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Launch of the MOH Clinical Practice Guidelines on Screening for Cardiovascular Disease and Risk Factors 23rd April 2011 Global Risk Assessment Dr Low Lip Ping Low Cardiology Clinic Global Risk Assessment • • • • • • Categories of Risk Absolute (Global) Risk Multivariable Risk Assessment Risk Scores Singapore Coronary Risk Score Managing Risk Groups Cardiovascular Risk Assessment Assessment of a patient's cardiovascular risk may be used for • the targeting of preventive treatments of individual patients who are asymptomatic but at increased risk for the development of CVD • adjustment of the intensity of risk reduction therapy to the level of risk Risk Categories • Appropriate application of preventive measures requires an understanding of the categories of risk • 3 risk categories often referred to viz absolute risk relative risk attributable risk. Absolute Risk • Absolute risk is also referred to as Global risk • Absolute risk defines the probability of developing disease over a finite period can be qualified as high or low can be either short-term (eg over 10 years) or long-term or even lifetime Relative Risk The relative risk (RR) is a measure of association between a disease or condition and a factor under study. It is calculated by dividing the incidence rate among those exposed to the factor by the incidence rate among those not exposed to the factor. RR = Incidence in the exposed Incidence in the nonexposed Attributable Risk Population attributable risk (PAR): is the portion of the incidence of a disease in the population (exposed and nonexposed) that is due to exposure. It is the incidence of a disease in the population that would be eliminated if exposure were eliminated. The PAR is calculated by subtracting the incidence in the unexposed from the incidence in total population (exposed and unexposed) Multivariable risk prediction Epidemiological studies have identified key risk factors that account for most CVD burden in the community, and demonstrated the clustering and conjoint influences of multiple risk factors in mediating cardiovascular risk. Risk of coronary disease by number of associated risk factors Multivariable risk prediction These research findings have been used to devise multivariable risk prediction tools that synthesize vascular risk factor information to yield estimates of absolute (global) CVD risk in individual patients These tools are also referred to as risk scores Multivariable risk prediction These risk scores can be used to assess in individual patients the absolute risk of developing all atherosclerotic CVD or specific components of CVD, ie, coronary heart disease, stroke, peripheral vascular disease, or heart failure.20 Importance of global CVD risk assessment • Cardiovascular prevention strategies may vary in benefit depending on the underlying level of cardiovascular risk. • The absolute reduction in risk is important to estimate, to adequately assess the risk versus benefit of any prevention strategy. Importance of global CVD risk assessment • If the relative risk reduction is equal across risk strata, the absolute reduction would be greater in a high-risk cohort than in a lowrisk cohort. • For this reason, it is very important to accurately estimate the cardiovascular risk Importance of global CVD risk assessment In addition to rendering treatment most costeffective, multivariable risk assessment also avoids overlooking high risk CVD individuals with multiple marginal risk factors and avoids needlessly alarming persons with only 1 isolated risk factor. High short-term CHD risk Might be • defined as a probability of developing a fatal or nonfatal myocardial infarction of >20% in the next 10 years • identified by the presence of clinical atherosclerotic disease in other arterial beds, by the presence of subclinical atherosclerosis, or by multiple risk factors. Risk Scores • Several algorithms or risk scores have been described to facilitate the assessment of risk in individual patients. • Most risk scores have included age, sex, blood pressure level, smoking status, diabetes mellitus, and lipid values. • Although obesity is a risk factor, it is frequently omitted because its influence is largely mediated through other cardiovascular risk factors in the short term (5- to 10-year timeline of most risk estimation algorithms). Table 1 Characteristics of the Various Cardiovascular Risk Scores Study FRS Variables Included Outcomes Age, sex, BP, CHD (angina, smoking, use of MI, sudden HTN death) medications, TC, and HDL Population Derived Population Validated ROC Limitations U.S. white men Men, women, 0.7744 (w) and women, blacks, Europe, 0.7598 (m) ages 30–62 yrs Mediterranean, and Asia Age <30 yrs, >65 yrs, JapaneseAmerican men, Hispanic men, NativeAmerican women, LVH, DM, and severe HTN 0.793 (w) 0.763 Mainly white (m) Global Age, sex, SBP, CHD, stroke, U.S. white men Framingham cardiovascular smoking, TC, CHF, or PVD and women, offspring risk HDL, DM, and ages 30–74 yrs use of HTN medications BMI = body mass index; BP = blood pressure; CABG = coronary artery bypass graft surgery; CHD = coronary heart disease; CVD = cardiovascular disease; DM = diabetes mellitus; FRS = Framingham risk score; HDL = high-density lipoprotein; hgb = hemoglobin; hsCRP = high-sensitivity C-reactive protein; HTN = hypertension; LVH = left ventricular hypertrophy; m = men; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angiography; ROC = receiver-operating characteristic; TC = total cholesterol; TIA = transient ischemic attack; w = women. Study SCORE ASSIGN Reynolds QRISK Reynolds, men Variables Included Outcomes Population Derived Population Validated ROC Limitations Age, sex, smoking, Fatal CV events European men and Europe either TC or TC/HDL women, ages 45–64 ratio, broken up into yrs areas of high and low CVD risk Age, sex, SBP, TC, CV death, CHD Scotland men and Scotland HDL, +family admission, CABG, or women, ages 30–74 history, social PTCA yrs deprivation Age, SBP, smoking, MI, stroke, coronary U.S. women, age >45 U.S. women total cholesterol, revascularization, or yrs HDL, hsCRP, CV death +family history, hgbAIc if DM 0.71–0.84 No nonfatal events, "single" risk factor measurements made, rather than "usual" 0.7841 (w) 0.7644 (m) Age, sex, SBP, smoking, ratio of TC/HDL, +family history, use of HTN medications, BMI, social deprivation Age, sex, SBP, smoking, total cholesterol, HDL, hsCRP, +family history, hgbAIc if DM 0.7879 (w) 0.7674 (m) Marginally better than Framingham, still overestimated risk Mainly white, all women, socioeconomic status not generalizable, BP, weight, and family history, all taken by self-report "Home advantage," data validated from same population it was originally derived MI, CHD, stroke, TIA United Kingdom men United Kingdom and women, ages 35– 74 yrs MI, stroke, coronary U.S. men, ages 50–80 U.S. men revascularization, or yrs CV death 0.808 (w) 0.7–0.714 (m) Mainly white, middle-aged, socioeconomic status and access to care not generalizable, selfreported with family history ASSIGN = Assessing Cardiovascular Risk to Scottish Intercollegiate Guidelines Network/SIGN to Assign Preventative Treatment; BMI = body mass index; BP = blood pressure; CABG = coronary artery bypass graft surgery; CHD = coronary heart disease; CVD = cardiovascular disease; DM = diabetes mellitus; FRS = Framingham risk score; HDL = high-density lipoprotein; hgb = hemoglobin; hsCRP = high-sensitivity C-reactive protein; HTN = hypertension; LVH = left ventricular hypertrophy; m = men; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angiography; ROC = receiver-operating characteristic; QRISK = QRESEARCH Cardiovascular Risk Algorithm; SBP = systolic blood pressure; SCORE = Systematic Coronary Risk Evaluation; TC = total cholesterol; TIA = transient ischemic attack; w = women. 3.2 Global cardiovascular risk assessment In asymptomatic individuals it is recommended that the risk of cardiovascular disease first be estimated based on the global assessment of risk Grade C, Level 2+ S The Framingham Risk Score adapted to the Singapore population should be used to give an estimate of an individual’s risk of major coronary artery disease events. Grade D, Level 4 Singapore CHD Risk Score • 10-Year CHD Risk Score for Chinese, Malay and Indian males and females in Singapore derived from the Framingham-based NCEP ATP III 10-Year Risk Score Tables which have been modified taking into account the Singapore cardiovascular epidemiological data. • The score gives an estimate of an individual’s risk of major coronary artery disease events, including myocardial infarction and coronary death Singapore CHD Risk Score These risk scores are derived from the Framingham-based NCEP ATP III 10-Year Risk Score Tables which have been modified taking into account the Singapore cardiovascular epidemiological data. This modification was carried out as part of a collaboration between investigators at the Singapore Ministry of Health, Singapore General Hospital, National University of Singapore and Prof. Ralph B D’Agostino from the Framingham Heart Study, USA. Table 2A-1 Estimation of 10-year coronary artery disease risk for men Allocate points based on person’s • • • • age, total and HDL cholesterol levels, smoking status and systolic blood pressure (BP). Check the total points against Table for estimate of that person’s 10-year CHD risk. Stratification for cardiovascular disease risk From the global cardiovascular assessment, asymptomatic individuals can be categorised into 3 risk group categories viz: • High risk (10-year CHD risk >20%) • Intermediate risk (10-year CHD risk 10-20%) • Low risk (10-year CHD risk <10%) For the purpose of risk assessment, the 10-year CHD risk refers to the risk of having myocardial infarction or coronary death in the next 10 years. Low risk asymptomatic individuals In low risk individuals (<10% 10year risk of coronary artery disease) further testing for coronary artery disease is not routinely recommended Grade C, Level 2++ Intermediate risk asymptomatic individuals Further testing for coronary artery disease to reclassify asymptomatic individuals in the intermediate risk group to high risk group needs to be considered because interventions to reduce cardiovascular risk is intensified as the risk category increases from low to high risk individuals Limitations of Singapore Coronary Risk Score • Substantial underestimation of lifetime risk, when only a 10-year risk model is used • Diabetes and family history not included • Only coronary risk estimated not all atherosclerotic disease eg stroke, peripheral arterial disease, heart failure Limitations of Singapore Coronary Risk Score • Misclassification of high-risk subjects as low or intermediate risk and of very low-risk subjects into higher strata of risk • Minority of patients with coronary heart disease have none of the traditional risk factors • In a large proportion of patients with >1 risk factors, coronary heart disease does not develop Change in risk status Periodic monitoring is needed to assess whether risk status has changed because absolute risk rises with advancing age, emergence of additional risk factors or development of atherosclerotic disease Original Singapore CHD Risk Score Step 1 Identify the following individuals who automatically fall into the High Risk Group: (1) Individuals with established CHD (2) Individuals with CHD Risk Equivalents defined as: (a) diabetes mellitus (b) atherosclerotic cerebrovascular disease, peripheral artery disease or abdominal aortic aneurysms (Estimation of the 10-Year CHD Risk Score in these individuals is not necessary). East West Study: Patients with Diabetes at Similar Risk to No Diabetes with MI p<0.001 7-year incidence rate of MI (%) 50 40 30 p<0.001 No prior MI MI 20 10 0 No diabetes (n=1373) Diabetes (n=1059) Adapted from Haffner SM et al. N Engl J Med 1998;339:229–234 Diabetic Patients The results of studies by Haffner which concluded that diabetes is a coronary artery disease risk equivalent because it is associated with an absolute risk equivalent to that for recurrent major coronary events in patients with established coronary artery disease have been accepted worldwide for a decade now. Diabetics have therefore been automatically assigned to the high risk category Diabetic Patients This view is now questioned by a metaanalysis by Bulugahapitiya et al. DIABETICMedicine 26, 142–148 (2009) Is diabetes a coronary risk equivalent? Systematic review and meta-analysis U. Bulugahapitiya, S. Siyambalapitiya, J. Sithole* and I. Idris DIABETICMedicine 26, 142–148 (2009) Is diabetes a coronary risk equivalent? Systematic review and meta-analysis A meta-analysis of 45,108 patients showed that patients with diabetes without prior myocardial infarction had a 43% lower risk of developing total coronary artery disease events compared with patients without diabetes with previous myocardial infarction (summary odds ratio 0.56, 95% confidence interval 0.53-0.60). Diabetic Patients • Their meta-analysis did not support the hypothesis that diabetes is a ‘coronary heart disease equivalent • The explanation for this discrepancy is likely to be that diabetic patients now receive optimal aggressive treatment strategy including, the use of statins and antihypertensive agents. Diabetic Patients People with diabetes should no longer be automatically assigned to the high risk category for cardiovascular risk. They should therefore be based on appropriate patients’ coronary artery disease risk estimates Grade A, Level 1++ Limitations of Singapore Coronary Risk Score • Only coronary risk estimated not all atherosclerotic disease eg stroke, peripheral arterial disease, heart failure General Cardiovascular Risk Score • Primary care physicians engaged in preventive health maintenance may want to assess risk of developing any major atherosclerotic CVD event using a general CVD risk assessment tool. Ralph B. D’Agostino, Sr, PhD; Ramachandran S. Vasan, MD; Michael J. Pencina, PhD; Philip A. Wolf, MD; Mark Cobain, PhD; Joseph M. Massaro, PhD; William B. Kannel, MD General Cardiovascular Risk Profile for Use in Primary Care The Framingham Heart Study Ralph B. D’Agostino, Sr, PhD; Ramachandran S. Vasan, MD; Michael J. Pencina, PhD; Philip A. Wolf, MD; Mark Cobain, PhD; Joseph M. Massaro, PhD; William B. Kannel, MD Circulation. 2008;117: 743-753 General Cardiovascular Risk Profile for Use in Primary Care The Framingham Heart Study General Cardiovascular Risk Profile for Use in Primary Care The Framingham Heart Study A sex-specific multivariable risk factor algorithm can be conveniently used to assess general CVD risk and risk of individual CVD events (coronary, cerebrovascular, and peripheral arterial disease and heart failure). Interactive Risk Calculator From The Framingham Heart Study CHD(MI and Coronary Death) Risk Prediction Enter Values Here National Cholesterol Education Program Adult Treatment Panel III Units (Type Over Placeholder Values in Each Cell) male (m) or female (f) years mg/dL mg/dL mmHg yes (y) or no (n) yes (y) or no (n) f 70 130 60 119 n y 10 years 10 0.03 3% Risk Factor Gender Age Total Cholesterol HDL Systolic Blood Pressure Treatment for Hypertension {Only if SBP>120} Current Smoker Time Frame for Risk Estimate Your Risk (The risk sco re sho wn is derived o n the basis o f an equatio n. Other NCEP materials, such as A TP III print pro ducts, use a po int-based system to calculate a risk sco re that appro ximates the equatio n-based o ne.) Notes If value is < the minimum for the field, enter the minimum value. If value is > the maximum for the field, enter the maximum value. 0.04 0.03 0.05 age Lowest Low age 32 37 42 47 52 57 62 67 0 0 0 0.01 0.02 0.03 0.05 0.07 0 0.01 0.01 0.02 0.04 0.06 0.08 0.1 32 37 42 47 52 57 62 67 77 0.12 0.16 77 0.10 0.15 0.20 0.25 Comparative Risks for Same Age and Gender Lowest=Total Chol<160, HDL>60, Optimal SBP, No Trt for Htn, Non-Smoker; Low=Total Chol 160-199, HDL 50-59, Normal SBP, No Trt for Htn, Non-Smoker 0.30 Tables for Graph Lowest 0.02 0.09 0.01 These functions and programs were prepared by Ralph B. D'Agostino, Sr., Ph.D. and Lisa M. Sullivan, Ph.D., Boston University and The Framingham Heart 0.09 Study and Daniel Levy, M.D., Framingham Heart Study, National Heart, Lung and Blood Institute. Your Risk Estimate, WOMEN Lowest=Total Chol<160, HDL>60, Optimal SBP, No Trt for Htn, Non-Smoker; Low=Total Chol 160-199, HDL 50-59, Normal SBP, No Trt for Htn, Non-Smoker 0.02 0.00 MEN Lowest = Total Chol<160, HDL>60, Optimal SBP (<120), No Trt for Htn, Non-Smoker Low = Total Chol 160-199, HDL 50-59, Normal SBP (<130), No Trt for Htn, Non-Smoker Low 0.02 0 0.02 Summary • Cardiovascular prevention strategies may vary in benefit depending on the underlying level of cardiovascular risk. • Assessment of a patient's cardiovascular risk may be used for the targeting of preventive treatments of individual patients who are asymptomatic but at increased risk for the development of CVD adjustment of the intensity of risk reduction therapy to the level of risk Summary • The absolute reduction in risk is important to estimate, to adequately assess the risk versus benefit of any prevention strategy. • Several algorithms or risk scores have been described to facilitate the assessment of risk in individual patients. • Most risk scores have included age, sex, blood pressure level, smoking status, diabetes mellitus, and lipid values. Summary People with diabetes should no longer be automatically assigned to the high risk category for cardiovascular risk. They should therefore be based on appropriate patients’ coronary artery disease risk estimates Summary In asymptomatic individuals it is recommended that the risk of cardiovascular disease first be estimated based on the global assessment of risk Grade C, Level 2+ The Framingham Risk Score adapted to the Singapore population should be used to give an estimate of an individual’s risk of major coronary artery disease events. Grade D, Level 4 Summary From the global cardiovascular assessment, asymptomatic individuals can be categorised into 3 risk group categories viz: • High risk (10-year CHD risk >20%) • Intermediate risk (10-year CHD risk 10-20%) • Low risk (10-year CHD risk <10%) For the purpose of risk assessment, the 10-year CHD risk refers to the risk of having myocardial infarction or coronary death in the next 10 years. Grade C, Level 2++ Summary In low risk individuals (<10% 10-year risk of coronary artery disease) further testing for coronary artery disease is not routinely recommended Grade C, Level 2++ Further testing for coronary artery disease to reclassify asymptomatic individuals in the intermediate risk group to high risk group need to be considered because interventions to reduce cardiovascular risk is intensified as the risk category increases from low to high risk individuals Summary • Periodic monitoring is needed to assess whether risk status has changed. • Suggested improvements in risk score application include development of a general CVD risk score, incorporation of dabetes and family history and development of an online interactive risk calculator