There was a buzz about this year’s H·E·A·R·T UK – The Cholesterol Charity’s annual conference. An impressive array of speakers, plus the pertinent theme, Beyond Risk Assessment: Non Invasive Assessment of Atherosclerosis, meant that each lecture attracted enthusiastic audiences.
Dr Peter Brindle, the Research and Development Director and GP at the Bristol Primary Care Trust, lit the spark by taking the first lecture spot. With the title Advances and Controversies in CVD Risk Estimation he was stepping into the lions’ den. Earlier in the year H·E·A·R·T UK welcomed the continued use of well-established and validated risk calculation tools within the National Institute of Health and Clinical Excellence (NICE) lipid modification guideline and had endorsed the guideline group’s decision not to recommend more novel experimental approaches. So the delegates were keen to hear Dr Brindle announce the launch of QRISK2, based on patient level data from 2.8 million people over a 15-year period – 1993–2008. This is an improvement on the original QRISK, which was derived from a database of 1.3 million people from 318 practices. After discussing the benefits of QRISK2, Dr Brindle added: “After this I don’t know how much further we can go.”
Dr Brindle emphasised that the second version has an advantage over Framingham as it enables first-line ethnicity and social deprivation to be tested for the first time. This is particularly relevant as a recent study revealed that the accuracy of the Framingham score in 27 different populations ranged from overestimating true risk by 2.9 times, to underestimating by 57%. In particular, that survey showed that the Framingham score systematically underestimated cardiovascular disease (CVD) risk in people from deprived areas compared with people with identical risk factors but from more affluent areas. Dr Brindle reminded his audience that these anomalies could lead health officials to underestimate the risk in the manual social classes.
Dr Brindle stressed that effective risk assessment is essential for policymakers too. “It is important to get CVD risk assessment right for both the policymakers and individuals.” Looking ahead to the future, he concluded by saying: “There are exciting prospects ahead for CVD risk assessment with the improved electronic patient record systems and improving data sources”.
An appreciative audience gave Dr Brindle a cautious approval for his innovative new system and H·E·A·R·T UK looks forward to the further development of more accurate cardiovascular risk assessment tools for the UK population, such as QRISK2 and ASSIGN in Scotland (ASSessing cardiovascular risk using SIGN) as a means of targeting at-risk groups and ensuring that they receive appropriate advice and treatment to reduce the enormous impact of CVD in the UK.
Coronary artery calcium score
Professor Robert Elkeles, Consultant Physician, Professor of Diabetic Medicine, Unit for Metabolic Medicine at St Mary’s Hospital, London, offered a very different option for CVD risk assessment – measurement of coronary artery calcium score (CACS). The Prospective Evaluation of Diabetic Ischemic Heart Disease by Computed Tomography (PREDICT) study was created to see whether CACS was predictive of cardiovascular (CV) events in type 2 diabetes. It could also investigate whether there was any correlation between conventional and novel cardiovascular risk factors. The results were that CACS was highly predictive of CV events in type 2 diabetes and that it had a greater predictive value than other risk factors. Professor Elkeles told the delegates that: “CACS is a powerful indicator for asymptomatic individuals – especially those of intermediate risk”. He went on to say: “it would be a good idea to use CACS as a biomarker as an increased calcium score is highly predictive”.
Reversal of atherosclerosis
The Myant Lecture was given by Professor Cesare Sirtori, Professor of Clinical Pharmacology, and Dean School of Pharmacy at the University of Milan. His lecture, entitled Reversal of Atherosclerosis – Science Fact or Science Fiction, confirmed that reversal is definitely not fiction, but hard fact with plenty of science to support it. Established atherosclerosis may appear unlikely to be reversible but Professor Sirtori presented a wealth of evidence to show that this can indeed occur, mainly in lipid rich areas of plaque, when induced by aggressive lipid reduction or increasing of cholesterol mobilising lipoproteins such as high-density lipoprotein (HDL).
Professor Sirtori emphasised that carotid intimae media thickness (CIMT) could be a useful marker of CVD. “It is generally agreed that a reading below 1.0 mm is fine,” he said. He then explained how CIMT may be useful in the clinical setting: “If you have a low-risk patient with a high CIMT then I would consider them to be high risk and would need treatment”.
More sophisticated methods, such as arterial computed tomography (CT) and magnetic resonance imaging (MRI), are beginning to show considerable promise in this field. CT has been used mainly to determine coronary calcium but MRI can assess the overall vascular structure and, with some limitations, chemical composition. Professor Sirtori revealed that early clinical studies have indicated the potential value of MRI, adding that it may become a widely used method for the assessment of atheroma extent.
Risk factor management
Dr Anthony Wierzbicki, past Chairman of H·E·A·R·T UK’s Medical & Scientific Research Committee, emphasised the importance of risk factor management when he revealed the findings of a recent survey of hypercholesterolaemia management in the UK – undertaken by H·E·A·R·T UK and sponsored by Genzyme Ltd. This UK-wide survey resulted in a greater understanding of lipid service provision and practice around the UK. The survey showed that there are great variations in where patients with lipid disorders are cared for, which can lead to differences in organisational infrastructure and approaches to management that can affect service provision. Clinical biochemistry/chemical pathology and lipid clinics were the most commonly cited departments, and chemical pathology, cardiology and diabetes and endocrinology were the most common host directorates.
The survey also revealed that a variety of guidelines and targets are followed across the UK and Dr Wierzbicki called for widespread consensus on this so that all appropriate patients can access and receive the same high-quality standard of care.
Investing in treatment
A GP who took risks for his patients generated much interest during the Healthcare section original papers session of the conference. Dr John Revill, a GP from South Yorkshire told the delegates: “I have been quoted as the most expensive GP in Sheffield, prescribing the largest amount of statins by a long way in my city. I took a risk, but I felt I could not wait with such good drugs around,” he said.
Although his primary care trust (PCT) was not best pleased, his risk taking has paid dividends for his patients. Mortality for ischaemic heart disease and stroke was reduced by 42% across his practice list from 1981 to 2007, and over half in those aged 70 to 79 years.
Cost of drugs and treatment were also discussed when Professor Mike Kelly, Director of the Centre for Public Health Excellence at NICE spoke on The Future of Prevention Strategies for Cardiovascular Disease. The spotlight is currently on NICE, who are launching their familial hypercholesterolaemia (FH) guidelines in August, but Professor Kelly looked ahead to how interventions can effectively reduce mortality and morbidity from CVD on a population basis.
He confirmed that NICE would insist that intervention must include primary prevention and tackle at least two CVD risk factors, such as smoking, poor diet, lack of physical activity, high blood pressure/cholesterol and obesity. He also reminded delegates that there were 171,021 deaths from circulatory disease in England in 2005, costing £30 billion annually, with a higher incidence of death from CVD in the most deprived communities.
Professor Kelly admitted that historical public health strategies aimed to improve everyone’s health and often resulted in a widening of inequalities as the health of the most affluent improved most. Professor Kelly admitted that it is difficult to tackle inequalities but confirmed that NICE is looking to take a broader perspective. He reminded delegates that NICE had to balance that approach by considering which risk factor interventions are both clinically effective and cost-effective. NICE is also only too well aware that brief advice from the GP is not enough to change habits and he agreed with a comment from Dr John Reckless, Trustee of H·E·A·R·T UK, that NICE guidance will need to resonate with the general public to make change effective.
Although Professor Kelly concentrated on public health, Professor Steve Humphries from the Centre for Cardiovascular Genetics, Department of Medicine at University College Hospital, focused on how the forthcoming NICE guidelines for the detection and management of FH may work in practice. He presented Genetics of Lipid Disorders Made Easy and revealed that it may be possible in the future to identify those individuals at risk of early chronic heart disease (CHD) by using a panel of common genetic variants or ‘SNPs’. Availability of a panel of SNPs could have a significant impact on risk prediction and, consequently, risk factor management. Although the effect of defective genes can be masked by environmental factors, the dominant effect of the mutations identified in FH patients means that it is already of proven clinic utility. As the new NICE FH guidance is expected to recommend DNA testing to all patients with a clinical diagnosis, DNA testing is going to become a routine and effective procedure.
Andrew Harrison, a director of communications and public affairs company Hanover, who has supported H·E·A·R·T UK’s campaigning activities for five years and is a member of the charity’s Patient Committee, opened the conference with some insightful comments on the political will with regard to heart health, and the vascular screening in particular, but it would be pertinent to conclude with a comment from him: “The Government’s anti-smoking campaign was allocated only one third of the money to be used for the obesity strategy.” Considering how successful the no smoking campaign has been suggests that there are exciting times ahead for those involved with improving the health of the nation’s hearts.
For further information on the work of H·E·A·R·T UK – The Cholesterol Charity, and copies of factsheets and publications please log on to www.heartuk.org.uk or call the charity on 01628 777 046. The charity also runs a confidential helpline, which is staffed by fully trained nurses and dietitians. If your patients need further advice on heart health then ask them to call our advice line on 0845 450 5988.