Cardiovascular Disease Risk Control

A number of clinical conditions, including hypertension, diabetes, dyslipidemia and kidney disease contribute significantly to the risk of developing cardiovascular disease. Effective long-term control of these conditions can substantially decrease the risk of CVD. Individual guidelines for the management of hypertension, diabetes andchronic kidney disease may be found on this web site. The management of dyslipidemia is covered in this guideline.

The following are considerations for cardiovascular disease risk control. Atherosclerosis and vascular damage that precede clinical CVD can also be prevented by reduction of the risk factors discussed below.⁹

1. Blood pressure (BP) control: Promote a healthy lifestyle through smoking cessation, weight reduction, increased physical activity, low-salt and low-fat food intake (DASH diet), and the use of antihypertensive medications where appropriate, with consideration for the presence of other CVD risk factors.¹⁰
2. Diabetes management: Promote a healthy lifestyle through smoking cessation, a healthful diet and increased physical activity, and use medications where appropriate to control blood glucose.^11,12
3. Measure lipids under the following circumstances:
   1. Baseline full lipid profile (TG, TC, HDL, LDL) for men ≥40 yrs, women ≥ 50 yrs and postmenopausal women of any age. Reassess only if major CVD risk factors change.
   2. Full lipid profile if patient has hypertension, diabetes mellitus (type 1 or 2), chronic kidney disease or abdominal obesity, even if younger than 40 years-of-age.
   3. Full lipid profile if patient has a family history of premature CHD (onset before age 55 for men, and before age 65 for women), hypercholesterolemia, or signs of hyperlipidemia (for example, tendon xanthoma).
   4. Consider apolipoprotein B (apoB) for follow-up testing in high-risk patients who are undergoing treatment for hypercholesterolemia (but not for other dyslipidemias). Other lipid tests are not required if using apoB for follow-up. ApoB is a more accurate measurement of atherogenic particles than LDL.¹³Fasting is not required for apoB measurement. See Appendix D for more information.
4. Lipid management: Recommend lifestyle management (reduced dietary intake of saturated and trans-fats and cholesterol, increased physical activity) as first-line treatment for patients in all risk categories.¹⁴ If lifestyle management is insufficient in achieving desirable lipid levels, consider therapy with lipid-lowering medications, especially for patients at high risk (see Table 1).¹⁴ A decrease of 30-40% in lipids leads to sufficiently reduced CHD risk for most patients, including those with metabolic syndrome and diabetes.
5. Global risk assessment: *
   1. Framingham risk chart for patients without diabetes: The Framingham risk assessment chart (Appendix B) is helpful in estimating the 10-year CHD risk for adults who do not have CVD or diabetes. The risk factors included in the Framingham calculation are: gender, age, total cholesterol, HDL cholesterol, systolic blood pressure and cigarette smoking.
   2. UKPDS risk chart for patients with diabetes: The United Kingdom Prospective Diabetes Study¹⁵(UKPDS) risk assessment chart (Appendix C) is helpful in estimating the 10-year CHD risk for adults with diabetes. The risk factors included in the UKPDS risk assessment are: gender, age, hemoglobin A1c, total cholesterol, HDL cholesterol, systolic blood pressure and cigarette smoking. Refer to the BC diabetes guideline for further information on the UKPDS risk calculator.
   3. The U.S. Preventative Services Task Force (UPSTF) recently reviewed the use of non-traditional risk factors, including high sensitivity C-reactive protein (hs-CRP) and state that the current evidence is insufficient to assess the balance of benefits and harms of using hs-CRP to routinely screen asymptomatic men and women with no history of coronary heart disease in order to prevent coronary events.³³
   
   * This excludes high-risk patients with known CVD.

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Table 1. Framingham risk levels and desirable lipid results

(printable PDF)

CLASSIFICATION	RISK LEVEL	LDL (mmol/L)	ApoB (g/L)	TC/HDL RATIO
High *	≥ 20% without CHD	< 2.5	< 0.85 for follow - up	< 4.0
Moderate **	10% - 19%	< 3.5	< 1.05	< 5.0
Low ***	< 10%	< 5.0	< 1.25	< 6.0

Abbreviations: Apo B, apolipoprotein B; CHD, coronary heart disease; LDL, low-density lipoprotein; TC/HDL, total cholesterol/high-density lipoprotein ratio

* Adults with diabetes or chronic renal disease should not automatically be considered high risk. Use the UKPDS risk assessment chart to determine the level of risk for patients with diabetes. Use the Framingham risk assessment charts to determine the level of risk for patients with chronic renal disease.

** Patients in the moderate risk category may be at high long-term CVD risk. This group includes many patients with abdominal obesity (metabolic syndrome).

*** Patients with severe genetic lipoprotein disorders, such as familial hypercholesterolemia or type III dyslipidemia should be treated regardless of their Framingham risk score.

Note: Although triglyceride levels are no longer indicated as a primary treatment target, the optimal level of triglycerides for high-risk patients is < 1.5 mmol /L.

6. Albumin/creatinine ratio: In most patients with diabetes or hypertension, measurement of the albumin/creatinine ratio is recommended (for details, refer to the BC diabetes and hypertension guidelines). An elevated albumin/creatinine ratio (men: > 2.0 mg/mmol, women: > 2.8 mg/mmol) is associated with an increased risk of heart disease and stroke. Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) can be used to manage proteinuria, including microalbuminuria.¹⁶
7. Kidney function: Impaired kidney function (eGFR < 60 mL/min) is associated with an increased risk of heart disease and stroke. ACEI and ARBs are effective in improving outcomes related to cardiovascular disease and kidney disease in patients with impaired kidney function.^17,18 The benefits of statin therapy have not been fully evaluated in this patient group.

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Additional considerations

1. Women: Statins do not appear to prevent heart disease or improve survival for most women without known heart disease (primary prevention), based on a large subset of women (5052) in the North American ALLHAT-LLT trial¹⁹ and a meta-analysis of more than 11,000 women.²⁰
2. Older adults: The PROSPER trial found that statins did not reduce CHD and stroke events in men and women over age 69 without heart disease.²¹ There was a significant reduction in cardiovascular events for individuals with coronary heart disease (secondary prevention). 
   
   Overall (mixed primary and secondary prevention), there was a significant reduction in cardiovascular events, but a corresponding increase in major adverse events, such as cancer and hemorrhagic stroke. There is currently insufficient evidence for the safety of statins and improved overall outcomes in older adults.
3. Aspirin therapy: Low-dose aspirin (e.g. 81 mg) to prevent platelet aggregation is recommended for people under age 70 who are not aspirin intolerant and who have a ten-year CHD risk ≥ 20% (no known CHD).²²Blood pressure must be well controlled. Low-dose aspirin therapy for patients (men and women) over age 70 is not recommended at this time due to insufficient evidence.²³
4. Metabolic syndrome: Metabolic syndrome includes three or more of the following criteria:
   • Abdominal obesity (waist circumference: men > 102 cm, women > 88 cm)
   • Triglycerides ≥ 1.7 mmol/L
   • HDL (men < 1.0 mmol/L, women < 1.3 mmol/L)
   • BP > 130/85 mm Hg
   • Fasting glucose 5.7-6.9 mmol/L
   
   The American Heart Association recommends lifestyle intervention as first-line therapy for the management of metabolic syndrome as there is insufficient evidence to recommend the use of drugs as first-line therapy for treating the underlying causes.²⁴
5. Socioeconomic factors: Socioeconomic factors may play a role in exacerbating risk and should be considered.²⁵ 

Source:
Nadeem Zia, B.Pharm, RPh,

OpenDoor Team, www.OpenDoor.cc

Consulting Pharmacist, Vancouver, BC Canada

LinkedIn: http://ca.linkedin.com/in/NadeemPharmacist

Google + : google.com/+NadeemZiaRPh

Vancouver, British Columbia, Canada

Reference: http://www.bcguidelines.ca/guideline_cvd.html

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