To estimate an individual's total 10 year risk of developing CVD choose the table for his or her sex, lifetime smoking status, and age. Within this square define the level of risk according to the point where the coordinates for systolic blood pressure and the ratio of total cholesterol to high density lipoprotein (HDL) cholesterol meet. If no HDL cholesterol result is available, then assume this is 1.0 mmol/l and the lipid scale can be used for total cholesterol alone

• Higher risk individuals () are defined as those whose 10 year CVD risk exceeds 20%, which is approximately equivalent to a CHD risk of >15% over the same period

• The chart also assists in the identification of individuals whose 10 year CVD risk is moderately increased in the range 10–20% () and those in whom risk is lower than 10% over 10 years()

• Smoking status should reflect lifetime exposure to tobacco and not simply tobacco use at the time of assessment. For example, those who have given up smoking within five years should be regarded as current smokers for the purposes of the charts

• The initial blood pressure and the first random (non-fasting) total cholesterol and HDL cholesterol can be used to estimate an individual&#39;s risk. However, the decision on using drug therapy should generally be based on repeat risk factor measurements over a period of time

• Men and women do not reach the level of risk predicted by the charts for the three age bands until they reach the ages of 49, 59, and 69 years, respectively. The charts will overestimate current risk most in the under 40s. Clinical judgement must be used in deciding on treatment in younger patients. However, it should be recognised that blood pressure and cholesterol tend to rise most, and HDL cholesterol to decline most, in younger patients already possessing adverse values. Thus their untreated risk at age 49 years is likely to be higher than the projected risk shown on the age-less-than 50 years chart. From aged 70 years the CVD risk, especially for men, is usually ≥20% over 10 years and the charts will underestimate true total CVD risk

• These charts (and all other currently available methods of CVD risk prediction) are based on groups of patients with untreated blood pressure, total cholesterol, and HDL cholesterol values. In patients already receiving antihypertensive therapy in whom a decision is to be made about whether to introduce lipid lowering medication, or vice versa, the charts can only act as a guide. Unless recent pretreatment risk factor values are available it is generally safest to assume that CVD risk is higher than that predicted by current levels of blood pressure or lipids on treatment

• CVD risk is also higher than indicated in the charts for:
  • those with a family history of premature CHD or stroke (male first degree relatives aged <55 years and female first degree relatives aged <65 years), which increases the risk by:
    • a factor of 1.5 if one relative has such a history
    • a factor of 2 if more than one relative has such a history
  • those with raised triglyceride values (>1.7 mmol/l)
  • women with premature menopause
  • those who are not yet diabetic, but have impaired fasting glycaemia (≥6.1 but <7.0 mmol/l) or impaired glucose tolerance (two hour glucose in an oral glucose tolerance test ≥7.8 mmol/l but <11.1 mmol/l)

• In some ethnic minorities the risk charts underestimate CVD risk, because they have not been validated in these populations. For example, in patients originating from the Indian subcontinent it is safest to assume that the CVD risk is higher than predicted from the charts (1.4 times)

• An individual can be shown on the chart the direction in which his or her risk of CVD can be reduced by changing smoking status, blood pressure, or cholesterol. It should be borne in mind that the estimate of risk is for a group of patients with similar risk factors and that within that group there will be considerable inter-individual variation in risk. It should also be pointed out in younger patients that the estimated risk will generally not be reached before the age of 50, if their current blood pressure and lipid levels remain unchanged. The charts are primarily to assist in directing intervention to those who typically stand to benefit most

Joint British Societies' guidelines on the prevention of cardiovascular disease in clinical practice continued

Joint British Societies' cardiovascular disease risk prediction chart

full guidelines available from…

D Wood, R Wray, N Poulter, B Williams, M Kirby, V Patel, P Durrington, J Reckless, M Davis, F Sivers and J Potter. Joint British Societies guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 (supplement 5): v1-v52