Objectives Guidelines...5 March 2016 Cardiovascular Risk Assessment: Determining Ticking Time Bomb...

Cardiovascular Risk Assessment

UBC Pharmacy Update 2016 Copyright Arden Barry PharmD 1

5 March 2016

Cardiovascular Risk Assessment:Determining Ticking Time Bomb Tickers

Arden Barry, BSc, BSc(Pharm), PharmD, ACPRClinical Pharmacy and Research Specialist, Chilliwack General Hospital

Assistant Professor (Partner), Faculty of Pharmaceutical SciencesAssociate Member, Department of Family Medicine, Faculty of Medicine

University of British ColumbiaEmail [email protected]

Twitter @ArdenBarry

Disclosure

• No real or potential conflicts of interest to declare

• Primary panel member of the 2015 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult

Objectives

• To identify which patients should undergo a CV risk assessment;

• To gain familiarity with the available CV risk assessment calculators, and identity at least one advantage and disadvantage of each;

• To be able to calculate a patient’s CV risk using the Framingham Risk Score;

• To briefly review the current Canadian treatment recommendations based on a patient’s CV risk score.

Guidelines

Can J Cardiol 2013;29:151-67

Guidelines

Can Pharm J (Ott) 2015;148:21-8

Guidelines

Can Fam Physician 2015;61:857-67



5 March 2016

Guidelines

Circulation 2014;129[suppl 2]:S1-S45

CV Risk Assessment

Why?

• Most patients are asymptomatic

• Objective measure of risk

• Reassure low-risk patients

• Identify modifiable CV risk factors

• Encourage healthy lifestyle behaviours

• Motivate patients

Screening

Can J Cardiol 2013;29:151-67

• Secondary prevention (established CVD such as CAD, ACS, CABG surgery, cerebrovascular disease, stroke/TIA, PAD, abdominal aortic aneurysm)

• DM (age ≥40 or age ≥30 with DM duration ≥15 yr or microvascular disease)

• CKD (eGFR ≤45 or ACR ≥30 or eGFR ≤60 and ACR ≥3)

• HTN with ≥3 CV risk factors (age >55, smoker, TC/HDL-C ratio >6, LVH, family history of premature CVD, ECG abnormalities, microalbuminuria)

Is the Patient Already High Risk?

Can J Cardiol 2013;29:151-67



5 March 2016

Risk Calculators

Fasting Lipid Profile

• Fasting x ≥10 hr

• Components:– Total cholesterol (TC) (mmol/L)

– High-density lipoprotein cholesterol (HDL-C) (mmol/L)

– Low-density lipoprotein cholesterol (LDL-C) (mmol/L)

– Triglycerides (TG) (mmol/L)

– Non-HDL-C (mmol/L)

– TC/HDL-C ratio

• Alternate: apolipoprotein B (apoB) (g/L)

Calculating CV Risk

• ++ CV risk tools exist

• ++ variance between tools

• No tool is 100% accurate

• Arbitrary thresholds for risk

• Not intended for patients on treatment

• Not intended to estimate effect of treatment

CV Risk Calculators

• Framingham Risk Score

• QRISK2

• ACC/AHA ASCVD Calculator

• Reynolds Risk Score

• CardioRisk Calculator

Framingham Risk Score

• Estimates 10-year risk of total cardiovascular disease (CVD) = CAD, stroke, PAD and HF

• Reported as %

Circulation 2008;117:743-53


• Components:

– Sex (M or F)

–Age (yr)

– TC (mmol/L)

–HDL-C (mmol/L)

– SBP (mmHg)

–DM (Y or N)

– Smoker (Y or N)

Circulation 2008;117:743-53



5 March 2016


• Limitations:

–Middle-aged white American population

–Not validated in patients >75 years of age

–Calculates total CVD

– Limited to 10-year risk

– Family history (“modified FRS”)

QRISK2

• Calculates 10-yr % risk of CVD

– MI, angina, stroke, TIA

• Components:

– Sex (M or F) and age (yr)

– Ethnicity

– DM, AF, CKD or RA (Y or N)

– Family history of CVD (first-degree relative <60)

– TC/HDL-C ratio, SBP (mmHg) and BMI (kg/m2)

– Smoker (Y or N)

qrisk.orgBMJ 2010;340:c2442

QRISK2

qrisk.orgBMJ 2010;340:c2442

QRISK2

• Limitations:

–Middle-aged United Kingdom population

– Limited to age 35-73 yr

–Calculates total CVD

• Angina or TIA vs MI or stroke

– Limited to 10-year risk

–Does not account for family history

– Less patient-friendly to complete

ACC/AHA ASCVD Risk Estimator

• Based on American community-based cohort of African-American and non-Hispanic white men/women aged 40-79

• Calculates 10-year % risk of fatal/nonfatal MI and fatal/nonfatal stroke

• Also calculates lifetime % risk for those aged 20-59 years

tools.acc.org/ASCVD-Risk-EstimatorCirculation 2014;129:S49-S73


• Components:– Age (20-79 yr)

– Sex (M or F)

– Race (AA, WH or other)

– TC (mg/dL)

– HDL-C (mg/dL)

– SBP (mmHg)

– DM (Y or N)

– Smoker (Y or N)

tools.acc.org/ASCVD-Risk-EstimatorCirculation 2014;129:S49-S73



5 March 2016


tools.acc.org/ASCVD-Risk-Estimator


• Limitations:

–Middle-aged American population

–Patients >79 yr of age not included

–Only calculates MI and stroke

–10-year risk may exceed lifetime risk

–Does not account for family history

– Less clinical experience

–American units and guidelines

http://bestsciencemedicine.com/chd/calc2.html http://cvrisk.mvm.ed.ac.uk/calculator/calc.asp

Reynolds Risk Score

• Calculates 10-year % risk of CV death, MI, stroke or coronary revascularization

• Components:– Sex (M or F) and age (yr)

– Smoker (Y or N)

– SBP (mmHg)

– TC and HDL (mg/dL or mmol/L)

– hsCRP (mg/L)

– Family history (parent with MI <60 years of age)reynoldsriskscore.org

JAMA 2007;297:611-9Circulation 2008;118:2243-51

Reynolds Risk Score

reynoldsriskscore.org

http://bestsciencemedicine.com/chd/calc2.html

http://cvrisk.mvm.ed.ac.uk/calculator/calc.asp



5 March 2016

Reynolds Risk Score

• Limitations:

–Middle-aged white American population

–Utilizes hsCRP (not CRP)

–Coronary revascularization vs CV death/MI/stroke

– Excludes DM

–Maximum age 80 yr

CardioRisk Calculator

www.circl.ubc.ca/webcardiorisk.html

Metabolic Syndrome

• No uniform classification system

• Higher risk than individual risk factors alone?

• Do not use metabolic syndrome for CV risk assessment

Diabetes Care 2005;28:2289-304



http://www.circl.ubc.ca/webcardiorisk.html



5 March 2016

• Step 1: calculate total points

• Step 2: use points to determine risk %

• Step 3: modify for family history of premature CVD

• Step 4: use points to determine “heart age”

• Step 5: use risk % to determine risk level


Low risk Intermediate risk High risk

<10% 10-19% ≥20%

Case Example

Case: B.S.

• 66 yo M with a hungry heart

• PMHx: Ø

• SocHx: non-smoker, Ø EtOH, vegetarian

• Rx: Ø

• Would you screen this patient?

• Why or why not?

Case: B.S.

• Based on your recommendation, he has a fasting lipid profile drawn:

• BP 135/80 mmHg

• Non-diabetic

TC LDL-C HDL-C TG

5.6 mmol/L 3.9 mmol/L 1.25 mmol/L 1.0 mmol/L

Case: B.S.

• Is he primary or secondary prevention?

• What additional information do you require?

• What is his FRS?

–Points =

–10-year CVD risk =

• Heart age =

• Risk level =

• What if he was 56-years-old?

• What if he was 64-years-old?

• What if he was a 66-year-old female?

• What if he was a 76-year-old female?

Case: B.S.



5 March 2016

Practical Tips

• What is the biggest contributor to risk?

• Access to labs via my ehealth

• Ex-smokers

• Positive family history of premature CVD

• Communicating risk

Case: B.S.

FRS 25.3%

CardioRisk 22%

QRISK2 16.3%

ASCVD 16.1%

RRS 13%

The Absolute CVD Risk/Benefit Calculator

FRS 23.5%QRISK 15.4%ASCVD 14.6%

Treatment

• Recommend for all patients at risk of CVD

• Health behaviours:

– Smoking cessation

– Exercise (150 min per week)

– Limit EtOH intake (1-2 drinks per day)

– Dietary modifications

– Psychological stress management

Lifestyle Modifications

0-5-30

Can J Cardiol 2013;29:151-67

Dyslipidemia

Can J Cardiol 2013;29:151-67

Dyslipidemia

Can J Cardiol 2013;29:151-67



5 March 2016

Statin Myth-Busting

www.albertahealthservices.ca/scns/page10585.aspx

Hypertension

Can J Cardiol 2015;31:549-68

Hypertension

Can J Cardiol 2015;31:549-68

ASA

Can J Cardiol 2011;27:208-21

Case Examples

Case 1

ID 45-year-old F

PMHx Ø

MedHx Salmon oil 1000 mg PO daily, ECASA 81 mg PO daily

SocHx Ex-smoker, Ø EtOH

FamHx Father had MI at age 45

BP 122/66 mmHg

Labs TC 8.0 mmol/LLDL-C 5.7 mmol/LHDL-C 1.9 mmol/LTG 1.0 mmol/LFBG 5.6 mmol/L



5 March 2016

Case 2ID 50-year-old F

PMHx DM type 2, dyslipidemia, hypothyroidism

MedHx Metformin 500 mg PO bid, ramipril 5 mg PO daily, levothyroxine 112 mcg PO daily

SocHx Non-smoker, Ø EtOH

FamHx Non-contributory

BP 128/73 mmHg

Labs TC 5.7 mmol/LLDL-C 3.7 mmol/LHDL-C 1.0 mmol/LTG 2.3 mmol/LA1c 8.6%

Case 3

ID 29-year-old M of Indian descent

PMHx Ø

MedHx Ø

SocHx Smoker (1 ppd x 15 yr)

FamHx Father has DM type 2 (Ø CVD)

BP 134/82 mmHg

Labs TC 6.2 mmol/LLDL-C 4.3 mmol/LHDL-C 1.2 mmol/LTG 1.5 mmol/LFBG 6.2 mmol/L

Case 4ID 56-year-old M

PMHx HTN, dyslipidemia, chronic back pain

MedHx Ramipril 10 mg PO bid, amlodipine 10 mg PO daily, atorvastatin 10 mg PO daily, naproxen 500 mg PO bid

SocHx Smoker (40 pack-yr hx)

FamHx Unknown

BP 118/65 mmHg



PMHx DM type 2

MedHx Metformin 500 mg PO bid

SocHx Non-smoker


BP 124/83 mmHg


Case 6

ID 35-year-old M from Fort McMurray

PMHx Obesity (BMI 33 kg/m2)

MedHx Ø

SocHx Smoker (½ ppd x 25 yr), occasional cocaine use


BP 148/90 mmHg

Labs TC 6.8 mmol/LLDL-C unable to measureHDL-C 0.8 mmol/LTG 5.5 mmol/LA1c 9.6%


PMHx AF, OA, HTN, osteoporosis

MedHx Alendronate 70 mg PO q weekly, warfarin 5 mg PO daily, bisoprolol 5 mg PO daily, acetaminophen 1000 mg PO tid, calcium 500 mg PO bid, vitamin D 1000 units PO daily

SocHx Ex-smoker (quit in 1956)


BP 110/70 mmHg

Labs TC 4.3 mmol/LLDL-C 2.1 mmol/LHDL-C 1.8 mmol/LTG 0.8 mmol/L



5 March 2016

Case 8ID 65-year-old M

PMHx CAD (STEMI 6 months ago), HTN, dyslipidemia

MedHx ECASA 81 mg PO daily, ticagrelor 90 mg PO bid, rosuvastatin 40 mg PO daily, bisoprolol 5 mg PO daily, perindopril 4 mg PO daily

SocHx Ex-smoker (quit 6 months ago)


BP 112/72 mmHg

Labs TC 3.4 mmol/LLDL-C 2.3 mmol/LHDL-C 0.7 mmol/LTG 0.8 mmol/L

Questions?

Objectives Guidelines...5 March 2016 Cardiovascular Risk Assessment: Determining Ticking Time Bomb...

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