Angina module 2: prevention

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Prevention of cardiovascular disease

The presence of well-recognised cardiovascular risk factors increases the risk of developing chronic stable angina. There is therefore a compelling case to screen for the presence of risk factors (table 1) within populations with a view towards intervention and disease prevention.

Screening for CVD

Figure 1. NHS Health Checks vascular risk assessment and management programme

The costs of population-based screening can be reduced by either targeting selective ‘at risk’ groups, e.g. males living in the west coast of Scotland, or by practising widespread screening such as that introduced by the NHS Health Checks programme in 2009 (figure 1). In the UK, adults aged 40 to 74 years without a diagnosis of vascular disease will be contacted by their primary care trust and offered a health check.1 From 2012–13, the first full year of implementation, 2.7 million offers were made and 1.26 million appointments were taken up. The aim is for 20% of the eligible population to be offered an NHS Health Check each year, with a take up rate of 75%.2

This programme targets those who have not yet been diagnosed with heart disease, stroke, diabetes or kidney disease. Every five years the individual’s risk of each, along with advice on how to lower such risk, will be offered during consultation. Factors including blood pressure, body mass index (BMI), cholesterol (total [TC] and high-density lipoprotein [HDLC]), ethnicity and family history will be recorded, and the results and potential consequences discussed with a healthcare professional.

Risk engines can aid in determining individual population risk. The Framingham Heart Study provided insight into the influence of modifiable risk factors on cardiovascular disease (CVD), and their impact over time. The Framingham score was developed during the peak incidence of CVD in America, leading to fears that it encouraged over-prediction of risk in European populations.3

This led to the development of the QRISK system for UK assessment of CVD risk. Dr Julia Hippisley-Cox (University of Nottingham, UK) and colleagues, developed a score shown to be better calibrated to the UK population. Although QRISK has itself been found to under-predict 10-year CVD risk,4 the QRISK2 update improved the score’s identification of CVD risk by incorporating ethnicity, deprivation and other clinical conditions into its algorithm.5

QRISK2 was recommended by the National Institute for Health and Care Excellence (NICE) in their 2014 lipid modification update6 to assess risk for the primary prevention of CVD in people up to the age of 84 years. It recommends that anyone with a 10-year risk of CVD is 10% or more should be prioritised for a full risk assessment.

The updated Joint British Societies’ Guidelines on Prevention of Cardiovascular Disease in Clinical Practice (JBS3),7 however, reject the established method of 10-year risk assessment, recommending instead the use of a lifetime risk score.8 JBS3 says its recommendations encompass much more of the population, such as young individuals and women, who may have a high lifetime risk of CVD but a low 10-year risk using current guidance. A key feature of JBS3 is a novel online risk calculator (see Figure 2), which communicates clearly to individuals their long-term risk of CVD, using tools such as a person’s ‘heart age’ and years of CVD event-free survival.

Figure 2. Detail from the new JBS3 risk calculator showing a patient’s lifetime cardiovascular risk