Hot Topics Blog
On Wednesday the 29th January we ran the first in a series of three free evening CVD Webinars, with a view to getting into the real detail of cardiovascular disease management in primary care over the next few months. We were joined by a consultant cardiologist and it was great to discuss that interaction between primary and secondary care, particularly around secondary prevention. We know that this area is increasingly complex and truly risks the patient falling into a gap between primary and secondary care following a CV event.
We had a huge audience both live that evening and on catch up with lots of questions asked, which repeated on similar themes, some of which I will tackle in this blog.
What does CVD actually mean?
A good lesson for me was the reminder that cardiovascular disease refers to anything affecting the vascular system – so Mi/angina, CVA, peripheral arterial disease, microvascular disease and so on. Of course, atherosclerotic diseases share common risk factors and many patients will have disease in multiple vascular territories and are thus at particularly high risk.
What is the most up to date CV risk calculator?
A significant update on QRisk2 is the Qrisk3 10 year CV risk calculator. It contains a number of additional CV risk factors such as rheumatoid arthritis, CKD stage 3 (as well as 4 and 5), severe mental illness, migraine and erectile dysfunction. Although it has been around for a while it has not yet been incorporated into most GP computer systems. Watch this space…(hopefully)! https://www.qrisk.org/three/
What is the role for ezetimibe?
Ezetimibe selectively blocks LDL (bad) cholesterol absorption. It has not been tested as an alternative to statins (unlike fibrates). In addition to statins, they reduce cholesterol a little more. We now have some outcome data to show improved CV outcomes for secondary prevention (patients post-ACS) where ezetimibe is added to simvastatin (IMPROVE-IT study) - Addition of ezetimibe to simvastatin reduced the relative risk of a CV event by 6% requiring treatment of 50 people to prevent 1 event. When the breakdown was analysed this was predominantly in people with diabetes such that we only need to treat 20 people with diabetes to prevent an event whereas close to 200 people to prevent 1 in those without diabetes.
In summary - Not an alternative to statins. Consider in secondary prevention post-ACS in addition to statins for those with diabetes who do not reach targets (possibly if they have had a CV event on statins).
What are the PCSK9 inhibitors all about?
LDL receptors on the cell membrane are responsible for bringing LDL into the cells. Once in the cell, the PCSK9 molecule holds them in the cell and breaks them down. By blocking the PCSK9, the LDL receptors are free to return to the cell membrane and bring down the cholesterol further. Using biologics (synthetic antibody fragments) the PCSK9 molecule can be blocked over a long time period up to 3 months.
In the very high risk, and those who’s cholesterol is not responsive to statins, these reduce risk of heart attacks and stroke a further 15-20%. Currently, these are expensive, however as technology develops they are becoming cheaper. They have the benefit over tablets in that 3 monthly injections have better adherence, the disadvantage is that they are injections and may need a day case treatment centre to give them. Use of these drugs will be through secondary care, but it is important to bear them in mind as an option for patients with familial hypercholesterolaemia who do not reach their target cholesterol level with high intensity statins +/- ezetimibe - if you are in an area without access to a specialist lipid clinic consider referral to your local cardiologist for consideration if you have patients in this situation.
What is the up to date evidence on aspirin in primary prevention?
We have known for a while that aspirin is not advised in primary prevention and most recent evidence supports this. A number of trials over the last few years including ASCEND in people with diabetes and ASPREE in older people have reinforced that the risk of bleeding outweighs any benefits in primary prevention. In terms of the numbers, a large metanalysis in 2016 showed a relative risk reduction in MI of 22% but a 59% increase in GI bleeding and a 33% increase in haemorrhagic stroke
What are the anti-platelets advised for each type of CVD?
Anti-platelet and anti-coagulation strategies in secondary prevention of CVD is an area where regimens have become increasingly complex. The risk stratification and evidence base vary between different type of CV disease, meaning that patients end up on very different regimens both in terms of content and duration. The take-home message for me is that we are moving to an age of personalised medicine where individual risk needs to be taken into account when selecting strategies.
We have emerging evidence of advantages from adding low dose DOACs to anti-platelets, namely rivaroxaban (NICE approved Oct 2019). The evidence in stable coronary artery disease comes from the COMPASS trial which showed small but significant benefits in the highest risk patients i.e. those with multiple sites of CVD and multiple risk factors. Of course, benefits need to be closely balanced with bleeding risks.
We have also seen emerging evidence in TIA and CVA management from a systematic review published in the BMJ which was triggered by the publication of the large POINT trial. This review showed benefits of dual antiplatelet treatment for the first 10 to 21 days after a TIA or minor CVA over and above aspirin alone.
So, fascinating emerging evidence in this area. But are these more complex regimens all for secondary care to decide and commence? What about our patients with stable coronary artery or peripheral artery disease under primary care? Of course, we asked our secondary care colleague where the decisions and prescribing should lie – and interestingly he felt in future this would lie mainly with primary care once national guidelines are updated, further evidence emerges and clinical confidence increases. An interesting area for further discussion…
See my simplified table below with the most recent evidence currently available. The key is individualised choice according to patient risk vs benefit profile, a highly informed discussion is vital.
Join us for the next instalment on 23rd April when we will focus mainly on Primary Prevention of CVD – a case based discussion about how best to do prevent CV disease, how to optimise treatment and improve compliance.
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