Background to cardiovascular disease risk assessment and management

• Reason for the consensus statement
• Cardiovascular disease risk assessment
• Equity
• Groundwork
• Who was involved?
• Implementing the advice

Morbidity and mortality from Cardiovascular Disease (CVD) continues to be one of the largest burdens of disease for New Zealanders.

More people are surviving acute events, and there have been advances in the prevention and treatment of CVD, however, CVD is still responsible for 40 percent of deaths (often premature and preventable) in New Zealand.

The consensus statement builds on the significant investment in the heart and diabetes checks health target.

As part of the health targets programme 1.2 million Kiwis (90 percent of the eligible population) were risk assessed.

The sector is now in an excellent position to focus on risk factor management.

CVD risk assessment has become part of normal general practice and local pathways for risk management are regularly promoted and used.

New cardiovascular (CVD) risk equations are now available. We now have the ability to estimate risk and predict future cardiovascular events based on contemporary New Zealand data.

The goal of a cardiovascular disease risk assessment is to reduce CVD risk for individuals and provide appropriate advice about reducing the risk of developing diabetes.

A cardiovascular disease risk assessment informs people about their risk of cardiovascular events, as well as strategies to improve their heart health.

It also helps to identify people with diabetes to receive care and learn about helpful lifestyle changes.

The overarching principle remains that the intensity of recommended intervention should be proportional to the estimated combined CVD risk.

There remains a significant disparity between Māori and non-Māori access to primary care services and risk assessments making an equity focus for assessment coverage and risk management imperative.

The Heart Foundation was commissioned by the Ministry of Health in 2015 to review the relevant evidence and other guidelines in key relevant areas.

In June 2016 following the launch of the NZ Health Strategy a series of roadshows were facilitated by subject matter experts from the Heart Foundation and the University of Auckland to discuss the evidential review, new equation development and potential impacts.

In attendance were consumer advocates, clinicians, DHB/PHO representatives, and NGO/professional association delegates.

The goal of the roadshows was to provide discussion and feedback about the guideline update processes and rationale.

Discussions focused on:

• the evidence and methodology behind the new equations and implications for moving from Framingham to PREDICT
• the international treatment threshold landscape as well as the joint mental illness review with Te Pou. (Read a summary of the review - Te Pou website)
• potential timelines for this work and the formation of steering and IT groups to oversee guideline implementation.

Questions around the process for guideline development were raised at an open invitation stakeholder workshop in December 2016.

A formal guideline development process was not possible. Therefore the process was to develop a stakeholder consensus statement for cardiovascular disease risk assessment and risk factor management to complement the upcoming release of CVD risk equations.

The Ministry of Health facilitated the discussion and consensus. Primary care, specialist and consumer advisors provided feedback.

For comorbidities the Ministry sought input from lead agencies/organisations for example Te Pou for mental health and the National Diabetes Leadership Group.

Researchers were consulted on for the new CVD risk equations (including equations for the diabetes cohort).

At this time the Ministry of Health is working through a process to identify how best to integrate the new equations into usual practice.

As part of this process we will be considering options for implementation that will support national consistency.

Until new tools for risk communication are available, management recommendations can be applied now using current CVD risk assessments identifying high, intermediate and low-risk individuals.

When comparing the new equations to the risk scores under the old equations, the old equations generally overestimate risk.

The advice that we have received is that:

• a risk score of >20% is likely to be >15% (high risk) under the new equations
• a risk score of 10-20% is likely to be 5-15% (moderate risk) under the new equations
• a risk score of <10% is likely to be <5% (low risk) under the new equations.

In practice people who are currently high risk will remain high risk, those of moderate risk will remain moderate risk or move to low risk.

There is also a programme of work being undertaken by the Heart Foundation, through an existing contract with the Ministry, which is designed to support General Practice in implementing the new guidance.

Visit the Heart Foundation website for more information.