The concept of doctor targets based on quality guidelines: focus on blood pressure
Garfield Weston Chair of Cardiovascular Medicine, Imperial College, London, UK
Corresponding author. E-mail address: d.wood{at}imperial.ac.uk
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Abstract |
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 Top Abstract IntroductionThe scientific rationale for...How to calculate total...How to manage blood...ConclusionsReferences |
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Clinicians are taught to diagnose and manage disease starting with the question does this patient have disease or not—yes or no. As a consequence, cardiovascular risk factors were viewed historically as being dichotomous. However, over the past decade, there has been a shift towards the concept of total cardiovascular risk as the primary determinant for making clinical decisions about treating individual risk factors. This change is reflected in the European guidelines, developed by the European Society of Cardiology in partnership with the European Society of Hypertension and the European Atherosclerosis Society, in a common approach to coronary and subsequently cardiovascular disease (CVD) prevention. Cardiovascular risk is strongly related to lifestyle, a high saturated fat diet, physical inactivity, and smoking tobacco. Thus, lifestyle changes are at the heart of guidelines. Patients with established CVD have declared themselves to be at high total risk of a further vascular event and, therefore, they require the most intensive intervention, including appropriate drug therapies, in order to achieve risk factor goals including a systolic blood pressure < 140 mmHg and a diastolic blood pressure < 90 mmHg. Similarly, patients with a high total cardiovascular risk, and patients with diabetes, can benefit from reducing blood pressure below 140/90 mmHg or even lower. Despite wide awareness of guidelines, recent European surveys show that one-quarter of the patients with elevated blood pressure were unaware of their hypertensive status. There is also a high prevalence of elevated blood pressure in patients with established coronary heart disease, half of whom require more intensive blood pressure management and, where appropriate, antihypertensive medication. The challenge for primary prevention in people at high risk of developing CVD is even greater.
Key Words: Total cardiovascular risk • Blood pressure • Targets
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Introduction |
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TopAbstractIntroductionThe scientific rationale for...How to calculate total...How to manage blood...ConclusionsReferences |
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The development of cardiovascular disease (CVD) is strongly related to lifestyle: a high saturated fat diet, physical inactivity, and smoking tobacco. These promote adverse changes in biochemical and physiological characteristics, which in turn promote and accelerate the development of atherosclerosis and its complications. Cardiovascular risk factors interact with each other and taken together determine the overall risk of developing or having recurrent atherosclerotic disease.
Adopting a healthy lifestyle and effective risk factor management can reduce the risk of developing CVD, and subsequent disease in those who survive their initial event. This scientific evidence has been summarized as a series of recommendations on CVD prevention in clinical practice, first published by the Joint European Societies in 1994 and then updated in 1998 and 2003.1–3 Lifestyle and related modifiable risk factors shown in Table 1 are all associated with the risk of developing coronary artery disease or atherosclerotic disease elsewhere.
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The Third Joint Task Force, which produced the most recent Joint European Societies guidelines on CVD prevention, is a collaboration of eight groups: European Society of Cardiology, European Society of Hypertension, European Society of Atherosclerosis, European Society of General Practice/Family Medicine, European Heart Network, International Society of Behavioural Medicine, European Association for the Study of Diabetes, and the International Diabetes Federation Europe.
The 2003 European guidelines differ from previous ones in that the emphasis has moved from coronary heart disease prevention to CVD prevention. The guidelines define priorities (Table 2) and thresholds for treatment and treatment targets.
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The top priority is patients with established atherosclerotic disease: namely established coronary artery disease, peripheral artery disease, and cerebral artery atherosclerotic disease. The second priority group is asymptomatic, apparently healthy, individuals identified as being at high risk of developing atherosclerotic CVD in the future, on the basis of their lifestyle and associated risk factors. This group of high-risk individuals now includes patients with diabetes. The third priority group is close relatives of patients with early onset atherosclerosis, and asymptomatic individuals at particularly high risk (e.g. families with familial hypercholesterolaemia or other forms of inherited dyslipidaemia).
Several cardiovascular risk models have been developed to identify from the general population those who are at sufficiently high risk to require professional lifestyle intervention and drug treatment. The European guidelines recommend the SCORE (Systematic Coronary Risk Evaluation) system (Figures 1 and 2) and its associated software programme HEARTSCORE (www.escardio.org/heartscore). The SCORE risk assessment system is derived from a large pool of prospective European epidemiological studies.4 From an individual's age, gender, smoking habit, systolic blood pressure (SBP), and total cholesterol:high density lipoprotein (HDL) cholesterol ratio, it provides an estimate of their total risk of developing fatal CVD over a period of 10 years. The importance of this approach is that the absolute risk of developing CVD is a function of the interaction of all risk factors, rather than the effect of one risk factor in isolation. To base a treatment decision on a single risk factor, such as blood pressure, misses the overall picture of cardiovascular risk. This represents a paradigm shift in thinking about CVD prevention and the clinical challenge is now to assess total CVD risk and then manage all risk factors together; this will achieve the greatest clinical reduction in CVD.
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The scientific rationale for total multifactorial risk |
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TopAbstractIntroductionThe scientific rationale for...How to calculate total...How to manage blood...ConclusionsReferences |
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Clinicians are taught to diagnose and manage disease starting with the question does this patient have disease or not—yes or no. As a consequence, cardiovascular risk factors were viewed historically as being dichotomous. Patients were classified as having hypertension (yes/no), dyslipidaemia (yes/no), or diabetes (yes/no) and this practice continues to this day. However, this dichotomous view is not consistent with the epidemiology of these risk factors. Blood pressure, cholesterol, and glucose are all continuously distributed in the population. As each risk factor level increases, so does the risk of developing CVD. At any given level of these risk factors across their respective distributions, there is an absolute risk of developing CVD. So the definition of hypertension, dyslipidaemia, and diabetes is arbitrary, and the rationale for each definition is different.
Hypertension is defined as that level of blood pressure above which there is randomized controlled trial evidence that lowering it reduces cardiovascular risk. In contrast, type 2 diabetes is defined as that level of glycaemia on the distribution that is associated with an increased risk of microvascular complications, particularly retinopathy. Yet individuals with blood pressure levels below that defined as ‘hypertension’ still have a risk of developing CVD for a given blood pressure level, and the same is true for cholesterol and glucose. The concept of absolute or total cardiovascular risk—the term ‘total’ is preferred in clinical practice—is not consonant with a dichotomous medical classification, namely those with and without disease. Yet cardiovascular risk continues to be seen as separate ‘diseases’ with specialists in hypertension, lipids, and diabetes each addressing their own risk factor as a unique disease entity. This medical approach is reflected by numerous single risk factor guidelines, especially from the USA, but this is now changing towards total risk assessment and management.
Over the past decade, there has been this paradigm shift towards the concept of total cardiovascular risk (the absolute risk of developing CVD over a defined time period) as the primary determinant for making clinical decisions about treating individual risk factors. Jackson5 was the first to advocate this approach in the context of blood pressure management in 1993. The following year, the first joint European Societies recommendations on prevention of coronary heart disease in clinical practice put forward the same concept for managing all risk factors.1 As the aetiology of CVD is multifactorial, the total risk of developing disease is an integral function of all these risk factors. Although a given blood pressure level carries a certain risk of developing disease, the ultimate expression of disease is a function of the overall risk factor context of which blood pressure is one part. An SBP of 154 mmHg in someone who is a lifelong non-smoker with a cholesterol of 3.8 mmol/L is associated with a lower total risk of developing CVD compared with an SBP of 144 mmHg in a heavy cigarette smoker with a cholesterol 6.8 mmol/L. So in deciding whether or not to treat a given risk factor it is necessary to take account of the collective contribution of other risk factors. A coronary risk chart was developed for the first European recommendations to enable the clinician to quickly estimate total multifactorial risk, based on simultaneous assessment of all major risk factors. Other charts, such as those produced for the New Zealand guidelines on hypertension and a British coronary risk prediction chart, followed this example. This European consensus on a total risk approach was achieved because the European Society of Cardiology worked in partnership with the European Society of Hypertension and the European Atherosclerosis Society leading to a common approach to coronary and subsequently CVD prevention.
The advantages of the total risk approach are several. First, the use of total multifactorial risk avoids the traditional dichotomous classification of risk factors into those with the so-called disease who all require treatment and those with the so-called ‘normal’ risk factors who do not. This concept of normality, often expressed as a normal range, is false as it implies no risk. So patients can be falsely reassured that their risk factors are all ‘normal’ and yet they can be at high multifactorial risk. With the total risk approach, the patients are told their risk of developing disease, and the implications of this in terms of lifestyle change and the use of drug therapies can be considered. In this way, the patient is informed of their true level of overall CVD risk rather than being categorized as ‘hypertensive’, or falsely reassured that their blood pressure is normal. At the same time, the physician can base treatment decisions for any given risk factor in the context of total multifactorial risk. Paradoxically, this may lead to drug treatment in one person whose blood pressure is lower than the next because of the presence of other risk factors. Second, the level of total multifactorial risk at which treatment is given is not fixed and the threshold chosen is a function of scientific evidence, practicalities, and costs of identifying and treating high-risk individuals in the population. The European guidelines now advocate a total CVD risk of 
5% for fatal CVD over 10 years as the threshold at which treatment should be considered. Whatever level of total risk is chosen, this approach will always mean that those at highest CVD risk receive treatment, and benefits of treatment will be greatest in this group. A relative risk reduction of 20% for a given treatment will result in a greater absolute risk reduction in those at highest multifactorial risk compared with those at low risk. The numbers need to treat to save one event will be lower in those at high multifactorial risk and treatment will be more cost-effective. Conversely, the multifactorial risk approach also avoids the unnecessary treatment of individuals with single elevations of risk factors who are at low multifactorial risk. The disadvantage of the total risk approach is that it concentrates treatment in the older population. This is because total risk increases with age reflecting the duration of exposure to lifestyle and related risk factors. Therefore, the European recommendations advocate that, in addition to estimating total risk today, the total risk of an individual should also be projected to age 60. In this way, individuals who are going to become high risk (total CVD risk 5%) in later life can be identified earlier and targeted for more intensive risk factor monitoring and, where appropriate, earlier treatment. Since the publication of the first Joint European Societies recommendations on coronary prevention in 1994, every international, continental, and national guideline, with the exception of the hypertension guidelines in the USA, has embraced the concept of total multifactorial risk.
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How to calculate total cardiovascular disease risk: Systematic Coronary Risk Evaluation |
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TopAbstractIntroductionThe scientific rationale for...How to calculate total...How to manage blood...ConclusionsReferences |
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Patients with established CVD have declared themselves to be at high total risk of a further vascular event. Therefore, they require the most intensive lifestyle intervention, and where appropriate drug therapies in order to achieve risk factor goals and the prescription of prophylactic drugs.
In asymptomatic, apparently healthy subjects, preventive actions should be guided in accordance with the total CVD risk level. Those at highest total risk should be identified and targeted for intensive lifestyle interventions and when appropriate drug therapies.
The third Joint European Societies guidelines provided a new model for total risk estimation based on the SCORE system.3 This risk chart based on the SCORE study represents several advantages compared to the previous chart. The SCORE risk assessment system is derived from a large data set of prospective European studies and predicts any kind of fatal atherosclerotic endpoint, i.e. fatal CVD events over a 10-year period. Since this chart uses fatal events instead of a composite coronary endpoint, the threshold for being at high risk is now 5% instead of the previous 20%. On the basis of SCORE system, several individually tailored CVD risk charts have been produced for individual countries where reliable national mortality information is available.
Total risk is estimated on the basis of the major risk factors including HDL cholesterol. Practitioners should use total CVD risk estimates when decisions are taken to intensify preventive actions, i.e. when dietary advice should be more specified, when the physical activity prescription should be more individualized, when drugs should be prescribed, dosages adapted, or combinations started to control risk factors; these decisions should usually not be based on the level of any one risk factor alone, neither should they be linked to only one arbitrary cutpoint from the continuous total CVD risk distribution.
Total CVD risk can easily be derived from printed charts (Figures 1 and 2) or from the web where in addition the HEARTSCORE system will provide physicians and patients with information on how total risk can be reduced by interventions (both lifestyles and drugs) that have been proved to be efficacious and safe in descriptive cohort studies and/or in randomized controlled trials.
Instructions on how to use the chart
- To estimate a person's total 10-year risk of CVD death, find the table for their gender, smoking status, and age. Within the table, find the cell nearest to the person's SBP (mmHg) and total cholesterol (mmol/L or mg/dL)
- The effect of lifetime exposure to risk factors can be seen by following the table upwards. This can be used when advising younger people.
- Low-risk individuals should be offered advice to maintain their low-risk status. Those who are at 5% risk or higher or will reach this level in middle age should be given maximal attention.
- To define a person's relative risk, compare their risk category with that of other people of the same age and gender.
- The effect of changing cholesterol, smoking status, or SBP can be read from the chart.
Qualifiers:
note that total CVD risk may be higher than that indicated in the chart:
- as the person approaches the next age category;
- in asymptomatic subjects with preclinical evidence of atherosclerosis (e.g. CT scan, ultrasonography);
- in subjects with a strong family history of premature CVD;
- in subjects with low HDL cholesterol levels, with raised triglyceride levels, with impaired glucose tolerance, and with raised levels of C-reactive protein, fibrinogen, homocysteine, apolipoprotein B, or Lp(a);
- in obese and sedentary subjects.
Both the SCORE charts and the HEARTSCORE system also allow the estimation of total CVD risk projected to age 60 which may be of particular importance for guiding young adults at low absolute risk at the age of 20 or 30, but already with an unhealthy risk profile which will put them at much higher risk when they grow older. Both systems allow the use of relative risk estimates which, in addition to total absolute risk, may be of interest in particular cases.
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How to manage blood pressure in the context of total cardiovascular disease risk |
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Lifestyle modification
Lifestyle modification is the foundation of any preventive cardiology programme and the European guidelines address the issue of lifestyle change. The aim is to help patients with coronary heart disease or other atherosclerotic disease and healthy high-risk individuals to stop smoking, make healthy food choices, and be physically active and, as a consequence, to reduce weight and weight distribution. The decision to start treatment, however, depends on the level of blood pressure and an assessment of total cardiovascular risk. In patients with established CVD, the choice of antihypertensive drugs depends on the underlying CVD.
A guide to blood pressure management in asymptomatic people is given in Figure 3. The decision to lower blood pressure with drugs depends not only on the total cardiovascular risk but also on the presence of target organ damage. Drug therapy is necessary for individuals with a sustained SBP > 160 mmHg and/or a diastolic blood pressure (DBP) > 100 mmHg, despite lifestyle interventions and regardless of their total CVD risk. At this level of blood pressure, there is compelling evidence that reducing it will reduce the risk of CVD and heart and kidney failure.
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People at high total risk with sustained SBP of 140–159 mmHg and/or DBP of 90–99 mmHg often require drug therapy if these blood pressure values are sustained. For such individuals, drugs should be used to lower blood pressure to < 140/90 mmHg. Similar elevations of BP in lower risk people without target organ damage should be followed closely, and lifestyle advice should be given. Drug treatment might be considered taking the patients' preference into account.
With few exceptions, individuals with SBP < 140 mmHg and/or DBP < 90 mmHg do not need drug therapy, but patients with a high or very high total cardiovascular risk profile, and patients with diabetes, can benefit from reducing blood pressure below the traditional value of < 140/90 mmHg.
Antihypertensive drugs should not only lower blood pressure effectively, they should also have a favourable safety profile and be shown to reduce cardiovascular morbidity and mortality. Five classes of drugs currently meet these requirements: diuretics, beta-blockers, ACE-inhibitors, calcium-channel blockers, and angiotensin II antagonists.
In many clinical trials, blood pressure control is achieved by the combination of two or even three drugs, and drug combination therapy is often necessary in routine clinical practice. In patients at high total risk and requiring several drugs, poly-pharmacy can easily become a major problem, with implications for long-term compliance, and good clinical management is required. In all patients, blood pressure reduction should be achieved gradually.
How is blood pressure being managed in clinical practice
To investigate to what extent physicians and patients act upon these recommendations, two consecutive surveys [European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE I and II)] were undertaken in the European population, involving 3569 and 5556 patients with established coronary heart disease, respectively. The EUROASPIRE I survey was conducted during 1995–1996 in 21 hospitals in nine selected regions in the Czech Republic, Finland, France, Germany, Hungary, Italy, The Netherlands, Slovenia, and Spain.6 Twenty of these hospitals also participated in the second survey (EUROASPIRE II), which was conducted during 1999–2000.7 The original sample was extended with the addition of 27 hospitals from Belgium, France, Greece, Ireland, Poland, Sweden, and the UK. Within each hospital, consecutive patients < 70 years were identified with the following diagnoses: first coronary artery bypass graft (CABG), first percutaneous transluminal coronary angioplasty (PTCA) without previous CABG, first or recurrent myocardial infarction without previous CABG or PTCA, and first or recurrent acute myocardial ischaemia without previous CABG, PTCA, or myocardial infarction. Information on demographics, cardiac history, risk factor management, and prescribed medication were obtained from the medical record. An invitation was then sent to patients, who were interviewed by a trained research assistant at least 6 months after the index event, in order to obtain information on lifestyle, risk factors, and medication. During the interview, blood pressure was measured on the right upper arm in a sitting position by the use of automatic digital sphygmomanometers (Takeda UA 731 in EUROASPIRE I and Omron 711 in EUROASPIREII). In EUROASPIRE I, blood pressure was measured once, but in EUROASPIRE II, it was measured twice. The results from the second survey are based on the arithmetic average of both measurements, except in analyses in which the results of the two surveys are compared. In that case, the first measurement is used. Since two different blood pressure recording devices were used, the performance of both was compared by taking 100 randomly ordered blood pressure measurements from cardiology outpatients in the coordinating centre (National Heart and Lung Institute, London, UK). For SBP, no systematic bias was observed. For DBP, however, the Omron device systematically gave higher readings than the Takeda (+2.64 mmHg). DBP readings from the first survey were adjusted to correct for this systematic difference. Elevated blood pressure was defined as an SBP > 140 mmHg and/or a DBP > 90 mmHg, irrespective of treatment.
In EUROASPIRE I, 4863 consecutive patients were identified who satisfied the inclusion criteria. Among the 4576 patients who were contacted and found to be alive, 3569 agreed to be interviewed, which resulted in a participation rate of 78%. In EUROASPIRE II, 8181 eligible patients were identified, and 5556 were interviewed, namely 76% of the 7310 patients who were contacted and found to be alive. In EUROASPIRE II, blood pressure measurements were available in 5540 patients (99.7%) who attended the interview. Among these, 1368 (25%) had a DBP > 90 mmHg, and 2539 (46%) had an SBP > 140 mmHg. Isolated systolic hypertension was observed in 26%. Altogether, 2795 patients (51%) were classified as having elevated blood pressure during the interview. Large variations were observed between participating centres, with prevalence values ranging from 37 to 64% (Figure 4). Among the 2526 (46%) patients who claimed to be unaware of a past diagnosis of hypertension, 880 (35%) actually had elevated blood pressure. The median blood pressure in these patients was 149/88 mmHg (IQR 143/81–158/94 mmHg). The prevalence of elevated blood pressure in patients who were aware of a past diagnosis of hypertension was 64% (1891 patients; median blood pressure 157/90 mmHg, and IQR 147/82–170/97 mmHg). Conversely, 25% of patients who were classified as having elevated blood pressure during the interview claimed to be unaware of their hypertensive status. A relatively high prevalence of elevated blood pressure was observed in patients included after CABG or ischaemia, and in patients with additional (modifiable or non-modifiable) cardiac risk factors. Elevated blood pressure was observed in 51% of the 4785 (86%) patients taking blood pressure lowering medication (which was not necessarily taken as an antihypertensive treatment). Among patients who claimed to be unaware of a past diagnosis of hypertension, the prevalence of elevated blood pressure was associated with the number of antihypertensive agents used: 40, 36, 29, and 29% in patients using zero, one, two, and three or more different antihypertensive agents, respectively. No such association was observed in patients who were aware of a past diagnosis of hypertension. Patients with elevated blood pressure had a higher prevalence of other cardiovascular risk factors than normotensive patients, as they were older and more likely to be diabetic, hypercholesterolaemic, and obese. Information with regard to a history of hypertension and recent blood pressure measurements were equally available in the medical record of patients with and without elevated blood pressure. Sixty-seven per cent of patients with elevated blood pressure were classified as hypertensive in the discharge letter that was associated with the index event vs. 44% of their normotensive counterparts. Remarkably, 19% of patients who claimed to be unaware of a past diagnosis of hypertension were actually classified as hypertensive in the discharge letter. In the period between hospital discharge and the interview, blood pressure was measured in 98% of patients.
The prevalence of elevated blood pressure during the interview in EUROASPIRE I and EUROASPIRE II was virtually identical (55 vs. 54%).8,9 Among patients with elevated blood pressure, there was a slight improvement in the percentage of patients who had ever been diagnosed with hypertension (67 vs. 71%), the percentage of patients using any blood pressure lowering medication (85 vs. 91%), and, among the latter, the percentage of patients using at least two different blood pressure lowering agents (53 vs. 61%) (Figure 5). However, among patients using blood pressure lowering medication, the proportion achieving the blood pressure goal of < 140/90 mmHg had only increased from 44 to 45%.
These European surveys show a high prevalence of elevated blood pressure in patients with established coronary heart disease. The blood pressure goal of 140/90 mmHg was not reached in about half of the patients. Despite the liberal use of blood pressure lowering medication, blood pressure was inadequately controlled in all participating regions, both in men and women, across different diagnostic categories and otherwise clinically important subgroups. One-quarter of the patients with elevated blood pressure were unaware of their hypertensive status. These European data are in agreement with other observations from elsewhere in Europe and more widely. So there is still considerable potential throughout Europe for the therapeutic control of blood pressure, and about half of all coronary patients require more intensive blood pressure management and, where appropriate, antihypertensive medication. The challenge for primary prevention in people at high risk of developing CVD is even greater.
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Conclusions |
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TopAbstractIntroductionThe scientific rationale for...How to calculate total...How to manage blood...ConclusionsReferences |
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The paradigm change from a dichotomous view of patients either having disease such as hypertension or not, towards the concept of total cardiovascular risk assessment and management, represents an important development in medical thinking and has profound implications for patient management. Targets for individual risk factors such as blood pressure are now considered in the context of cardiovascular risk. Nevertheless, reducing cardiovascular risk through lifestyle changes and medication, whether in primary prevention or in patients with established coronary artery disease, will remain a great challenge to society for the foreseeable future.
Conflict of interest: none declared.
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References |
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