CVD Prevention

 

Identifying and assessing cardiovascular (CVD) risk

For the primary prevention of CVD in primary care, use a systematic strategy to identify people who are likely to be at high risk

Prioritise people for a full formal risk assessment if their estimated 10-year risk of CVD is 10% or more

Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years

Do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate (eGFR) less than 60 ml/ml/min/1.73m2 and/or albuminuria.  These people are at increased risk of CVD

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Drug-based prevention of CVD

Lipid modification therapy

Before starting lipid modification therapy for the primary prevention of CVD:

  1. Take at least 1 lipid sample to measure a full lipid profile
    1. This should include measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol, and triglyceride concentrations. A fasting sample is not needed
  2. Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD
    1. Estimate the level of risk using the QRISK2 assessment tool
  3. Start statin treatment in people with CVD with atorvastatin 80 mg.  Use a lower dose of atorvastatin if any of the following apply:
    1. potential drug interactions
    2. high risk of adverse effects
    3. patient preference
  4. Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment (both primary and secondary prevention, including atorvastatin 20 mg for primary prevention) at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol
  5. If a greater than 40% reduction in non-HDL cholesterol is not achieved:
    1. discuss adherence and timing of dose
    2. optimise adherence to diet and lifestyle measures
    3. consider increasing dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement

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Familial lipid disorders

NICE recommends the use of QRISK, clinical findings, lipid profile and family history to judge the likelihood of a familial lipid disorder rather than the use of strict lipid cut off values alone

The use of 5.0 mmol/L as a cut-off for total cholesterol is neither a reference range, appropriate risk threshold or a treatment target – the NICE guideline proposes a target of 40% reduction in non-HDL cholesterol as a target

Approximately 80% of the UK population aged 45-65 years will have a total cholesterol >5.0 mmo/L (Health Survey for England 2003), so it is not an effective way of filtering higher risk results

EKHUFT Biochemistry have introduced alerts on lipid reports for total cholesterol and non-HDL cholesterol >7.5 mmol/L and triglyceride > 4.5 mmol/L as these are stated action points in the NICE guidance. However, these are clearly somewhat high values and concentrations lower than these may require intervention in the context of clinical risk assessment. Explanation of the change to lipid reports can be read in full here

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Lifestyle modifications for the primary and secondary prevention of CVD

Through education and support a person's risk of CVD can be reduced by addressing some of the most common risk factors

Healthy diet

Advise people at high risk of or with CVD to eat a diet in which total fat intake is 30% or less of total energy intake, saturated fats are 7% or less of total energy intake, intake of dietary cholesterol is less than 300 mg/day and where possible saturated fats are replaced by mono-unsaturated and polyunsaturated fats

Advise people at high risk of or with CVD to do all of the following:

  • choose wholegrain varieties of starchy food
  • reduce their intake of sugar and food products containing refined sugars including fructose
  • eat at least 5 portions of fruit and vegetables per day
  • eat at least 2 portions of fish per week, including a portion of oily fish
  • eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

For more information, you can contact or refer a patient to the Health Improvement Service, which offers a number of programmes for healthy eating including Get Food Smart and the Health Trainers service

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Physical activity

Advise people at high risk of or with CVD to do the following every week:

  • at least 150 minutes of moderate intensity aerobic activity or
  • 75 minutes of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity

For more information, you can contact or refer a patient to the Health Improvement Service, which offers a number of programmes for increased physical activity including the Exercise Referral and Health walks schemes,  and the Health Trainers service

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Weight management

Offer people at high risk of or with CVD who are overweight or obese appropriate advice and support to work towards achieving and maintaining a healthy weight

For more information, you can contact or refer a patient to the Health Improvement Service, which offers a number of weight management programmes including the Fresh Start, Health Weight and Specialist Weight  Management programmes, and the Health Trainers service

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Alcohol consumption

Be aware that men should not regularly drink more than 3–4 units a day and women should not regularly drink more than 2–3 units a day. People should avoid binge drinking

For more information, you can contact or refer a patient to the East Kent Drug and Alcohol Service

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Smoking cessation

Advise all people who smoke to stop

Offer people who want to stop smoking support and advice, and referral to Kent Stop Smoking Service

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Plant stanols and sterols

Do not advise any of the following to take plant stanols or sterols for the prevention of CVD:

  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes

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QRISK

The QRISK2 risk calculator is an algorithm designed to calculate a person's risk of developing cardiovascular disease over the next 10 years by answering some simple questions

The online algorithm can be found here

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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