Download Cardiovascular Disease: Prevention in General Practice

Quality in Practice Committee
Cardiovascular Disease:
Prevention in General
Practice
Authors: Dr John Cox &
Professor Ian Graham
Disclaimer and Waiver of Liability
Whilst every effort has been made by the Quality in Practice Committee to ensure the accuracy
of the information and material contained in this document, errors or omissions may occur in the
content.
This guidance represents the view of the ICGP which was arrived at after careful consideration
of the evidence available.
The guide does not however override the individual responsibility of healthcare professionals
to make decisions appropriate to the circumstances of individual patients in consultation with
the patient and/or guardian or carer.
ICGP Quality in Practice Committee
QIP Committee 2013
Dr. Paul Armstrong (Chair), Dr. Patricia Carmody, Dr. Sheena Finn, Dr. Susan McLaughlin, Dr.
Ray O’Connor, Dr. Maria O’Mahony, Dr. Margaret O’Riordan, Dr. Ben Parmeter, Dr. Philip
Sheeran Purcell
Evidence-Based Medicine
Evidence-based medicine is the conscientious, explicit and judicious use of current best
evidence in making decisions about the care of individual patients.
In this document you will see that both the level of evidence and the strength of
recommendation of particular treatment options are classified using two different classification
systems; the European Society of Cardiology (ESC) – recommended method of evaluation
(Tables 1 and 2) and the GRADE rating system (Table 3).
In the 2012 European guidelines on cardiovascular disease prevention in clinical practice,1 the
Joint Task Force (JTF) chose to use both systems so that readers acquainted with the former
method and those preferring the GRADE system can find their individually adapted but still
congruent guidance in the combined recommendations tables.
GRADE uses a transparent and rigorous process to assess the quality of evidence in terms of
whether further research would or would not change confidence in the estimate of
intervention effects or diagnostic accuracy. Specific quality indicators are: study limitations;
inconsistency of findings; indirectness of evidence; imprecision; and publication bias (Table
3).2,3
Table of Contents
Page
1
Introduction
1.1
1.2
1.3
2
When to assess CVD risk
How to assess CVD risk & CVD risk assesment tools
SCORE
HeartScore
Relative Risk and Risk Age
CVD risk categories
1
3
4
5
12
13
Management of CVD risk
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4
1
1
1
CVD risk assessment
2.1
2.2
2.3
2.4
2.5
2.6
3
Definition
Background
Aim of this document
Smoking
Nutrition
Physical activity
Weight reduction
Hypertension
Diabetes
Lipids
References
14
16
17
18
19
23
23
25
1. Introduction
1.1 Definition
Cardiovascular disease (CVD) prevention can be defined as a coordinated set of actions, at population
and individual level, aimed at eradicating, eliminating or minimising the impact of cardiovascular
diseases and their related disability.
1.2 Background
CVD remains the leading cause of premature death worldwide. In Ireland, it accounts for 35% of all
deaths and more importantly, 20% of premature deaths (i.e. death in those under 65 years). 4
As most of theses patients are followed up in the primary care setting, the general practitioner is
ideally situated to carry out screening for and management of CVD risk factors in his or her practice.
This document provides a summary of the European guidelines on cardiovascular disease prevention
in clinical practice (version 2012) which were produced by the Fifth Joint Task Force of the European
Society of Cardiology (ESC) and Other Societies on Cardiovascular Disease Prevention in Clinical
Practice (constituted by representatives of nine societies, including the European Society of General
Practice/Family Medicine -ESGP/FM/WONCA- and by invited experts).1 The complete copy of these
guidelines is available at:
http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-CVDprevention.pdf
1.3 Aim of this document
The aim of this document is to give an update of the present knowledge in preventive cardiology for
general practitioners.
2. CVD Risk Assessment
2.1 When to assess CVD risk
A general practitioner should assess CVD risk in the following circumstances:
•
When a person asks for it.
•
In men ≥40 years, in women ≥50 years or if postmenopausal.
•
One or more of the following risk factors are present: smoking, poor food habits or
overweight, physical inactivity, hyperlipidaemia, hypertension or diabetes mellitus.
•
There is a family history of premature CVD (CVD in men under 55 and women under 65 years)
or of major risk factors such as hyperlipidaemia or diabetes.
•
There are symptoms suggestive of CVD
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Table 4 Risk estimation recommendations
Table 5 Age and gender recommendation
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2.2 How to assess CVD risk & CVD risk assessment tools
The following actions should be taken in CVD risk estimation:
•
History taking and clinical judgment.
•
Assess CVD risk using a relevant risk assessment tool e.g. SCORE chart or HeartScore unless
the person is already at high to very high risk because of documented CVD, diabetes,
moderate or severe chronic kidney disease or markedly raised single risk factors (total
cholesterol greater than 8 mmol/l or systolic blood pressure greater than 180 mmHg), in
which case immediate risk factor management is indicated.
General practitioners have a choice of a number of risk assessment tools available, including:
•
•
•
•
•
•
SCORE (Systemic Coronary Risk Estimation)
http://www.escardio.org/guidelines-surveys/escguidelines/GuidelinesDocuments/guidelines-CVD-prevention.pdf (Figure 1)
HeartScore http://www.heartscore.org/Pages/welcome.aspx
Framingham http://hp2010.nhlbihin.net/atpiii/calculator.asp
ASSIGN (CV risk estimation model from the Scottish Intercollegiate Guidelines Network)
http://assign-score.com/estimate-the-risk/visitors/
Q-Risk http://www.qrisk.org/
PROCAM (Prospective Cardiovascular Munster Study)
http://www.chdtaskforce.de/procam_interactive.html
All of these perform rather similarly. The current ESC Guidelines recommend the use of the SCORE
system or the HeartScore system. Risk charts such as SCORE and HeartScore are intended to facilitate
risk estimation in apparently healthy persons with no signs of clinical or pre-clinical disease.
Patients who have documented CVD, diabetes, moderate or severe chronic kidney disease or
markedly raised single risk factors (total cholesterol greater than 8 mmol/l or systolic blood
pressure greater than 180 mmHg), are already at very high or high risk and automatically qualify
for intensive risk factor evaluation and management.
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2.3
SCORE
Risk charts such as SCORE are intended to facilitate risk estimation in apparently healthy persons
with no signs of clinical or pre-clinical disease. SCORE assesses CVD risk using five variables; gender,
smoking status, age, systolic blood pressure and total cholesterol.
How to use the SCORE risk estimation charts:
Find the correct table for gender, smoking status and age. Within the table, find the cell nearest to
the person’s BP and total cholesterol. Risk estimates will need to be adjusted upwards as the person
approaches the next age category.
Figure 1: SCORE chart: 10-year risk of fatal cardiovascular disease (CVD) in countries at low CVD
risk including Ireland
With the decline in CVD mortality in many European regions, Ireland now falls into the low risk
category for risk of fatal cardiovascular disease. Up to recently, all SCORE charts used in this country
were based on the premise that Ireland was listed as a country at high CVD risk. These should now be
discarded. The correct version of the SCORE chart for use in Ireland, as given in Figure 1 can be found
on page 64 of the ICGP Yearbook and Diary 2013 or can be downloaded directly from
http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-CVDprevention.pdf
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2.4 HeartScore
HeartScore is an electronic CVD risk assessment tool. It replicates SCORE in an electronic format
using the same five variables as SCORE (gender, smoking status, age, systolic blood pressure, total
cholesterol) with the addition of a sixth variable - HDL.
HeartScore is free to access at http://www.heartscore.org/Pages/welcome.aspx
An example of how to use HeartScore is provided in the following screen shots:
Step 1:
• Enter HeartScore Website via http://www.heartscore.org/Pages/welcome.aspx
• Click “ Get started”
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Step 2
• Click “Europe low risk (English)”
With the decline in CVD mortality in many European regions, Ireland now falls into the low risk
category for risk of fatal cardiovascular disease. The present version of HeartScore (last accessed on
12/06/2013) does not reflect this, but this has been revised and will be updated shortly. For the
present, please ensure you click on “Europe low risk (English)” and follow the steps from there.
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Step 3
•
Click “Access HeartScore”
Step 4
•
Click “Join Now”
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Step 5
•
As an example, a male test patient has been used. This 60 year old male has a systolic blood
pressure of 160mmHg, total cholesterol of 6.5 mmol/L, HDL of 1.6 mmol/L and is a smoker.
•
Enter patient details
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HeartScore Results
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2.5 Relative risk and risk age
A young person with several cardiovascular risk factors (e.g. smoker, high systolic blood pressure,
raised total cholesterol) can have a low absolute risk because of his or her age and at the same time
be at a high relative risk of developing cardiovascular disease. Risk age illustrates the likely reduction
in life expectancy that such a young person will be exposed to if preventive measures are not
adopted.
Risk age can be estimated visually using the SCORE chart (Figure 1). For example, a 40 year old male
smoker with total cholesterol of 8 mmol/L and a systolic blood pressure of 180 mmHg has a SCORE
risk of only 2%, which is a low absolute risk. However, it can be seen from the same SCORE chart that
this risk of 2% is the same as that for a managed 60 year old with an ideal risk profile (non-smoker,
total cholesterol of 4 mmol/L and a systolic blood pressure level of 120 mmHg). Risk age is
automatically calculated by HeartScore (see results section “Actual Total CVD Risk Level” above).
A relative risk chart (Figure 2) is a useful tool for estimating relative risk. This can be helpful in
identifying and counselling young persons with several cardiovascular risk factors (e.g. smoker, high
systolic blood pressure, raised total cholesterol) of the need for lifestyle change, when absolute risk
levels are low. For example, it can be demonstrated using the relative risk chart below, that a person
in the top right-hand box who is a smoker with a total cholesterol of 8 mmol/L and a systolic blood
pressure of 180, has a risk that is 12 times higher than a person in the bottom left-hand box with an
ideal risk factor profile (i.e. non-smoker, total cholesterol of 4 mmol/L and systolic blood pressure
120 mmHg).
Figure 2: Relative risk chart for 10 year mortality
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2.6 CVD risk categories
Cardiovascular risk assesment is used as a guide to dictate the appropriate treatment intervention.
There are four categories of risk as depicted in the table below; low risk, moderate risk, high risk and
very high risk. Please note that the terms “SCORE” and “HeartScore” are interchangable in the table
below.
Figure 3: Cardiovascular Risk Categories
Low risk and moderate risk categories are decided purely on a SCORE or HeartScore of < 1% or
between 1 – 5 % respectively.
Patients who have documented CVD, diabetes, moderate or severe chronic kidney disease or
markedly raised single risk factors (total cholesterol greater than 8 mmol/l or systolic blood pressure
greater than 180 mmHg), are at already at very high or high risk and automatically qualify for
intensive risk factor evaluation and management.
“Documented CVD” refers to CVD diagnosed by means of invasive or non-invasive testing (such as
coronary angiography, nuclear imaging, stress echocardiography or carotid plaque on ultrasound),
previous myocardial infarction, acute coronary syndrome, coronary revascularization and other
arterial revascularization procedures, ischaemic stroke and peripheral artery disease.
“Diabetes mellitus” includes type 1 or type 2 and “end organ damage in diabetic patients” includes
the presence of microalbuminuria of 30–300 mg/24 h.
“Severe chronic kidney disease” refers to an eGFR of less than 30 mL/min/1.73 m2 and “moderate
chronic kidney disease” refers to an eGFR 30–59 mL/min/1.73 m2.
“Markedly elevated single risk factors” include “familial dyslipidaemias” where total cholesterol is
greater than 8 mmol/l and “severe hypertension” is defined as systolic blood pressure greater than
180 mmHg.
Other risk assessment recommendations:
• Genetic testing has no place in CVD risk assessment (III, B, Strong)
• Psychosocial factors should be taken into account in risk assessment (IIA, B, Strong)
• Fibrinogen, high sensitivity CRP and / or homocysteine may be measured as part of a refined
risk assessment in patients with an unusual or moderate CVD risk profile (IIB, B, Weak)
• In patients with a moderate CVD risk profile the use of carotid IMT, ABI (ankle-brachial index)
(IIA, B, Strong) or CT-scan calcium score (IIA, B, Weak) may be considered
• Risk assessment should be conducted in patients with sleep-apnoeic disease (IIA, A, Strong),
or those with erectile dysfunction (IIA, B, Strong)
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3. Management of CVD Risk
3.1 Smoking
All smoking, including exposure to passive smoking has to be avoided. All smokers should be advised
to quit and offered assistance with pharmacotherapy as required.
Table 6: Smoking recommendations
Assessing whether the person is willing to try to quit, brief reiteration of the cardiovascular and other
health hazards, and agreeing on a specific plan with a follow-up arrangement are the decisive first
steps of the brief initial advice in clinical practice (Figure 4).
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Figure 4: Modified World Health Organization (WHO) smoking cessation algorithm.
General practitioners will find the patient information leaflet “Just be smoke free” from the Irish
Cancer Society to be especially useful. This can be viewed on
http://www.cancer.ie/sites/default/files/content-attachments/hp_smoke_free.pdf
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3.2 Nutrition
A healthy diet is recommended as being the cornerstone of CVD prevention:
Table 7: Nutrition recommendations
•
Saturated fatty acids to account for <10% of total energy intake, through replacement by
polyunsaturated fatty acids.
•
Trans unsaturated fatty acids: as little as possible, preferably no intake from processed food,
and <1% of total energy intake from natural origin
•
<5 g of salt per day.
•
30 – 45 g of fibre per day, from wholegrain products, fruits and vegetables.
•
200 g of fruit per day (2-3 servings).
•
200 g of vegetables per day (2-3 servings).
•
Fish at least twice a week, one of which to be oily fish.
•
Consumption of alcoholic beverages should be limited to 21 units (men), 14 units (women)
per week
General practitioners and practice nurses will find the patient information leaflet “HEALTHY EATING
to reduce your risk of heart disease and stroke” published by the Irish Heart Foundation to be
especially useful. This can be downloaded at:
http://www.irishheart.ie/media/pub/informationleaflets/healthy_eating_2011__final.pdf
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3.3 Physical activity
Healthy adults of all ages should spend 2.5-5 hours a week on physical activity of at least moderate
intensity (optimally 30 minutes or more daily, but any physical activity is better than none).
Table 8: Physical activity recommendations
Again, general practitioners and practice nurses will find the patient information leaflet “BE ACTIVE
and reduce your risk of heart disease and stroke” published by the Irish Heart Foundation to be
especially useful. This can be downloaded at:
http://www.irishheart.ie/media/pub/informationleaflets/be_active_2011__final.pdf
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3.4 Weight reduction
Both being overweight and obesity are associated with a risk of death from CVD.
Table 9: Weight recommendation
•
Weight reduction in overweight (BMI > 25 kg/m2) and especially in obese (BMI > 30 kg/m2)
people is recommended as this is associated with favourable effects on blood pressure and
dyslipidaemia, which may lead to a more favourable cardovascular risk profile.
•
Action level 1—waist circumference ≥94 cm in men and ≥80 cm in women represents the
threshold at which no further weight should be gained.
•
Action level 2—waist circumference ≥102 cm in men and ≥88 cm in women represents the
threshold at which weight reduction should be advised.
Information on nutrition, physical activity and weight reduction an can be easily conveyed to the
patient using the Irish Heart Foundation patient information leaflet “LOSE WEIGHT to reduce your
risk of heart disease and stroke” which can be viewed on:
http://www.irishheart.ie/media/pub/informationleaflets/lose_weight_2011__final.pdf
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3.5 Hypertension
Elevated BP is a major risk factor for cardiovascular disease, heart failure, cerebrovascular disease,
peripheral arterial disease, renal failure, and atrial fibrillation. In the absence of a European
Hypertension Society guideline on the management of hypertension since 2007, the 2011 National
Collaborating Centre for Chronic Conditions (NICE) guideline on hypertension entitled Hypertension:
clinical management of primary hypertension in adults18 is recommended. This can be accessed at
http://guidance.nice.org.uk/CG127 . The following is a short summary of this guideline.
Blood pressure targets (non-diabetic patients)
Clinic blood pressure measurement (CBPM):
•
•
People aged under 80 years : < 140/90 mmHg
People aged over 80 years: <150/90 mmHg
Daytime average ambulatory blood pressure measurement (ABPM) or home blood pressure
measurement (HBPM) during the person’s usual waking hours
•
•
People aged under 80 years: <135/85 mmHg
People aged over 80 years:
<145/85 mmHg
See Section 3.6 for blood pressure targets in diabetic patients.
Measurement of blood pressure - While blood pressure measurement in the clinic remains part of
risk assessment, the NICE Guidelines18 give more emphasis to ABPM in the diagnosis of hypertension.
The first step in the diagnosis of hypertension remains the measurement of blood pressure in the
clinic setting (CBPM). Blood pressure should be measured in both arms initially and if the difference
in readings between arms is more than 20 mmHg on repeated measurement, the arm with the
higher readings should be used for all subsequent blood pressure recordings. If CBPM is 140/90
mmHg or higher, a second measurement should be taken during the consultation and if the second
measurement is substantially different from the first, a third measurement should be taken and the
lower of the last two measurements used as the clinic blood pressure. The diagnosis of severe
hypertension is based solely on a clinic systolic blood pressure of 180 mmHg or higher, or clinic
diastolic blood pressure of 110 mmHg or higher. This group should be started on antihypertensive
drug treatment without waiting for the results of ABPM or home blood pressure monitoring (HBPM).
ABPM is now recommended for the diagnosis of hypertension in all patients where the clinic blood
pressure is 140/90 mmHg or higher. Moreover, specific information is given on the number of
measurements required. Thus at least two measurements per hour taken during the person’s usual
waking hours e.g. between 08:00 and 22:00 are recommended. The average value of at least 14 such
measurements is taken as the ABPM level for diagnosis.
When ABPM is not available or is not acceptable to the patient, HBPM can be used. Care should be
taken to ensure that for each blood pressure recording, two consecutive measurements are taken, at
least 1 minute apart with the person seated. Blood pressure should be recorded twice daily, ideally in
the morning and evening for at least 4 days, (ideally for 7 days).Measurements taken on the first day
are discarded and the average value of all the remaining measurements is used for the diagnosis of
hypertension.
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The role of ABPM/ HBPM in the diagnosis of hypertension is summarised in Figure 6.
Figure 6: Care pathway for hypertension
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As can be seen from Figure 6, stage 1 hypertension is present when the clinic blood pressure is
140/90 mmHg or higher and subsequent ABPM daytime average (or HBPM average) blood pressure
is 135/85 mmHg or higher. Stage 2 hypertension is present when clinic blood pressure is 160/100
mmHg or higher and subsequent ABPM daytime average (or HBPM) average blood pressure is
150/95 mmHg or higher.
Initiating treatment- According to the new guideline, antihypertensive drug treatment is offered to
people of any age with stage 2 hypertension, i.e. CBPM 160/100 mmHg or higher and subsequent
ABPM daytime average (or HBPM average) blood pressure is 150/95 mmHg or higher.
In those with stage 1 hypertension, antihypertensive drug treatment is recommended for people
aged less than 80 years who have one or more of the following:
− target organ damage e.g. left ventricular hypertrophy, hypertensive retinopathy
− established cardiovascular disease e.g. ischaemic heart disease or cerebrovascular disease.
− renal disease e.g. chronic kidney disease stage 1 to 5 as diagnosed on eGFR.
− diabetes (See Section 3.6)
− a 10-year cardiovascular risk equivalent to 20% or greater, (Joint British Societies Cardiovascular
Disease Risk Assessment Charts) which would be equivalent to a 10 year risk of fatal CVD of 5% or
greater using HeartScore.
Because risk assessments can underestimate the lifetime risk of cardiovascular events in people aged
under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular
disease, renal disease or diabetes, it is recommended that specialist evaluation of secondary causes
of hypertension and a more detailed assessment of potential target organ damage should be
arranged.
Antihypertensive drug treatment - The by now familiar “A (B) CD” algorithm from previous versions
of the NICE guideline on hypertension has been simplified to an “AC” algorithm (see Figure 7).
Figure 7: Summary of antihypertensive drug treatment
Aged under
55 years
Aged over 55 years
or black person of
African or Caribbean
family origin of any
age
C2
A
Summary of
antihypertensive
drug treatment
Step 1
A + C2
Step 2
A+C+D
Step 3
Resistant hypertension
Step 4
Key
A – ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C – Calcium-channel blocker
(CCB)
D – Thiazide-like diuretic
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
See slide notes for details of
footnotes 1-5
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(1) If an ACE inhibitor is prescribed and is not tolerated (e.g. because of cough), a low-cost ARB
should be offered.
(2) For second line therapy, a CCB should be offered, but a thiazide-like diuretic can be
considered if a CCB is not tolerated or if the patient has oedema, evidence of heart failure or
a high risk of heart failure.
(3) A low dose of spironolactone can also be considered
(4) Alternatively, a higher doses of a thiazide-like diuretic can also be considered.
(5) An alpha-blocker or beta-blocker should be considered if further diuretic therapy is not
tolerated, is contraindicated or is ineffective.
The NICE guideline also makes a number of general recommendations on drug treatment.
• Non-proprietary drugs taken only once a day should be offered if possible.
• People aged over 80 years should be offered the same antihypertensive drug treatment as
people aged 55–80 years, taking into account any comorbidities.
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)
should not be combined.
• If treatment with a diuretic is being started, or changed, a thiazide-like diuretic, such as
chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or
2.5 mg once daily) is recommended in preference to a conventional thiazide diuretic such as
bendroflumethiazide or hydrochlorothiazide. However, those whose blood pressure is stable
and well controlled on treatment with bendroflumethiazide or hydrochlorothiazide can
continue treatment with same.
• Beta-blockers are not preferred in step 1. However, they may be considered for younger
people if ACE inhibitors and ARBs are contraindicated or not tolerated or there is evidence of
increased sympathetic drive, and for women of child-bearing potential.
• For black people of African or Caribbean family origin, consider an ARB in preference to an
ACE inhibitor, in combination with a CCB for step 2 treatment
• If a beta-blocker was used in step 1, add a CCB rather than a thiazide-type diuretic for step 2,
to reduce the risk of developing diabetes.
• Regard clinic blood pressure that remains at 140/90 mmHg or higher after step 3 treatment
with optimal or best tolerated doses as resistant hypertension.
• For step 4 treatment, further diuretic therapy with low-dose (25 mg once daily)
spironolactone if blood potassium level is 4.5 mmol/l or lower can be considered. Particular
caution should be exercised in people with a reduced eGFR, because of increased risk of
hyperkalaemia. Where blood potassium levels are higher than 4.5 mmol/l, a higher-dose
thiazide-like diuretic should be offered. Sodium and potassium and renal function should be
checked within1 month and repeated as required thereafter.
• If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an
alpha- or beta-blocker. However, if blood pressure remains uncontrolled with optimal or
maximum tolerated doses of four drugs, expert advice should be obtained.
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Monitoring response to treatment
CBPM should be used to monitor the response to treatment. However, for people identified as
having a ‘white-coat effect’ (defined as a discrepancy of more than 20/10 mmHg between clinic and
average daytime ABPM or average HBPM measurements at time of diagnosis), ABPM or HBPM
should be considered as an adjunct to CBPM to monitor the response to treatment. This should be
done annually initially and the frequency thereafter can be determined by the response to
treatment.
3.6 Diabetes
The target for antihypertensive treatment in diabetic patients should be ≤ 140/80 mmHg
Intensive management of hyperglycaemia in diabetes reduces the risk of microvascular complications
and, to a lesser extent, that of cardiovascular disease.
Table 10: Diabetes mellitus recommendations
3.7 Lipids
The 2011 European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) Task
Force guideline for the management of dyslipidaemias, published in mid 2011, 25 are recommended.
This can be assessed by clicking on: http://www.escardio.org/guidelines-surveys/escguidelines/GuidelinesDocuments/guidelines-dyslipidemias-FT.pdf
In patients at very high CVD risk, the recommended LDL cholesterol target is <1.8 mmol/L or a ≥50%
LDL-cholesterol reduction when the target level cannot be reached. In patients at high CVD risk, a
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LDL-cholesterol goal <2.5 mmol/L is recommended. In those at moderate risk (SCORE level > 1 and >
5%) a LDL-cholesterol goal <3.0 mmol/L is recommended.
In addition, the main points from this guideline are to be found on page 61 of the ICGP Yearbook and
Diary, 2013.
Figure 8: Guide to lipid management
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4. References
(1) Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on
cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the
European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical
Practice (constituted by representatives of nine societies and by invited experts). Eur.Heart J. 2012
Jul;33(13):1635-1701.
(2) Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ. GRADE: an
emerging consensus on rating quality of evidence strength of recommendations. BMJ 2008;336:924–
926.
(3) Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ. What is ‘quality of
evidence’ and why is it important to clinicians? BMJ 2008;336: 995–998.
(4) Department of Health and Children. Changing Cardiovascular Health. National Cardiovascular
Health Policy 2010 – 2019. May 2010. Available from:
http://www.dohc.ie/publications/pdf/changing_cardiovascular_health.pdf?direct=1
(5) Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, et al. Evidence-based guidelines for
cardiovascular disease prevention in women: 2007 update. Circulation 2007 Mar 20;115(11):14811501.
(6) Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, et al. European guidelines on
cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the
European Society of Cardiology and other societies on cardiovascular disease prevention in clinical
practice (constituted by representatives of nine societies and by invited experts).
Eur.J.Cardiovasc.Prev.Rehabil. 2007 Sep;14 Suppl 2:S1-113.
(7) Jousilahti P, Vartiainen E, Tuomilehto J, Puska P. Sex, age, cardiovascular risk factors, and coronary
heart disease: a prospective follow-up study of 14 786 middle-aged men and women in Finland.
Circulation 1999 Mar 9;99(9):1165-1172.
(8) Thun MJ, Myers DG, Day-Lally C, Namboodin MM, Calle EE, Flanders WD, Adams SL, Heath CW.
Age and the exposure–response relationshipsbetween cigarette smoking and premature death in
Cancer Prevention Study II. Changes in Cigarette-Related Disease Risks and Their Implications for
Prevention and Control. Smoking and Tobacco Control Monograph No. 8. Bethesda, MD: US
Department of Health and Human Services, Public Health Service, National Institutes of Health,
National Cancer Institute; 1997. 383–413.
(9) He J, Vupputuri S, Allen K, Prerost MR, Hughes J, Whelton PK. Passive smoking and the risk of
coronary heart disease--a meta-analysis of epidemiologic studies. N.Engl.J.Med. 1999 Mar
25;340(12):920-926.
(10) Lightwood JM, Glantz SA. Declines in acute myocardial infarction after smoke-free laws and
individual risk attributable to secondhand smoke. Circulation 2009 Oct 6;120(14):1373-1379.
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