Prevention of Cardiovascular Disease (Joint British Societies' Guideline)

Recommended assessments, management and targets.

Assessment
  • Estimate 10-year and lifetime CVD risk using JBS3 calculator (www.jbs3risk.com) - if CVD risk <10%, repeat within 5 years
  • Risk assessment not needed in patients with existing CVD, diabetes >40 years, CKD stage 3-5 or familial hypercholesterolaemia* - proceed directly to lifestyle intervention and treatment
  • JBS3 calculator includes:
     - Age and sex
     - Ethnicity
     - Family CVD history
     - Systolic BP
     - Smoking history
     - History of hypertension, diabetes, CKD, atrial fibrillation, rheumatoid arthritis
     - Height and weight
     - Non-fasting TC and HDL-C
Aims
  • Reduce BP to <140/90mmHg or
     - <130/80mmHg in stroke, or CKD with albuminuria
     - 120/75-80mmHg in patients <40 years with type I diabetes and persistent albuminuria
     - <150/90mmHg if starting treatment at ≥80 years
  • Reduce non-fasting non-HDL-C to <2.5mmol/L
  • Maintain HbA1c 48-58mmol/mol in type I diabetes
Lifestyle changes
  • Reduce fat intake; limit saturated fats to <10% of total fat intake
  • Consume at least 2 servings of fish (preferably oily) per week
  • Consume 5 portions of fruit and vegetables per day
  • Limit weekly alcohol intake to <21 units (men) or <14 units (women)
  • Limit salt intake to <6g/day
  • Lose weight if appropriate
  • Undertake regular physical activity comprising ≥150 mins moderate activity (in ≥10 min bouts) or ≥75 mins vigorous activity per week, incl two to three 30-40 min bouts of moderate to high intensity aerobic exercise, plus muscle strengthening activity at least twice weekly
  • Stop smoking
Treatment
  • Implement statin therapy to achieve non-fasting non-HDL-C targets in patients with:
     - Established CVD (avoid in haemorrhagic stroke)
     - 10-year CVD risk ≥10%
     - High lifetime CVD risk where lifestyle changes alone insufficient
     - CKD stage 3-5
     - Familial hypercholesterolaemia*
  • Type II diabetes and:    
     - ≥40 years
     - >40 years + ≥1 of the following: proliferative retinopathy; treated hypertension; persistent albuminuria; eGFR <60ml/min/1.73m2; autonomic neuropathy
  • Type I diabetes and: 
     - ≥50 years
     - 40–50 years unless <5 year history of diabetes and no other CVD risk factors
     - 30-40 years + ≥1 of the following: >20 year history of diabetes and poor glycaemic control (HbA1c >75mmol/mol); persistent albuminuria; eGFR <60ml/min/1.73m2; proliferative retinopathy; treated hypertension; smoking; autonomic neuropathy; TC ≥5mmol/L with HDL-C <1mmol/L in men or <1.2mmol/L in women; central obesity or family history of premature CVD
     - 18-30 years with persistent albuminuria
  • Give aspirin 75-100mg daily (clopidogrel 75mg daily if aspirin not tolerated) in patients with: 
     - Recent MI (in combination with another antiplatelet for 1-12 months if bare-metal stent or 6-12 months if drug-eluting stent)
     - Acute coronary syndrome (in combination with another antiplatelet, eg prasugrel or ticagrelor)
  • Give clopidogrel 75mg daily in peripheral arterial disease
  • Give aspirin 300mg daily for 2 weeks then clopidogrel 75mg daily after acute ischaemic stroke in patients without atrial fibrillation (alternatively, modified-release dipyridamole +/- aspirin if clopidogrel contraindicated/not tolerated; or modified-release dipyridamole 200mg twice daily +/- aspirin 75-150mg daily if TIAs)
  • Give warfarin (or newer oral anticoagulant) in patients with atrial fibrillation who have TIA or recent ischaemic stroke: target INR 2.5 (range 2.0-3.0)
  • Ensure glycaemic control in diabetes
  • Treat hypertension (see NICE guidance)
  • See NICE, SIGN and ESC guidelines on use of beta blockers, ACE inhibitors/angiotensin II antagonists and aldosterone antagonists following MI
  • Offer continuous positive airway pressure treatment to patients with obstructive sleep apnoea/hypopnoea syndrome as appropriate 

Further details in relevant prescribing notes/monographs.

*Specialist treatment required.


Adapted from: JBS3: Joint British Societies' consensus recommendations for the prevention of cardiovascular disease. Heart 2014; 100: ii1-ii67.