‘Lipids in the community’ was the general theme of this year’s HEART UK conference, attended by 200–250 participants, covering primary and secondary care, patients and industry. The event was held at the University of Hertfordshire from 16th–18th September 2015. General Practice Nurse Jaqui Walker reports some of its highlights.
Detecting undiagnosed familial hypercholesterolaemia (FH) in the community and helping families manage the condition before it leads to a cardiovascular disease (CVD) event was one of the key themes of the conference.
A second important theme was taking action on the risk factors and behaviours that are linked to CVD and other non-communicable diseases (NCDs). These risk factors and behaviours have been understood for decades, yet the challenges of finding effective ways to help the population change to healthier behaviours, and how to assess and monitor this in clinical practice, remain.
In his opening address Professor Huon Gray (National Clinical Director for Heart Disease, NHS England) discussed the Department of Health (DOH) 2013 Cardiovascular Outcomes Strategy,1 which has been instrumental in raising the profile of FH. As a result of this strategy an FH steering group with multi-representation was established. Its achievements have included:
- Funding by the British Heart Foundation (BHF) of FH nurses to cover 20 million people in England. These are pump-primed positions and will need to be funded locally by commissioners once BHF funding finishes.
- Meetings with the Chief Executive of Public Health and the Medical Director at NHS England, and at the Kings Fund and British Cardiovascular Society, have helped to raise the profile of FH, and to put FH detection and management on the agenda.
- 100,000 genome project with the inclusion of FH candidate genes.
- A greater understanding of the prevalence of FH.
- An agreement by the National Institute for Health and Care Excellence (NICE) to revise their FH clinical guidelines in 2016, due to the reduction in statin costs, and the likelihood that FH is more common than previously thought.
Currently the pathway for the detection and management of hyperlipidaemia is complex and disjointed but Professor Gray spoke with optimism for the future; he believes that hyperlipidaemia and, in particular, FH is gaining traction and beginning to be seen as a priority area for action. Personalised medicine and genetics will help, as FH is easily detectable and treatable. Progress is being made; disease prevention is high on the political agenda, especially with the governments ‘Five Year Forward View,’2 and there will be more progress in the future.
How do we manage high-risk patients?
Dr Dev Datta (University Hospital Llandough) tackled the subject of dealing with high-risk patients. Dr Datta defined a high-risk patient as: “A patient [for whom] through a multiplicity of risk factors, or the severity of one or more of them, a first or recurrent cardiovascular event is considered likely within a defined timescale.”
He explained that as healthcare professionals (HCP) we are often tempted to look at snapshots when what is actually important is the cumulative burden from risk factors over decades. It is for this reason that Dr Datta is in favour of lifetime risk calculators.
He presented some case studies and with these made a number of points. Firstly, he emphasised the importance of seeing the whole patient and considering a differential diagnosis e.g. hypothyroidism, liver disease, renal disease etc… Secondly, he looked at multifactorial risks. Patients with multiple risk factors can be a challenge to manage and this is often easier within a multidisciplinary team. The intervention may be more “discussion and behaviour change driven,” which is potentially more difficult and time consuming than medical treatments such as drugs.
The role of apheresis, which in simplistic terms could be described as dialysis for cholesterol, was examined. In the case of high-risk motivated patients (e.g. FH patients) this treatment can be highly effective. It is well tolerated but is costly and often involves a long journey to reach a centre where the treatment is available.
Emerging novel drug therapies, e.g. PCSK9 inhibitors, will offer a new avenue for patients who are at high risk due to their lipid profile.
Heart health a global issue with global strategies
A global perspective for cardiovascular disease was delivered by Professor David Wood (St Mary’s Hospital, Imperial College, London). In 2011 the Heads of State met to debate and agree a global strategy for NCDs. As a result, nine voluntary global NCD lifestyle, medicines and risk factor targets were developed and the ‘25 by 25’ agenda (to reduce premature disease from NCD by 25% globally by 2025) was agreed. The INTERHEART study3 conducted worldwide to look at the causes of CVD has shown that the relationship between risk factors and myocardial infarction (MI) is the same in every region of the world.
The World Heart Federation has adopted the ‘25 by 25’ strategy with a focus on CVD prevention. They highlight the need for partnerships and coalition building across all health disciplines in order to speak with one voice for CVD prevention and the importance of developing reliable health information systems in order to be able to monitor and measure what is being achieved in terms of cardiovascular mortality, morbidity and health behaviour. In the UK JBS3 (representing 11 professional organisations) signed up to a common agenda as an example of this sort of coalition.
The World Heart Federation has developed road maps for CVD prevention. They focus on secondary prevention of CVD, hypertension control and tobacco control in order to help achieve the ‘25 by 25’ aspiration. This is because 80% of CVD events occur in people with previous CVD, hypertension or who smoke. The roadmaps look at health policy, systems, availability and affordability of treatments, accessibility of preventative care, acceptance and adherence by patients to treatment over a lifetime. In essence they assess the entire picture of how to get from the current CVD healthcare environment to the aspiration of a 25% reduction in mortality by 2025. Methods of bypassing roadblocks to patients getting care are also included, making the roadmaps a very useful tool.
Variation occurs between countries depending on culture, health systems and health economy. The World Health Organization (WHO) targets for the use of priority interventions are not being achieved in most parts of the world. In addition many patients do not get the benefit from recommended programmes such as a comprehensive cardiac rehabilitation. The implementation of evidence into effectiveness is a great challenge throughout the world.
Familial hypercholesterolaemia – what will the future hold?
The Myant Lecture on the molecular genetics of FH was presented by Professor Steve Humphries (University College London [UCL]). Professor Humphries retires this year but will be continuing as Emeritus Professor at UCL, dedicating his time to FH. It will be interesting to look back 10 years after this lecture and see how far FH has developed. This session commenced with recognition of Nicolas Bruce Myant (1917–2015) and his lifelong passion for science and dedication to the field of lipidology.
Professor Humphries explored the history of FH gene discovery and the possibility of a fourth gene being discovered in the future. The current three genes and their frequency and severity were discussed. All three FH-causing genes have led to novel treatments. The discovery of low-density lipoprotein receptors (LDLR) led to the development of statins, apolipoprotein B (apoB) to antisense agents such as mipomersen, and PCSK9 to monoclonal antibodies.
It is now possible and relatively affordable to carry out deep sequencing of the whole genome or exome. The current issue is with bioinformatics. The laboratories are figuratively drowning in data – it is a problem even to store all the data, let alone analyse it!
Two new genes were identified as potentially interesting candidates; CH25H (Cholesterol 25-Hydroxylase) and INSIG2 (Insulin-induced gene 2).
Patients with DNA positive results for FH need early drug therapy and efficient relative testing (cascade testing). The frequency of FH was previously thought to be around 1/500 people, although recent data suggests 1/250 people maybe a more accurate prediction. This 1/250 frequency of FH would mean there are 240,000 monogenic FH patients to find in the UK. In 2016 the 100,000 genome project may find 200–400 new FH patients and cascade test their relatives.
The impact of undiagnosed FH presents a high burden to society with 50% of males experiencing MI before the age of 50, and 60% of females before the age of 60. Less than 10% of those predicted to have FH in the UK have been identified.
Obesity – focusing on what really matters
Professor Jean-Pierre Després (Quebec Heart and Lung Institute, Canada) examined the issue of obesity. He described obesity as a lifestyle marker not a disease, and stated that the medical model is not well designed to tackle it. He explained that the actual risk from obesity is largely determined by too much fat being stored in the wrong place; it is abdominal fat that is the problem.
Professor Després argued that improving cardiovascular fitness and reducing the waistline are better targets for CVD health than weight loss. With the current epidemic of chronic NCDs which are responsible for 60% of deaths worldwide, the WHO have identified four common risk behaviours: tobacco use, high alcohol consumption, poor nutritional quality of the diet and a lack of physical activity.
Simple tests to assess cardiovascular fitness and waist circumference are required. A tremendous opportunity is being missed if health behaviours are not measured and targeted effectively in clinical practice. Four variables should be assessed (Després 2015):
- Abdominal obesity
- Nutritional quality
- Cardiorespiratory fitness
- Physical activity habits.
Professor Després concluded that in our environment, non-healthy behaviours are often the easy behaviours – instead we need to reshape the environment so that healthy behaviours become the easy ones. This will require an individual- as well as a population-based approach.
Carbohydrates and heart health
Professor Bruce Griffin (University of Surrey) delivered an interesting talk exploring the role of dietary carbohydrate in heart health. He explained that carbohydrates are a diverse group of macronutrients, and the focus of his presentation was on the carbohydrates with the strongest and most consistent evidence for an association with disease. In a positive, protective sense this is dietary fibre and in an adverse way, although with more controversial data, free sugars. The Scientific Advisory Committee on Nutrition (SACN ) have issued new guidelines5 with recommendations to eat more dietary fibre (30 g/day) and cut sugar to less than 5% of total energy.
There is consistent evidence for the cholesterol-lowering effect of β-glucan shown in a meta-analysis of randomised controlled trials.6 A change in low-density lipoprotein cholesterol (LDL-C) of approximately 0.3 mmol/l occurs. Professor Griffin compared this to the use of plant sterols/stanols and described β-glucan from oats/barley etc… as about half as effective as stanols and sterols, but still a useful part of a portfolio of dietary measures to cut cholesterol.
Professor Griffin explored the role of dietary free sugar and concluded that, at high levels of intake almost twice the national average (>20% total energy), sugar has been shown to produce adverse metabolic effects that include increasing levels of internal fat, most notably in the liver. At lower levels of intake, the energy from sugar can contribute to weight gain and obesity. While the latter effect of sugar on body weight will increase cardiovascular risk in populations, subgroups of individuals with pre-existing non-alcoholic fatty liver disease may show increased sensitivity to the adverse effects of free sugars that are independent of body weight.
1. Cardiovascular disease outcomes strategy: improving outcomes for people with or at risk of cardiovascular disease. Department of Health, 2013. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/217118/9387-2900853-CVD-Outcomes_web1.pdf
2. Five year forward view. National Health Service, 2014. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
3. Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11,119 cases and 13,648 controls from 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:953–62.
4. Després JP. Obesity and cardiovascular disease: weight loss is not the only target. Can J Cardiol 2015;31:216–22. http://dx.doi.org/10.1016/j.cjca.2014.12.009
5. SACN Carbohydrates and health report. Public Health England 2015. Available from: https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report
6. Whitehead A, Beck EJ, Tosh S, Wolever TMS. Cholesterol-lowering effects of oat b glucan: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2014;100:1413–21. http://dx.doi.org/10.3945/ajcn.114.086108