Cardiovascular disease risk assessment -1.pptx

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1. Cardiovascular Risk Assessment for Health Professionals In Ethiopia December 2020

2. Unit 1: INTRODUCTION CVDs : are number one cause of death globally 17.9 million people deaths from CVDs in 2016, ( 31% of all global deaths). 80% occur in low- and middle-income countries, often in people less than 60 years of age. CVDs are rising alarmingly in Ethiopia on top of already existing CVDs like Rheumatic heart diseases, cardiomyopathy and cor-pulmonale .

3. Introduc .. CVDs are preceded by longtime exposure to single or combined risk factors which can be modifiable or non-modifiable. Continuing exposure to these risk factors leads to further progression of cardiovascular diseases which include one or more of the following: Coronary artery disease (CAD) manifested by fatal or nonfatal myocardial infarction (MI), angina pectoris, and/or heart failure Cerebrovascular disease manifested by fatal or nonfatal stroke and transient ischemic attack Peripheral artery disease manifested by intermittent claudication and critical limb ischemia Aortic atherosclerosis and thoracic or abdominal aortic aneurysm

4. Introduc .. Early identification, control and avoidance of the modifiable risk factors can significantly reduce or retard the progression of cardiovascular diseases . C ontrol of the risk factors before development of CVDs is the most cost effective and applicable intervention especially for low income countries likes Ethiopia. Several attempts were made globally and nationally for the control of these risk factors for reducing development of cardiovascular diseases.

5. Introduc … Single versus Multiple Risk factors approach Previous guidelines did not take into consideration some important facts: that multiple risk factors are responsible for cardiovascular disease, that risk factors and determinants of heart attacks and strokes are very similar, and, therefore, prevention approaches are similar. The new guidelines integrate the management of multiple risk factors e.g. raised blood pressure, raised cholesterol, and raised blood sugar and tobacco use.

6. Introduction.. Multiple risk factor-interventions targeting individuals with high baseline cardiovascular risk are cost effective especially in low income countries like ours. Though the presence of one risk factor may increase the chance of having future CV event, this chance of developing CVDs is variably influenced by the presence or absence of other risk factors. Therefore treatment decision of the single risk factor is better made on the analysis of the combined effect of the total risk factor than the sole magnitude of the single risk factor.

7. Unit 2.CARDIOVASCULAR RISK ESTIMATION Current components of management of individual CV risk factors for prevention of atherosclerosis and CVD include : CV risk assessment. Treatment of those at high risk for disease. Management adjusted to patient’s total risk of CHD or CVD; the higher the risk, the greater the intensity of management. Employment of a range of interventions to address risk factors for CVD

8. CV Risk Estimation.. No single absolute test or score used to predict the future development of CVDs. A general estimate of the relative risk for CVD can be approximated by counting the number of traditional risk factors present in a patient The increased risk of CVD resulting from multiple risk factors is frequently greater than simply additive. Hence we need a more precise estimation of the absolute risk for a first CVD event desirable when making treatment recommendations for a specific individual.

9. CV risk Estimation… The total risk approach relies on risk prediction scores derived from large epidemiologic cohort studies involving diverse groups of individuals with risk factors but with no CVDs at baseline. Score are developed after long years of follow up These prediction scores have been developed and validated primarily in high-income countries and subsequently adapted to other populations after re-calibration The World Health Organization (WHO) and the International Society of Hypertension (ISH) recently developed a set of CV risk prediction charts for use in all regions of the world

10. CV Risk Estimation.. The first WHO risk prediction chart was developed in 2007 and recent update was made in 2019. The world was divided into 21 GBD regions and Ethiopia is represented by the Eastern Sub-saharan African Region. It was suggested by the WHO working group of CV risk prediction chart that each country should adapt the risk chart to its national context. It is with this basis that the national CV working group developed this risk charts to be used in Ethiopia.

11. Case Study Case study 1 – A 40 year old smoker was evaluated at health center and had a BP of 130/85 and has no history or physical findings of previous stroke, heart failure, MI or diabetes mellitus. The second case was a 50 years nonsmoker with BP of 120/80 with no history or findings of stroke, heart failure, and diabetes mellitus but was diagnosed to have myocardial infarction 5 years ago.

12. Case study.. Q. 1.List the cardiovascular risk factors in these patients. 2. How do compare future cardiovascular risk of these two patients? Which one has higher risk and why? 3. For which patient WHO risk prediction chart is applicable?

13. Unit 3: WHO CV RISK CHARTS:

14. 1. Definitions of terms: CV risk : in the WHO risk assessment CV risk refers to the chance of having fatal or nonfatal heart attack or stroke in the next 10 years with the current risk profile of the patient. CV risk factors are any biologic or environmental conditions known to increase the inherent risk/chance of having CV event. They are classified into modifiable and non-modifiable risk factors.( See Table below)

15. CV risk Factors

16. Defini .. Cardiovascular disease (CVD) : is manifested cardiovascular event (stroke, heart attack, peripheral arterial or aortic disease). Risk chart : is collection of tables of risk estimates with different types and levels of risk factors. Primary Prevention : This is control of risk factors before cardiovascular disease develops. Secondary Prevention : Prevention of further occurrence or progression of previous cardiovascular disease.

17. 2. Types of WHO risk charts WHO risk charts were developed for estimation of the chance of future cardiovascular event in those individuals who never had cardiovascular diseases. It does not apply for patients who have already developed cardiovascular diseases. There are two types of WHO risk charts based on availability of laboratory facility to measure blood glucose and cholesterol levels

18. Laboratory-based WHO CVD risk charts These are CVD risk charts that include measurements of total cholesterol and information on diabetes mellitus . The laboratory-based CVD risk charts should be used for treatment decisions. This is the indicated risk chart in a setting where laboratory facilities and human and financial resources are accessible. These charts will facilitate health providers to initiate an intervention and treatment regimen, and to implement an appropriate follow-up plan based on the patient’s total risk status.

19. Parameters needed for Lab Based WHO Risk Chart The variables needed for using this chart are as follows: History : Age : specific numbers between 40 to 74 years. The risk prediction doesn’t apply for age category out of the specified range Smoking : current smoking Sex : Male OR Female Diabetes : Yes OR No. If history of diabetes is not known OR there is no blood sugar determination facility; then risk assessment should be done using the other risk prediction chart (non-laboratory based charts) Physical Examination Blood Pressure: measured value of the systolic blood pressure

20. Laboratory parameters for Lab Based WHO Risk Chart Blood sugar: to diagnose diabetes Total cholesterol: Measured valves of total cholesterol. In most of the Ethiopian Laboratories, total cholesterol is in mg/dl units; but the risk prediction score applies values in mmol /l units. The cholesterol value in mg/dl should be multiplied by 0.02586 before applying the value for risk prediction.

21. B.Non -laboratory-based WHO risk charts Many low-resource settings have limited testing facilities or limited financial and physical capacity for biochemical measurements (e.g. blood sugar determination and cholesterol assays). WHO CVD risk (non-laboratory-based) charts can be used to predict total CVD risk without information on total cholesterol and diabetes. In most primary health care facilities of Ethiopia, laboratory facilities exist to diagnose diabetes either with fasting or random blood glucose levels.

22. Non Lab.. If the patient is not diabetic, the non- laboratory based WHO risk chart correlates well with laboratory based risk chart when a 10 % cut of point is used as high risk. The non-laboratory-based WHO CVD risk charts are aimed at stratification in low-resource communities and office settings and can be used for decisions regarding referral. Patients diagnosed to have diabetes and non-diabetic patients with non-lab based risk level of greater than 10% should be considered high risk and managed accordingly in areas where serum cholesterol cannot be determined.

23. Variables for Non Lab based WHO Risk Chart To use this chart, the following variables should be available: History : Age : specific numbers between 40 to 74 years. The risk prediction doesn’t apply for age category out of the specified range Smoking : current smoking Sex : Male OR Female Physical Examination Blood Pressure: measured value of the systolic blood pressure BMI (Body Mass Index): Calculation of the BMI from weight and height. NO LABORATORY MEASUREMNET PARAMETER REQUIRED!

24. Figure 2: Steps in selecting appropriate Chart for WHO CV risk assessment

25. Unit 4: INSTRUCTIONS FOR USING THE WHO CVD RISK CHARTS

26. 1. Laboratory- based Risk Chart These charts are to be used only for individuals whose status regarding diabetes and total cholesterol is available. Tests for diabetes and cholesterol can be carried out at the time of assessment. If the information on diabetes and total cholesterol is not available, then refer to the instructions on use of non-laboratory-based risk charts

27. Instructions for using laboratory based WHO risk Chart

28. Step by Step Instructions for using laboratory based WHO risk Chart

29. Laboratory based WHO risk Chart

30. Examples :

31. 2. Non-laboratory-based Who risk charts These charts are for the use in settings where blood glucose and cholesterol cannot be measured. They can also be used to identify people at high risk who can be taken up for further investigations. Table 2 and Figure 3 present the steps to apply the non-laboratory WHO CVD risk charts .

32. Table 4: Instructions for using Non laboratory based WHO risk Chart

33. Step by Step Instructions for using Non-laboratory based WHO risk Chart

34. Non Laboratory based WHO risk Chart

35. Examples of Non laboratory based Risk Chart

36. Unit 5: APPLICATIONS OF WHO RISK CHARTS

37. A. For Whom? As stated above the WHO risk chart applies for patients who haven’t been diagnosed to have cardiovascular diseases like stroke, heart attack, peripheral arterial or aortic diseases. For patients with cardiovascular diseases, management should include specific disease management and more intense risk factor management with life style interventions and pharmacologic agents.

38. B. Specific Applications 1. Hypertension ( See HTN treatment protocol for details) Target blood pressure should be less than 140/90mmHG. For patients with high WHO risk (> 10% with non-lab based and >20% with lab based WHO risk), drug should be started to lower BP below 130/80 on top of life style intervention For patients with BP of 140-159/90-99 mmHG and no end-organ damage or cardiovascular diseases drug can be started after 3 months trial of life style interventions to keep BP <140/90mmHG For any WHO risk level and BP >160/100mmHG drug should be started to lower BP below 140/90 on top of life style intervention

39. B. Specific Recommendation 2. Statin Treatment Indications Patients with high CVD risks (>20% with lab-based and >10 % with non-lab based WHO risk Charts). All patients with TC of 324mg/dl or serum LDL of > 190 if lab is available. All diabetic patients older than 40 years should receive statin regardless of WHO risk level or serum cholesterol level Dose: Atrovstatin 20mg/day, Simvastatin 40mg/day for primary prevention of CV events. For patients with previous cardiovascular events double the above doses.

40. B. Specific Recommentat .. 3. Life style interventions All individuals should be encouraged to engage in healthy life style (see specific topic for details) at any risk level. If CVD risk is < 10% and no CVD risk factors, reassess CVD risk after 5 years. Patients with any behavioral (unhealthy diet, smoking, excess alcohol intake, sedentary life) and physiologic risk factors (obese or patients with metabolic syndrome) should be routinely evaluated for control of these risk factors and have annual CV risk assessment.

41. B. Specific Recommentat 4. For policy makers, Monitoring and evaluation of CVD interventions WHO risk can be used for baseline cardiovascular risk assessment at national, regional and facility level to assess the impacts of CV interventions at national and subnational levels.

42. Management guidance for total CVD risk

43. Case Studies on Using WHO Risk Charts:

44. Case Study 1 A 65 year old female individual found to have a weight of 86kg, height of 166cm, BP of 145/80 at one of remote health centers with no facility for laboratory evaluation.

45. Questions Q1. What further information do you need to calculate her future CV risk? On further inquiry she is found to be non-smoker and had no previous cardiovascular problems. Q2. Which chart will use to calculate her future cardiovascular risk? Q3. What is her 10 year future CV risk? Q4. How do you define her risk level? Q5. How will you communicate about the risk level with the patient?

46. Case Study 2 Ato Yalew is a 43year old male teacher at Bure high school . He was evaluated at Bure hospital and was found to have a weight of 72kg, height of 174cm, BP of 160/100 . He is smoker for greater than 10 years. His total cholesterol was 267mg/dl and his fasting blood glucose was 98mg/dl Q1

47. Case study 2…. Q1. What risk factors does Ato Yalew have? Q2. Which chart will use to calculate his future cardiovascular risk? Q3. What is his 10 year future CV risk? Q4. How do you define his risk level? Q5. How will you communicate about the risk level with the patient?

48. Case Study 3 Ato Abdi is a 53year old male farmer living in one of rural kebles in West Harege Zone . On examination at Woreda health center he had a weight of 66kg, height of 168cm, BP of 130/170 . He usually chews chat and smokes cigarettes . His total cholesterol and FBS couldn’t be determined.

49. Case study 3.. Q1 . What risk factors does Ato Abdi have? Q2. Which chart will use to calculate his future cardiovascular risk? Q3. What is his 10 year future CV risk? Q4. How do you define his risk level? Q5. How will you communicate about the risk level with the patient?

50. Case Study 4 W/o Amina is 65 years old woman who was found to have a weight of 75kg, height of 160cm, BP of 180/100 at one of health centers in Addis Ababa . She is known to be diabetic on insulin and her total cholesterol was 320mg/dl.

51. Case Study 4… Q1. What CV risk factors does W/o Amina have? Q2. Which chart will use to calculate her future cardiovascular risk? Q3. What is her 10 year future CV risk? Q4. How do you define her risk level? Q5. How will you communicate about the risk level with the patient?