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Course:PHAR451/Cardiovascular Risk Estimation

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Updated September 2013

Instructor

Dr. James McCormack, B.Sc.(Pharm), Pharm.D. | 604 603-7898

MOST OF THE CONTENT BELOW WAS DEVELOPED BY DR PETER LOEWEN

Why CV Risk Assessment Matters in Pharmacotherapy Practice

  • better target risk-reducing therapies/strategies toward patients who need it most
  • provide a context for talking with patients about risk, and about whether or not they want to take medication to reduce their risk
  • avoid drugs where they're not likely to be helpful
  • motivate patients to modify their risk
  • reduce individual / societal CV morbidity/mortality

Objectives

After the session, and with reflection and study, students should be able to

  1. explain what is meant by the various cardiovascular endpoints which drug therapy is aimed at improving.
  2. select and use an appropriate CV risk estimation tool to help a patient understand their level of risk.
  3. explain how this information could be applied to pharmacotherapeutic decision-making.

Preparation for the session

BEFORE arriving at the session:

1) REVIEW How To Critically Appraise an RCT In 10 minutes

2) For each of the following patients, estimate their 10 years risks of CVD, MIs, strokes and ASCVD using the The Absolute CVD Risk/Benefit Calculator WARNING - NOT ALL PATIENTS OR LAB VALUES CAN BE USED IN THE CALCULATOR

CASE 1

55 y/o white M
BP 145/90 on HCTZ. BMI 27 (172 cm, 80kg)
TChol 5.0. HDL 1.0. CRP 5.0
PMH: none
fam CV hx: none

CASE 2

67 y/o white F
BP 135/85. BMI 33 (160 cm, 82kg)
TChol 6.1. HDL 1.3. CRP 8.5
PMH: type 2 diabetes x 3y (HgB A1C 7.5%)
fam CV hx: none

CASE 3

59 y/o white M
BP 148/85 on 2 drugs. BMI 22 (170 cm, 65kg)
TChol 7.5. HDL 1.1. CRP 4.5
PMH: none
fam CV hx: Y
smoker

CASE 4

55 y/o white F
BP 125/80. BMI 20 (165cm, 55kg)
TChol 5.2. HDL 1.2. CRP 3.0
PMH: none
fam CV hx: none

CASE 5

71 y/o white M
BP 135/85. BMI 27 (172 cm, 80kg)
TChol 6.6. HDL 1.0. CRP 3.5
PMH: ischemic stroke, DM2 (x 5 years, A1C 6.5%)
fam CV hx: none

Examples of Risk Estimation Tools

Nearly all of these have a mobile app version or several. Search in your favorite App Store.

READ THE FOLLOWING ARTICLE FOR A DISCUSSION OF THE VARIABILITY OF DIFFERENT RISK CALCULATORS

Agreement Among Cardiovascular Disease Risk Calculators

* The Absolute CVD Risk/Benefit Calculator

  • Framingham "Interactive Risk Score Calculator using lipids"
WHO? for the "general CV Risk" version, individuals 30 to 74 years old and without CVD at the baseline examination
WHAT? for the "general CV Risk" version, 10-year risk of CVD (coronary death, myocardial infarction, coronary insufficiency, angina, ischemic stroke, hemorrhagic stroke, transient ischemic attack, peripheral artery disease, heart failure)
WHO? people who are "healthy and without diabetes" when you don't have any lab values (cholesterol) available
WHAT? 10-year risk of CVD (coronary death, myocardial infarction, coronary insufficiency, angina, ischemic stroke, hemorrhagic stroke, transient ischemic attack, peripheral artery disease, heart failure)
WHO? people who are "healthy and without diabetes"
WHAT? risk of having a future heart attack, stroke, or other major heart disease in the next 10 years
WHO? people who do not already have a diagnosis of heart disease or stroke
WHAT? risk of having a heart attack or stroke over the next ten years
WHO? same as QRisk
WHAT? risk of diabetes, heart disease, or stroke over the next 10 years
WHO? individuals with type 2 diabetes not known to have heart disease
WHAT? 10-year risk of non-fatal and fatal CHD, fatal CHD, non-fatal and fatal stroke, fatal stroke

Other, less popular, tools:

WHO? people with type 2 diabetes without CAD
WHAT? 4-year probability of major CV event (CV death, non fatal MI and non fatal stroke)
WHO? almost anyone without CAD
WHAT? cardiometabolic age, 10-year CV CVD risk
WHO? patients who do not already have stable angina
WHAT? risk of dying within 5 years from cardiovascular disease, including both stroke and heart disease
WHO? patients with stable angina
WHAT? risk of having a heart attack, stroke or death over the next 5 years
WHO? identifies people free of cardiovascular disease most likely to develop it over ten years
WHAT? ASSIGN score = estimated risk percent of getting cardiovascular disease over ten years

By Patient Type

Definitions

CVD = coronary death, myocardial infarction, coronary insufficiency, angina, ischemic stroke, hemorrhagic stroke, transient ischemic attack, peripheral artery disease, heart failure
CHD = coronary death, myocardial infarction, coronary insufficiency, angina
CAD = CHD
TChol = LDL+HDL+TG/5
mg/dL --> mmol/L CONVERSION FACTOR: 38.6

Common Misconceptions and Sticking Points

  • Are hypertension, hyperlipidemia, diabetes "cardiovascular disease"? | No. These are risk factors for CV disease, but they aren't CV disease.
  • Carefully consider before estimating risk whether or not your patient is in a PRIMARY PREVENTION situation. If they already have CAD, you already know they're at "HIGH" risk, though you might not know how high.
  • Don't be fooled into using a tool designed for patients without CAD in a patient who has CAD
  • How do i figure out which tool(s) to use in my practice?

References & Further Reading

  1. Systematic Review of Guidelines on Cardiovascular Risk Assessment: Which Recommendations Should Clinicians Follow for a Cardiovascular Health Check? | Screening for High-Risk Cardiovascular Disease: A Challenge for the Guidelines
  2. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults
  3. Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease
  4. REACH Registry. JAMA. 2010;304(12):(doi:10.1001/jama.2010.1322)
  5. TRITON-TIMI38. N Engl J Med 2007;357:2001-15
  6. Canadian Dyslipidemia Guidelines. Can J Cardiol 2009;25:567-79
  7. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2009;151:474-482
  8. Critical appraisal of CRP measurement for the prediction of coronary heart disease events: new data and systematic review of 31 prospective cohorts. Int J Epidemiol 2009;38:217–231
  9. Improving the accuracy of predicting cardiovascular risk. BMJ 2010;340:c2334
  10. The Effect of Giving Global Coronary Risk Information to Adults. Arch Intern Med. 2010;170(3):230-239 | Providing Patients With Global Cardiovascular Risk Information: Is Knowledge Power?
  11. Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: a systematic review. Heart 2006;92:1752–1759.
  12. Barriers to Routine Risk-Score Use for Healthy Primary Care Patients. Arch Intern Med. 2010;170(8):719-724
  13. The Challenges and Benefits of Cardiovascular Risk Assessment in Clinical Practice. Canadian Journal of Cardiology 27 (2011) 481– 487
  14. Cardiovascular Risk Prediction in Diabetic Men and Women Using Hemoglobin A1c vs Diabetes as a High-Risk Equivalent
  15. Impact of Pharmacist Care in the Management of Cardiovascular Disease Risk Factors
  16. A community pharmacy-based cardiovascular screening service: views of service users and the public
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