Prevention of Cardiovascular Disease - Summary of Joint British Societies' Guidelines

Target groups for CVD prevention
All high-risk individuals, with equal focus on each of the following groups: People with any form of established atherosclerotic CVD People with diabetes mellitus (type I or type II) Asymptomatic people without established atherosclerotic CVD but with a 10-year CVD risk > 20% Other individuals with elevated single risk factors, regardless of the presence of other risk factors: Elevated blood pressure >160mmHg systolic or >100mmHg diastolic, or lesser degrees of blood pressure elevation with target organ damage Elevated total cholesterol (TC) to high density lipoprotein (HDL) cholesterol ratio >6.0 Familial dyslipidaemia (specialist care required)
Assessment of CVD risk
Estimate total CVD risk using the JBS CVD risk prediction charts (www.bhsoc.org) Consider opportunistic comprehensive CVD risk assessment in all adults aged 40 years and above with no history of CVD or diabetes and who are not already receiving treatment for blood pressure or lipids, every 5 years. If CVD risk <20%, provide appropriate lifestyle advice and repeat assessment within 5 years. Assess CVD risk in younger adults with a family history of premature CVD (men <55 years, women <65 years) Risk assessment should include: Ethnicity Smoking habit history Family history of CVD Measurement of weight and waist circumference Blood pressure measurement Measurement of non-fasting lipids (TC, HDL-C) or full fasting lipid profile (TC, HDL-C, triglycerides [TG] and calculated low-density lipoprotein [LDL] cholesterol) Measurement of non-fasting plasma glucose LDL-C levels can be calculated using the Friedewald formula: LDL-C = TC - HDL-C - (TG/2.2) (not be used with non-fasting values or if TG >4.0mmol/L, less reliable in diabetes)
Aims
To reduce blood pressure to <130/80mmHg in people with atherosclerotic CVD, diabetes or chronic renal failure (audit standard <140/80mmHg), and to <140/85mmHg in asymptomatic people with 10-year CVD risk >20% (audit standard <150/90mmHg) To reduce TC to <4.0mmol/L or a 25% reduction, whichever is lower (audit standard <5.0mmol/L or 25% reduction) To reduce LDL-C to <2.0mmol/L or a 30% reduction, whichever is lower (audit standard <3.0mmol/L or 30% reduction) To maintain BMI <25kg/m² To maintain waist circumference <102cm or <88cm in white caucasian men and women, respectively, or <90cm or <80cm in Asian men and women, respectively To maintain fasting plasma glucose <6.0mmol/L in all high risk patients, plus an HbA1c <6.5% in people with diabetes (audit standard <7.5%)
Lifestyle Measures
Reduce weight if BMI >25kg/m² or if waist circumference above desired limits (see above) Reduce intake of total fat (<30% of energy intake) and saturated fats (<10% of total fat intake), increase consumption of oily fish Limit intake of dietary cholesterol to <300mg/day Consume at least five portions of fresh fruit and vegetables per day Limit weekly alcohol consumption to: <21 units (men) or <14 units (women) Reduce salt intake to <100mmol/day (<6g NaCl or <2.4g Na+ per day) Take regular exercise (at least 30 minutes of aerobic physical activity per day, most days of the week) Stop smoking
Treatment
Implement statin therapy to achieve TC and LDL-C targets in: - all people with atherosclerotic CVD - all asymptomatic individuals with a CVD risk >20% - diabetics aged >40 years - diabetics aged 18-39 years with >1 of the following: retinopathy, nephropathy, HbA1c >9%, hypertension, TC >6mmol/L, features of metabolic syndrome, family history of premature CVD Implement aspirin 75mg daily (or clopidogrel 75mg daily if aspirin not tolerated) in people with atherosclerotic CVD or diabetes and in asymptomatic individuals with a CVD risk >20% (once blood pressure is controlled to the audit standard of <150/90mmHg) Ensure glycaemic control in diabetics Treat elevated blood pressure according to the British Hypertension Society guidelines (click here to view) Consider anticoagulants in people with atherosclerotic CVD at high risk of systemic embolisation Implement beta-blocker therapy following myocardial infarction, unless contraindicated Implement ACE inhibitor therapy (or angiotensin II antagonist) in people with heart failure or left ventricular dysfunction; consider in other people with coronary disease and normal LV function if blood pressure not at target. Implement also in diabetics with renal dysfunction and microalbuminuria. Further details in relevant prescribing notes/monographs.
Adapted from: JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Wood D, Wray R, Poulter N et al. Heart 2005; 91 (Suppl V): v1-v52. (www.heartjnl.com)