The dramatic improvement in the management of cardiovascular disease over the past decade and the challenges that lie ahead were key elements of ‘Looking to the Future’, the 10th anniversary Annual Scientific Meeting of the Primary Care Cardiovascular Society held in London on 11th–13th October 2007. Over this period, the PCCS has grown from a small organisation to the influential body it is today. Medical journalist Rhonda Siddall reports from the meeting where an air of optimism embraced all the sessions, from celebration of past achievements to discussion of the future problems a new decade will bring.
The changes made in the diagnosis and management of cardiovascular disease over the past 10 years, led by primary care, were described as “momentous” by Primary Care Cardiovascular Society (PCCS) past chairman and board member Professor Richard Hobbs (Department of General Practice and Primary Care, University of Birmingham).
Presenting the opening address ‘A decade of advances in cardiovascular disease’ at the two-day annual scientific meeting, he said: “Primary care teams have led advances in the treatment of cardiovascular disease and cardiovascular risk factors. They should feel very proud of the contribution they have made to the decline in mortality from cardiovascular disease”.
Professor Hobbs summarised some of the key milestones of the past 10 years, citing the INTERHEART study as one of the most significant papers from a primary care cardiovascular perspective. “INTERHEART confirmed that the traditional risk factors we are focusing on in primary care are the prime drivers of cardiovascular disease.” He added that a key development over the past decade was recognising that a combination of cardiovascular risk factors is more than the sum of its parts. “The arrival of multiple risk scoring algorithms and risk score charts has changed how we approach assessing cardiovascular risk but a remaining challenge is for their use to be widespread rather than for them to be the subject of argument.”
Positive developments over the last 10 years, according to Professor Hobbs, are the recognition that diabetes is “accelerated cardiovascular disease”, improvements in hyperlipidaemia and heart failure management, and the implementation of evidence-based medicine. But recent data from the EUROASPIRE study shows that around half of hypertension patients remain uncontrolled, reflecting a status quo that Professor Hobbs said needs to change in the future and that should be aided by the joint guidelines from the British Hypertension Society/National Institute for Health and Clinical Excellence (BHS/NICE).
This was echoed by Professor Tom MacDonald (Department of Clinical Pharmacology, University of Dundee), who also welcomed the publication of the joint BHS/NICE guidelines, which he described as a “major advance in hypertension management”.
Speaking about developments in hypertension management, he said: “A key message to emerge over the past 10 years has been the notion that the benefit from lowering blood pressure depends on global risk: the higher a patients’ cardiovascular risk, the more events can be prevented from risk reduction strategies”.
Turning to advances in lipid management, Dr Jonathan Morrell (General Practitioner, Hastings, and a founding member of the PCCS), said there is still debate over cholesterol targets due to disagreement between those recommended by the Joint British Societies’ 2 (JBS 2) guidelines and the DoH directive that the higher targets enshrined in the new General Medical Services contract – and first set in the National Service Framework for Coronary Heart Disease (NSF for CHD) – should remain thresholds for intervention.
Sitting on the side of the ‘JBS 2 fence’, Dr Morrell said: “There is still debate over who should be treated, when and with what and how low to go. In my opinion, JBS 2 is pretty much a state of the art intervention document”.
Dr Morrell also warned that this debate over-played concerns about the side effects of potent statin treatment and threatened to cloud the benefits of cholesterol management in patients’ minds and impact on their compliance. “As we procrastinate over how low to go, we are in danger of obfuscating the issue of the great benefits that many people stand to gain from cholesterol lowering,” he said.
Revised NICE guidance on lipid modification, expected shortly, is likely to recommend no lowering in cholesterol targets but, according to Dr Morrell, implicitly acknowledges that lower targets are valid. In terms of the future, Dr Morrell predicted that GPs will be following guidelines recommending combination therapy for lipid modification in the vein of hypertension management and prescribing a lipid polypill.
“In the real world of side-effect issues, drug interactions and biological measurement variability, responses to lipid-lowering treatments, as with other medicines, are not always uniform. Practitioners need to understand and be skilled in the use of available therapies either as monotherapy or, increasingly, in combination.”
Concluding, Professor Hobbs said primary care has helped to deliver significant improvements in the management of cardiovascular disease in partnership with policymakers. The NSF for CHD, which set a 10-year goal in the year 2000 of reducing deaths from CHD and stroke by 40%, paved the way for a decade of quality care that has been accelerated by the introduction of incentives and targets – and early achievement of the 10-year goal.
The challenges ahead
So, can primary care teams now sit back and rest on their laurels? Professor Hobbs thought not. “Primary care deserves a slap on the back for its achievements in improved cardiovascular management. But faced with an epidemic of obesity and diabetes, primary care teams need more support from a larger evidence base to determine how best to assist patients to achieve the lifestyle changes that are necessary to make continued progress.”
Improvements in primary prevention, agreed all the speakers, are a major goal for primary care teams in the next decade, but support for targets and additional resources will be needed to achieve success.
Hints of future issues and what might drive progress in the coming decade were discussed by a panel of experts during a particularly lively session at the meeting. The panel comprised Dr Nicholas Boon, President, British Cardiovascular Society; Dr Donal O’Donoghue, National Clinical Director for Renal Services; Mr Murray Halliday, Expert Patient; Dr Terry McCormack, Chairman, PCCS; Dr Sheila Shribman, National Clinical Director for Children; and Professor Peter Weissberg, Medical Director, British Heart Foundation.
Talking about the future possibility that we may be able to predict which children are likely to be at higher risk of cardiovascular disease, Dr Boon told the meeting: “There is accumulating evidence that biochemical measures done on core blood might predict those individuals at higher risk of cardiovascular disease at a later stage in life. It is possible that we might find in the next five to six years biochemical tests available that identify these individuals”.
Professor Peter Weissberg said the British Heart Foundation was so concerned about the issue of childhood obesity that it has decided to make this issue a continued focus for its campaigns. The organisation is also developing a nurse risk-assessment programme, with a view to such nurses visiting areas where childhood obesity is more prevalent to support children and families in lifestyle choices and changes.
Mass prescribing of statins
More contentious was the possibility that there may be a future recommendation to prescribe statins for everyone over the age of 50. For different reasons, the panel thought that this was unlikely.
“There is a compelling case for everyone over age of 50 to receive a statin but we do not have the resources to do this,” argued Dr Boon. While Dr O’Donoghue said that he would be concerned about the cost of a mass prescribing programme. He thought that this would be effective only if implementation of such a programme addressed the complicated issue of compliance.
Professor Weissberg agreed that, in terms of population risk and reducing CV events, mass prescribing of statins to the over 50s would be beneficial but not feasible in the current climate with respect to concerns over statin safety. “The lay population is just not prepared to accept that there is a risk-benefit ratio and until we reach that level of sophistication, this kind of progamme will not be acceptable.
Dr McCormack added: “Addressing cardiovascular risk is not just about cholesterol. It would be better to offer a screening programme for cardiovascular risk at the age of 50 rather than automatically prescribe a statin.”
FH cascade testing
Professor Weissberg announced that the British Heart Foundation would be pushing for cascade testing for familial hypercholesterolaemia (FH) this year. The forthcoming NICE guidelines on FH, due in August, are likely to address this issue and will impact on primary care.
Professor Steve Humphries (BHF Chair of Cardiovascular Genetics, University College London) spoke about the outcome of a Department of Health-funded pilot study of FH cascade testing, which traces and tests relatives from known FH patients to identify new cases. The pilot was run for two years at five locations in England, resourced by a full-time nurse, to assess the feasibility of implementing a genetic service in the mainstream healthcare setting (lipid clinics). Low-density lipoprotein cholesterol measurements for the diagnosis of FH give a poor sensitivity and specificity.
Professor Humphries said: “We have demonstrated that cascade testing is cost-effective, with an overall cost for identifying a new FH patient of £500,” but that effective implementation requires the development of an integrated national infrastructure.
“Education programmes and incentives will be needed for a range of professionals in primary care teams to ensure patients with FH are identified and offered appropriate care. In particular, research to determine the optimum strategies for the identification of undiagnosed individuals in general practice is required, since cascade testing from known FH cases is likely to identify only half of the predicted 100,000 FH cases.”
Not all nice things are bad for you…
Professor Roger Corder (Department of Experimental Therapeutics, Queen Mary College, University of London) engaged the audience by discussing his research to uncover the truth behind the potential cardioprotective effects of regular red wine consumption. He isolated vascoactive polyphenols from a cabernet sauvignon wine extract and found that the purified red wine polyphenols were all identified as oligomeric procyanidins (OPC).
Investigation of wines from different origins indicates a potential relationship between increased longevity and consumption of wines with a higher procyanidin content. Research on cocoa extracts has also revealed OPC as a key vasodilator component. The next steps are to focus on factors affecting the bioavailability of OPC and to assess the response to increased consumption in patients and volunteers to define optimal daily amounts. It is unlikely that recruitment will be a problem!
Future wish list
So as another busy meeting drew to a close, which saw delegates enjoying the usual PCCS mix of discussion, debate and discourse, it was left to PCCS Chairman, Dr Terry McCormack, to sum up the proceedings. He concluded with a personal wish list, highlighting the following developments he would like to see in the coming decade:
- A change in patent laws so that patents are granted on new drugs on the day they are brought to market, rather than from the point they are first discovered, to extend the time frame available to collect end point data.
- A formal system for introducing the concept of specialist training early (within a framework of GPs remaining generalists), to secure more doctors to commit to a career in general practice.
- For patients with erectile dysfunction (ED) to be entitled to be prescribed medication on the NHS as in most instances ED is a vascular disease.
- For there to be no centrally-led edict that all people over the age of 50 should be prescribed a statin.
- For primary care to take a lead in commissioning.
- For the PCCS to continue to punch above its weight.