Find Courses Find Online Courses Find Booklets Find Appraisal Essentials Basket 0

Hot Topics Blog

CVD Webinar - Q&A Summary

Dr Sarah Davies - 13 Feb, 2020

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)!

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.

Screenshot 2020-02-12 at 14.10.29.png

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.

Find this blog useful? You can quickly add CPD to your account by writing a reflective note about the post you have read.

Log in to your NB Dashboard and use the 'Add Reflective Note' button at the bottom of a blog entry to add your note.


Improving early diagnosis of cancer: Goodbye tick boxes, Hello RDCs

Dr Simon Curtis - 11 Feb, 2020

Julie was 60 and presented with some cramping low abdominal pains and bloating. She had lost some weight and feels tired. She was a smoker. I did a CXR and some bloods. The CXR was fine, but she had a slight anaemia and raised platelets. I was worried that she may have cancer and wanted to urgently refer her, but to where? I referred her to colorectal, they did a colonoscopy and then referred her to upper GI. Nothing found. I then referred her to gynae and it was at this point, now about 6 weeks in from my original referral, that she started coughing up blood…Quick change of direction, and to respiratory she went where her lung cancer was diagnosed on CT scan. For poor Julie this was an avoidable delay in diagnosis. Recent data from the National Cancer Diagnosis Audit published in BJGP2018;68:e63 shows that a third of all avoidable diagnostic delays are not due to clinician or patient, but system related factors. We have all had patients like Julie, who as referrals have become pathway driven have fallen through the gaps between these pathways.

Improving early diagnosis of cancer has been a Hot Topic ever since the NICE NG12 suspected cancer guidance of 2015, and it has become more so as it is a key priority in the NHS Longterm Plan (LTP) published in 2019. At the moment in the UK, 50% of cancers are diagnosed at stage 1 or 2. The LTP has set an ambitious target to raise that figure to 75% over the next decade. They estimate this will lead to 50,000 more people each year surviving their cancer for more than 5 years. For GPs in England, NHSE have made early cancer diagnosis a major new QI domain in QOF for2020/21.

The NICE NG12 guideline is arguably the national guideline that has had most impact on clinical care and referral, and it is enshrined in most regions’ local urgent cancer referral pathways. It has many positive aspects and hopefully it will have led to many more patients having an early diagnosis of cancer, but it also re-enforces a tick-box pathway model and there are two fundamental problems with this. Firstly, as every GP knows, sometimes patients just don’t tick all the boxes and yet significant clinical concern remains. Secondly, patients like Julie may tick boxes on several different pathways but it is not clear where to refer her. This problem is compounded by the fact that we no longer refer to a clinician who will take clinical responsibility for the case, but to a nameless diagnostic pathway of an individual body system. Once cancer in that particular ‘silo’ has been ruled out, the patient is sent back to you and the process has to restart. Patients, like Julie, frequently fall then between the gaps and this can lead to significant diagnostic delays.

The NHS Longterm Plan (LTP) plans that there will be many more Rapid Diagnostic Centres (RDCs, sometimes called Multidisciplinary Centres or MDCs) across the country so that patients with possible cancer can be assessed and diagnosed in a single 'one stop shop' visit. These are now being rolled out (and already in place in some areas) to refer patients to who have non-specific symptoms that are concerning but do not 'fit' with a specific diagnosis. The longer-term plan however is for ALL suspected cancer referrals with suspected cancer to go through this single point of access to prevent patients falling through the gaps between different pathways.

 A recent pilot study , funded by CRUK and published in the BJGP January 2020 has just reported, looking at outcomes from a rapid diagnostic centre in Port Talbot, Wales. Patients were referred to the RDC if they did not fulfil criteria for a specific urgent cancer referral pathway, but had non-specific symptoms which their GP was worried may be due to cancer. They were matched with control patients not referred to the RDC. The RDC reduced mean time to diagnosis from 84 days in usual care to 6 days if a diagnosis was made in the RDC clinic, and if further investigations were needed from the initial RDC appointment the diagnostic delay was halved to 41 days.

These are very significant results and interestingly NICE have now announced that NG12 will not be updated, as we move towards a change in service delivery with RDCs at the centre of this (although outcomes from further pilot studies are awaited).

It’s too late for Julie, but hopefully over the next few years these changes will lead to fewer patients falling through the gaps and suffering avoidable delays in their cancer diagnosis. Ticking boxes may be helpful for to do lists and shopping, but for diagnosis of cancer we need a more subtle, flexible, thoughtful, clinical and above all holistic approach to diagnosis.

Find this blog useful? You can quickly add CPD to your account by writing a reflective note about the post you have read.

Log in to your NB Dashboard and use the 'Add Reflective Note' button at the bottom of a blog entry to add your note.