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management: a new
approach for primary care
Rod Jackson
School of Population Health
University of Auckland
New Zealand
Why bother about CVD in 1°care?
4.0 4.0
Risk of coronary disease
4.0
2.0 2.0
2.0
“Hyperchol-
1.0 “Hyper- 1.0
esterolaemia”
1.0
tension”
0.5
0.5 0.5 16 20 24
110 120 130 140 150 160 170 4.0 5.0 6.0 7.0 8.0
6 7.2
Odds Ratio
4
2 3.5
2
1
0
Reference Passive Ex-smoker Active Active
Few or no
participants 1.4% 34%
had a history of
stroke
Most or all
participants 5.1% 25%
had a history of
stroke or TIA
Treatment
0% 5% 10% 15% 20% 0.5 1.0 1.5
Control
Estimated 5 year stroke event rate Relative Risk and 95% CI
NZ threshold for CVD risk drugs
15% 5 yr risk
Message Number 2:
•Sex
•Age
•Diabetes
•Smoking
•BP
•TC
•HDL
•(LVH)
60 yr old man
BP 150/90 mmHg
45 yr old man
smoker
BP 150/90 mmHg
TC 6.0 mmol/L
non smoker
HDLC 1.0 mmol/L
TC 6.0 mmol/L
No ‘diabetes’
HDLC 1.2 mmol/L
new ‘diabetes’
5 yr CVD risk ≈ 25%
5 yr CVD risk ≈ 10%
Clinical risk:
short-term vs life-time?
Lifetime risk is clinically irrelevant
The risk of death is 1 / person (100%)
What’s clinically relevant is when it happens
The lifetime CVD risk chart
Who should we treat?
QuickTime™ and a
TIFF (U ncompressed) decompressor
are needed to see this picture.
Clinical risk treatment thresholds?
$$$$$$$$$$$$$$$$$$$$$$$
Aspirin
metformin?
Practice/PHO/DHB
population needs
assessment & service
planning
Making new risk prediction charts
NHI
NHI (encrypted)
NHI
NHI (encrypted)
Hx CVD
12%
Risk 15+%
9% Risk <10%
68%
Risk 10-<15%
11%
Results: estimated 5-year incidence
of CVD event
Mean est. 5-year incidence for Hx CVD is 28.4% (95%CI 26.3 to 30.4)
For prior CVD 5-year risk is: 20 + 1.3*Framingham score
Results: events in risk groups in first
30,878 patients from PREDICT
Hx CVD
12%
47%
Risk 15+%
9% 16% Risk <10%
68%
11% 26%
Risk 10-<15%
11%
‘metabollocks!’
Relative stroke risk and usual Blood Pressure
(45 prospective studies: 450,000 people 13,000 events)
4.0
Relative Risk
2.0
1.0
0.5
75 81 87 93 98 102
diastolic blood pressure (mmHg)
PSC Lancet 1995;346:1647-53
Relative stroke risk and usual Blood Pressure
(45 prospective studies: 450,000 people 13,000 events)
4.0
Relative Risk
75 81 87 93 98 102
diastolic blood pressure (mmHg)
PSC Lancet 1995;346:1647-53