@PCIssuesAnswers#IandA2019

MAKING BEST PRACTICE EVERYDAY PRACTICE

Issues and answers in … QRISK3

Speaker: Dr Clare Hawley

Chair: Dr Kathryn Griffith

QRISK®3PCCS November 2019

Dr Clare Hawley

MB ChB, MRCGP, PG Dip Cardiol, PG Cert Med Ed

Declaration of interest

Associate Specialist Cardiology Chesterfield Royal Hospital

GPwSI Chesterfield Refractory Angina Management Programme

Honorary Senior Lecturer University of Bradford PwSI Programme

This session is not sponsored

In the past I have received honoraria for educational sessions from a number of pharmaceutical companies.

CVD is a leading cause of mortality & disability in the UK and is largely preventable

• Mortality: CVD causes 1 in 4 premature deaths in UK

• Morbidity: 7 million people are living with CVD

• Expensive: £7.4B healthcare costs & £15.8B non healthcare costs pa

• PHE aims to prevent 150,000 strokes, MIs & dementia over next 10 years by

• optimising the detection & treatment of CV risk factors

• increasing the uptake of anti-coagulants, anti-hypertensives & statins

• They predict a return of £2.30 on every £1 spent

CVD is a continuum from exposure to risk factors through to stable & unstable CV disease, acute CV events and end stage disease

Atherosclerosis Progression can be modified by early interventionat different stages

Case 1

• Male

• 42 years

• Non smoker

• SBP 150/90 mmHg

• HbA1c = 38

• Height 178cm, weight 96 kg = BMI 30

Case 1

• Total C: HDL = 5

• Bangladeshi heritage

• Lives in Manchester City – an area of high deprivation

• FH: Father had MI at 54 years

QRISK®2 score at 42 years is 8.2%

‘In a crowd of 100 people with the same risk factors as him 9 are likely to have a heart attack or stroke in the next 10 years – 91 are not! – he is happy with that

QRISK®2 score at 42 years is 8.2% - but his heart age is 53 years

QRISK®- lifetime score shows in 43 years, 66 of the crowd of 100 will have had an event

Who is at risk & how do we know?

• Risk factors are the physical, biochemical & environmental characteristics of an individual or population associated with development of CVD

• Modifiable or

• Non modifiable

A: Age – probably the greatest risk

B: High Blood Pressure

• use average daytime ABPM/HBPM to make diagnosis

• non nocturnal dipping increases risk

• target organ damage LVH, proteinuria

• higher visit-to-visit SBP variability makes risk greater

C: Cigarette smoking – doubles risk, and more if very heavy smoking >20/day

C: Cholesterol

• non HDL cholesterol = LDL + VLDL – we use non fasting TC:HDL ratio

CVD Risk Factors – A:B:C

CVD Risk Factors – A:B:C

D: Diabetes

D: Diet & alcohol

D: Social deprivation – live in deprived areas 4x risk of living in affluent areas

Townsend score – postcode & census data: unemployment, overcrowding, lack of home & car ownership

E: Ethnicity – especially S Asian males

E: Erectile dysfunction - presents 2-3 years before CVD

E: Lack of exercise

F: Family history of CVD in 1st degree relative age <60 years

(BHF CHD statistics 2018)

G: eGFR – especially CKD 3-5 and degree of albuminuria*

G: Gender – men>women until after menopause

H: HIV/AIDS – probably related to retroviral drugs

I: Inflammation/autoimmune disease: rheumatoid arthritis, SLE

M: Mental illness – schizophrenia, bipolar disorder, severe depression

Atypical psychotropic drugs (olanzapine, clozapine, risperidone)

M: Migraine

CVD Risk Factors – A:B:C

*Go et al NEJM 2004

INTERHEART: Combined effect of long term exposure multiple risk factors is greater than the sum of their individual effects

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Estimating an individual’s CV risk – why bother?

• Being able to calculate an individuals risk of CVD enables us to:

• communicate that risk and identify modifiable risk factors

• help people to make an informed choice on lifestyle changes

• offer support to make those changes

• Identifies those who may benefit from primary prevention treatment

• BP lowering medication

• Cholesterol lowering with statins

• Individuals with higher absolute risk have most to gain from interventions vs whole populations

Who should be offered CV risk assessment

NICE recommend: An assessment of risk should be offered every 5 years to:

• adults aged 40 years & over

• individuals at any age with

• first-degree relative with premature CVD or

• familial hypercholestrolaemia

• NHS Health check or simple risk score from data already stored on clinical systems

High-risk groups who do not require CV risk assessment

People with

• established cardiovascular disease*

• CKD stage 3,4, 5 or albuminuria

• familial hypercholesterolaemia

• aged ≥40 years with diabetes

• aged <40 years with diabetes and any of the following:

• DM for at least 20 years

• target organ damage ( albuminuria)

• proliferative retinopathy or autonomic neuropathy

*includes previous MI, ACS, revascularisation, stroke, TIA, aortic aneurism, PAD, or significant plaque on coronary angiography or carotid ultrasound

Calculating CV risk using risk tools

• Risk assessment tools are equations or algorithms derived from studies of populations followed up over time

• Results most meaningful if individual is typical of population studied

Framingham risk score:

• US population-based, observational study started in 1950s

• Included 5200 men & women age between 28-62 years

• Ongoing over 3 generations to collect >50 years of complex data

• 2/3 lived in Framingham MA – not typical of UK population in 2019

• Data collected when CHD prevalence higher than today

• Overestimates risk by 50% in N European & UK populations

• Underestimates risk in people with risk factors not included

JBS2: based on Framingham data

10 year Risk based on:

• Diabetes

• Age

• Sex

• SBP

• TC:HDL

• Smoking status

• 20% risk means of 100 similar people, 20 would be expected to develop CVD over next 10 years (80 won’t) ie 1 in 5 chance of getting CVD in next 10 years

• Driven by age, lots of risk factors not factored in – no longer recommended

High risk = 20% moderate risk = >10% low risk <10%

Qresearch CVD risk algorithm: QRISK® 2007

• QResearch database used data from EMIS records of patients aged 35-74 years registered UK general practices

• At baseline, patients did not have CVD and were not taking statins

• Validated by comparing performance against other risk scores & on control group of practices - measured

• Calibration - how close the predicted risk is to the observed risk

• Discrimination - ability to differentiate between people who will & those who will not over next 10 years

• QRISK® outperformed Framingham & was soon updated to QRISK®2

QRISK®2 - 2008

• QRISK®2 algorithm is updated annually to reflect:

• changes in population: incidence of CHD, BP, obesity, smoking etc

• improvements in quality of electronic health records

• latest evidence regarding new or additional risk factors

• QRISK®2 is integrated into all EMIS, Vision, SystmOne and Microtest systems

• Assesses risk of developing MI or stroke over next 10 years

• Heart age – may be more meaningful to younger & older people

• Actual QRISK® 2 score - all values are available in patient's record

• Estimated QRISK®2 score - from individual’s data & predicted values if gaps

• NICE CG 181: QRISK®2 preferred algorithm for CV risk assessment

QRISK®2 score: 10 year CV risk & heart age

Additional risk factors

• Ethnicity

• Family History

• Social Deprivation

• HBP on treatment

• BMI

• Rheumatoid Arthritis

• CKD stage 4,5

• Atrial Fibrillation

Old guidelines recommended BP lowering & statins if 10 year risk =/> 20%

QRISK®2 has been replaced QRISK®3

Additional risk factors – chosen because thought to increase CVD risk by 10%

• Age 25-84 years

• CKD, includes stage 3,4,5

• Migraine

• Corticosteroid therapy

• Systemic lupus erythematosus

• Severe mental illness

• Atypical antipsychotics therapy

• Erectile dysfunction

• HIV/AIDS (not statistically significant)

• SBP variability – standard deviation of 2 readings

Still doesn’t include• extremes of alcohol• poor diet• lack of exercise

High risk =/> 10% over 10 years

BMJ 2017;357:12099

Case: Jenny age 54 years QRISK® 3

• non-smoker

• white

• affluent area

• father MI age 54 year

• BMI 33 kg/m2

• SBP 150 mmHg

• TC:HDL ratio 5.3

• 10 year CVD risk 6.4%

• below threshold for Tx

• Heart age is 63 years

Case: Jenny - QRISK®- lifetime (LTR) and what if?

• 10 year CVD risk 6.3%

• Heart age is 63 years

• LTR = 58% by 95 years

• LTR = 45% by 85 years

• She might expect to have CVE by age 84 (in 30 yrs)

With better risk factor control

LTR = 32% by 85 years

Expect to have CVE by 95 year so has gained 11 years

Case: Suman age 31 years – 10 year risk

• Indian heritage

• Lives in a deprived area

• Father died aged 54 MI

• Smokes 20 per day

• BMI 27.2kg/m2

• SBP 128mmHg

• TC:HDL ratio = 5

• 10 year CV risk 1.7%

• Heart age 42 years

10 year risk can underestimate lifetime risk in younger people & women even if they have substantially elevated mod risk factors

Case: Suman – lifetime risk

• 10 year risk <2%

• LTR = 53%

• Expected age for CVE is 85 years (in 54 years time) ‘Event free life years’

• With better risk control, CVE would be 95+ years (10 years later) ‘lifetime gains’

Case 3: Ronnie – 10 year risk

• 60 year old male

• white

• heavy smoker

• T2 diabetes

• TC:HDL ratio = 5

• SBP 140mmHg

• BMI 27.5 kg/m2

• Qrisk 10 year risk = 30.9%

• Heart age 80 years

Case 3: Ronnie - a heavy smoker

• Qrisk 10 year risk 31%

• Heart age 80 years

• LTR = 43% by age 85

• Ex smoker LTR = 38%

Case 3 – Jonnie - never smoked• 10 year risk 19.5% (less)

• Heart age = 73

• Life time risk = 43.4% (sl higher)

• non-smoker: lower risk of death from other causes (eg cancers) v heavy smoker • increasing chance of living longer & lifetime risk of developing CVD

Lifestyle advice for all

• Support with smoking cessation

• Mediterranean diet

• Fruit & veg

• Oily fish

• Avoid refined sugars & processed foods

• Regular exercise

• Alcohol – no more than 14U/week

• Maintain healthy weight

Beneficial effects from as early as possible

Blood pressure lowering

Recent BP meta analysis showed* every 10mmHg reduction in SBP results in:

• 13% reduction in all-cause mortality

• 17% reduction CHD

• 27% reduction for stroke

• 28% reduction for heart failure

Can be achieved by lifestyle measures or medication

NICE 136: BP lowering treatment to be considered for:

• adults <80 years with persistent stage 1 HT & CVD 10-year risk ≥10%

• as well as any age with persistent stage 2 Hypertension or stage 3

European Heart Journal, Vol 39, Issue 24, 21 June 2018, Pages 2243–2251, *Lancet p957–967, 5 March 2016

Who needs a statin?

• 4 million people in UK prescribed statins for primary prevention

• NICE CG 181 Statins for Primary prevention

Offer Atorvastatin 20mg od for people with:

• QRISK2 score 10 year risk =/>10%

• CKD 3-5

• T1 & 2 DM

• Over 85s (they are outside the age range)

• There is no recommendation on use of statins in people at low 10 year risk but high lifetime risk

Cholesterol lowering with statinsshould be offering statins at 10% 10 year risk?

Recent review of data for use of statins in primary prevention*

• Statins reduce major CV events by 25% for every 1mmol reduction in LDL

• Treat population of 10,000 with statin for 5 yrs will prevent 500 major CV events

BUT: 5 myopathy, 5-10 haemorrhagic stroke, 50-100 new diabetes, 50-100 other S/E

• For the individual benefit gained depends on absolute risk

• Benefits are different: for age, sex, choice of statin & level of baseline risk

• If 10 yr risk =/>20% all ages, both sexes likely to benefit NNT to prevent 1 CVE = 40

• If 10 yr risk =/10-15% benefit less convincing NNT = 400

*Byrne et al BMJ 2019;367:l5674

Lifetime risk (LTR)

• Novel way of communicating lifetime consequences of current lifestyle/risk factors and the opportunity to reduce/delay future CVD events by early appropriate lifestyle changes and possibly drug treatments

• NICE recommend assessing LTR as an alternative to 10-year risk.

• Will pick up younger people who have low short term risk (men, +veFH, non white heritage)

• May also mean fit & healthy older people decide not to take a statin

Dave: age 80 years cycles in to clinic

• Never smoked

• Not diabetic

• BP140/88mmHg

• TC:HDL=2.2

• BMI = 24.6

• 10 year risk = 25.9%

• Heart age is 77 years

Dave: age 80 years cycles in to clinic

• Never smoked

• Not diabetic

• BP140/88mmHg

• TC:HDL=2.2

• BMI = 24.6

• 10 year risk = 28.9%

• LTR = 15.4%

• Heart age is 77 years

QRISK®3: Summary

• CVD is the leading cause of mortality & disability in UK & is largely preventable

• The ability to estimate a person’s CV risk is helpful in communicating this risk & informing the need for lifestyle change & primary prevention

• In people without existing CVD, QRISK3 score can:

• Predict the likelihood of a CV event over the next 10-years

• Calculate heart age & predict lifetime risk which will identify younger people at low 10 year risk but high lifetime risk

• Inform the benefit of risk factor modification & lifestyle change from early on

• Inform the need to consider BP lowering medication and statins

• It might avoid over treatment in otherwise fit & healthy elderly people

• More evidence is needed before we routinely offer statins to people at lower risk

Other Heart Age scores: JBS3, NHS & BHF

• Heart age vs real age

• Also provides advice on how to reduce heart age

Joint British Societies - JBS 3

JBS3: Heart age & effect of intervention

Outlook

JBS 3 - Heart age compared

JBS 3 - Healthy years

JBS 3 - Outlook

JBS 3 - Compare

JBS 3 – Risk by age

JBS 3 - Outcomes

JBS 3 - balance

JBS 3 – years gained