Prof. Jaakko Tuomilehto
Department of Public HealthUniversity of Helsinki,
Department of Epidemiology and Health PromotionNational Public Health Institute
Helsinki, Finland;
Donau-Universität Krems, Krems, Austria;
Chair, Working Group on Epidemiology and PreventionEuropean Society of Cardiology
0 1000 2000 3000 4000 5000 6000 7000
Musculoskeletal diseases
Congenital abnormalities
Other neoplasms
Nutritional/endocrine disorders
Tuberculosis
Perinatal conditions
Diseases of the genitourinary system
Diabetes mellitus
Neuropsychiatric disorders
Respiratory infections
Digestive diseases
Respiratory diseases
Injuries
Malignant neoplasms
Cardiovascular diseases
DEVELOPED COUNTRIESDeaths in 2001 attributable to 15 leading causes
Number of deaths (000s)
98% of all deathsattributable to
15 leading causes
Source: WHR 2002
0 500 1000 1500 2000 2500 3000
Occupational risk factors for injury
Occupational particulates
Unsafe sex
Illicit drugs
Occupational carcinogens
Lead exposure
Urban air pollution
Alcohol
Physical inactivity
Low fruit and vegetable intake
High Body Mass Index
Cholesterol
Tobacco
Blood pressure
DEVELOPED COUNTRIES Deaths in 2000 attributable to selected leading risk
factors
Number of deaths (000s)
CVD PREVENTION WORKS
Age-adjusted mortality rates of
coronary heart disease in North Karelia and the
whole of Finland among males
aged 35-64 years from 1969 to
2001
Mortality per 100 000
population
100
200
300
400
500
600
700
70 75 80 85 90 95 2000
Year
Start of the North
Karelia Project Nationwide activity
Comparing the observed male mortality rates from CHD in N.E. Finland with those predicted from changes in the risk factors.
Vartiainen et al. 1994.
1975 1980 1985 1990-70
-60
-50
-40
-30
-20
-10
0
Observed mortality
Smoking
Blood pressure
All three risks
Cholesterol
Perc
en
t d
ecli
ne
CVD PREVENTION WORKS
• Japan: reduction of salt intake resulting in lower blood pressure levels and drastically reduced stroke mortality.
• Singapore: national programme associated with decline in NCD trends.
• Mauritius: changing cooking oil from palm to soy bean oil resulted in a 15% decrease in serum cholesterol in the population.
• Poland: sudden change in dietary fats, related to political changes - resulted in a 20% decline in heart disease mortality.
Serum cholesterol Men 30-59 years
5
5,5
6
6,5
7
7,5
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu Province
Lapland
mmol/lmmol/l
Diastolic Blood PressureWomen 30-59 Years
75
80
85
90
95
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu Province
Lapland
mmHg
Smoking PrevalenceMen 30-59 Years
0
10
20
30
40
50
60
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu Province
Lapland
%
Body-Mass IndexMen 30-59 Years
25
26
27
28
29
30
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio
Turku/Loimaa
Helsinki/VantaaOulu Province
Lapland
Kg/m2
Prevalence of HYPERGLYCEMIA in European people aged 30 - 92 years - DECODE
• Previously known diabetes: 4.9%
• Isolated fasting hyperglycemia: 2.1%
• Isolated post-challenge hyperglycemia: 1.7%
• Combined hyperglycemia: 1.6%
• Impaired glucose tolerance (IGT) 11.9%
• TOTAL HYPERGLYCEMIA 22.2%
DECODE Study Group. Lancet 1999;354:617–621
1994 First Joint Task Force Recommendations
1994 Joint European Societies Implementation
Group on Coronary Prevention
1995-96 EUROASPIRE I
1998 Second Joint Task Force Recommendations
1999-2000 EUROASPIRE II
2000 Joint European Societies CVD Prevention Committee
2003 Third Joint Task Force Guidelines
European Guidelines on Cardiovascular Disease
Prevention in Clinical Practice
The Third Joint Task ForceEuropean International European EuropeanAssociation Diabetes Society of Society offor the Study Federation General Hypertension Diabetes Europe Practice/Family
Medicine
International European European European
Society of Society of Heart Society of Behavioural Atherosclerosis Network
Cardiology Medicine
European Guidelines on Cardiovascular Disease Prevention in Clinical
Practice
What is new in these guidelines?• From CHD to CVD prevention• A new risk estimation model: SCORE• Update / adaptations of
– Priorities– Goals– Management aspects
Task force risk chart
Based on Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83(1):356-62
Age180
160
140 70120
180
160
140 60120
180
160
140 50120
180
160
140 40120
180
160
140 30120
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
Over 40%20% to 40%10% to 20%5% to 10%Under 5%10-year risk
150 200 250 300mg/dl
Cholesterol mmol
Women Men
Non-smoker Smoker Non-smoker Smoker
10-Year risk of coronary heart disease
Problems with the existing chart
• Based on the Framingham function which overpredicts in European populations with low or medium levels of disease incidence
Thomsen et al. Int J Epidemiology, 2002, In press
Problems with the existing chart
• Derived from a relatively small data set; few or no events in some risk factor combinations
• Difficult to accommodate other risk factors such as as HDL-cholesterol
• Uses end points which cannot be reproduced from other data sets; therefore hard to validate
• Probably underestimates the importance of diabetes
The SCORE ProjectThe Systematic COronary Risk Evaluation Project
Started in 1998 under the auspices of The European Society of Cardiology
Conducted and supported by: • Royal College of Surgeons in Ireland• EU BIOMED II programme
Contract BMH4-98-3186
• National funding agencies of the component studies
SCORE
SCORE objectives
To assemble databases representative of typical European populations to assess the accuracy of the existing European risk system.
To prepare a risk score system or systems which are optimised for coronary prevention in European clinical practice.
SCORE
The SCORE database
12 European cohort studies– Mainly population studies – Some with multiple component cohorts
In round figures:• A quarter of a million persons• 3 million person-years of observation• Over 7,000 fatal cardiovascular events
SCORE
Key differences
• Total fatal cardiovascular risk rather than just CHD
• Fatal events rather than total events• Charts for cholesterol and cholesterol:HDL
ratio• New chart shows more detail in 50-65 age range• No charts for those with established disease or
diabetes
SCORE
Better than current chart– or simply different?
Current predictionCurrent prediction– CHD– Includes nonfatal events– Uses idiosyncratic definition– Not possible to break down risk
into angina and MI – Over-predicts in low/medium-
risk regions– ”One size fits all”
SCORE predictionSCORE prediction– CVD (but can do CHD)– Restricted to fatal events – Uses common definition– Component risks can be calculated– Separate prediction for low risk
regions– Can be customised using national
mortality statistics
SCORE
Priorities of Cardiovascular Disease Prevention in Clinical
Practice• Patients with established coronary heart disease, peripheral artery disease and cerebrovascular atherosclerotic disease• Asymptomatic individuals who are at high risk of developing atherosclerotic cardiovascular disease because of:
Multiple risk factors resulting in a 10 year risk of > 5% now (or if extrapolated to age 60) for developing a fatal cardiovascular event.
Markedly raised levels of single risk factors: cholesterol > 8 mmol/l (320 mg/dl), LDL chol > 6 mmol/l (240 mg/dl),
blood pressure > 180/110 mmHg Diabetes Type 2 and diabetes Type 1 with microalbuminuria
• Close relatives (first degree relatives) of Patients with early-onset atherosclerotic cardiovascular
disease Asymptomatic individuals at particularly high risk
• Other individuals met in connection with ordinary clinical practice
Using the cardiovascular risk chart
Note that total CVD risk may be higher than indicated in the chart:- as the person approaches the next age category.- in asymptomatic subjects with pre-clinical 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
Using the cardiovascular risk chart
Qualifiers
European Guidelines on Cardiovascular Disease Prevention in Clinical
PracticeManagement of risk in clinical practice• Behavioural changes• Dietary changes• Smoking cessation• Physical activity• Control of arterial hypertension• Management of dyslipidemias• Management of diabetes• Prevention in subjects with the metabolic
syndrome• Prophylactic drug therapy
How to achieve intensive lifestyle change in patients with disease and in high risk people?
Strategies to make behavioural counselling more effective include:
• Develop a therapeutic alliance with the patient• Gain commitments from the patient to achieve lifestyle change• Ensure the patient understands the relationship between lifestyle
and disease• Help the patient overcome barriers to lifestyle change• Involve the patient in identifying the risk factor(s) to change• Design a lifestyle modification plan• Use strategies to reinforce the patient’s own capacity to change• Monitor progress of lifestyle change through follow-up contacts• Involve other health care staff wherever possible.
European Guidelines on Cardiovascular Disease Prevention in Clinical
PracticeManagement of risk in clinical practice• Behavioural changes• Dietary changes• Smoking cessation• Physical activity• Control of arterial hypertension• Management of dyslipidemias• Management of diabetes• Prevention in subjects with the metabolic
syndrome• Prophylactic drug therapy
Guide to Blood Pressure Management
Estimate absolute fatal CVD risk* using the SCORE Chart
Use initial office blood pressure# to estimate risk of fatal CVD
Absolute risk of fatal CVD < 5%
and no targetorgan damage
DBP 90-109 mmHgand/or
SBP 140-179 mmHg
Lifestyle advice forseveral monthswith repeat BPmeasurements
Absolute risk of fatal CVD < 5%and target
organ damageDBP 90 mmHg
and/orSBP 140 mmHg
Lifestyle advice and drug therapy#
DBP > 110 mmHgand/or
SBP > 180 mmHg
Lifestyle advice anddrug therapy#
promptly and independently of
total risk
BP< 140/90mmHg
Maintainlifestyleadvice
and annual follow-up
DBP90-94and/or
SBP 140-149mmHg
Reinforcelifestyleadvice;
drug therapyif preferredby patient
DBP> 95
and/orSBP > 150
mmHg
Drug#
therapy andreinforcelifestyleadvice
*High fatal CVD risk > 5% over 10 years or will exceed 5% if projected to age 60 years.This corresponds to the formerly used 20% absolute risk of a composite of coronary heart disease events.
# Consider causes of secondary hypertension. If appropriate, refer to a specialist.
CAUTION: Patients with normal or high normal pressure (130-139/85-89 mmHg) may qualify for antihypertensive treatment if they have a history of stroke, CHD, or diabetes.
Absolute risk of fatal CVD > 5%
andDBP 90 mmHg
and/orSBP 140 mmHg
Lifestyle advice anddrug therapy#
Goals:< 140/90 mmHg in all high risk subjects< 130/80 mmHg in patients with diabetes
Goals for CVD prevention in patients with type 2
diabetes
* HbA1c
* Fasting plasma glucose
* Self-monitored blood glucose
- fasting
- postprandial
* Blood pressure
* Total cholesterol
* LDL cholesterol
< 6.1%
< 6.0 mmol/l (110 mg/dl)
4.0-5.0 mmol/l (70-90 mg/dl)
4.0-7.5 mmol/l (70-135 mg/dl)
<130 / 80 mm Hg
<4.5 mmol/l (175 mg/dl)
<2.5 mmol/l (100 mg/dl)
European Guidelines on Cardiovascular Disease Prevention in Clinical
PracticeWhere to find more?• Executive summary
Eur Heart J 2003;24:1601-1610Eur J Cardiovasc Prevention & Rehab 2003; 10(4):S1-S11
• Pocket version• Full document
soon on the ESC webpublished later in 2003 EJCPR
