crabsallover highlights, key points, comments / links.
Recommendations from each section
- Use JBS3 risk calculator to estimate both 10-year risk and lifetime risk of CVD in all individuals except for those with existing CVD or certain high risk diseases i.e. diabetes age >40 years, patients with chronic kidney disease (CKD) stages 3-5, or familial hypercholesterolaemia (FH).
- Total cholesterol and HDL-cholesterol from a non-fasting blood sample should be used for lipid profile estimate of CVD risk in the JBS3 calculator
- Non-HDL-cholesterol, measured from a non-fasting blood sample as total cholesterol minus HDL-cholesterol, should be used in preference to LDL-cholesterol as the treatment goal for lipid-lowering therapy.
- Intensive risk factor modification with diet, lifestyle intervention and pharmacological therapy in patients with existing CVD, without the need for estimation of CVD risk.
- Intensive risk factor modification with diet, lifestyle intervention and pharmacological therapy, in individuals at particularly high risk of developing CVD: i.e. diabetics age >40 years, patients with CKD stages 3–5, or FH without the need for estimation of CVD risk.
- Diet, lifestyle intervention and pharmacological therapy in people at high short-term risk. Thresholds for treatment with statins based on 10-year CVD risk will be informed by NICE guidelines.
- Diet, lifestyle intervention and for some people, pharmacological therapy, in those with increased modifiable lifetime risk as informed by JBS3 calculator metrics.
2. Lifestyle Recommendations
- Professional support on how to stop smoking should be given, at every available opportunity, with provision of self-help material and referral to more intensive support, e.g. stop smoking services.
- The JBS3 risk calculator emphasises the benefits for early smoking cessation and the diminishing but still substantial returns for quitting at an older age.
- Patients should be offered behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective.
- Nicotine replacement therapy (NRT), varenicline or bupropion should be offered to people who are planning to stop smoking as part of an abstinent-contingent treatment in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date).
- People who have heart or respiratory diseases, and those who live with them, should be made aware of the risks of both active and passive smoking (second-hand smoke).
- For specific recommendations on quitting smoking in pregnancy and following childbirth, see NICE public health guidance 26.
- The importance of stopping smoking during pregnancy should be emphasized and guidance from the National Institute for Health and Clinical Excellence (NICE) followed.
Professional support to consume a diet associated with the lowest cardiovascular risk should be provided based on the following principles:
- Intake of saturated fat to <10% of total fat intake (preferably in lean meat and low-fat dairy products)
- Replace saturated fat with poly-unsaturated fat where possible
- Consume five portions per day of fruit and vegetables
- Consume at least two servings of fish (preferably oily) per week
- Consider regular consumption of whole grains and nuts
- Keep salt consumption <6 g per day
- Limit alcohol intake to <21 units per week for men and <14 units per week for women
- Avoid/reduce consumption of:
- Processed meats or commercially produced foods which tend to be high in salt and trans fatty acids
- Refined carbohydrates, such as white bread, processed cereals
- Sugar-sweetened beverages
- Calorie-rich, but nutritionally poor snacks, such as sweets, cakes and crisps
- Children and young people should be supported to consume a diet based on the same principles.
Physical activity and exercise
- An increase in overall levels of sustained physical activity and avoidance of prolonged sedentary behaviour are important for reduction of CVD risk.
- Emphasise walking, cycling and other aerobic physical daily activities, at moderate intensity, as part of an active lifestyle, for at least 150 minutes per week in bouts of ≥ten minutes, or 75 minutes per week of vigorous physical activity, or a combination of the two.
- Muscle-strengthening activities performed on at least two occasions per week
General population and those at low to moderate risk of CVD:
- Exercise training, incorporating a warm up and cool down period, should be performed at moderate to high intensity two to three times per week for 30 to 40 minutes each time.
- The mode of exercise should be aerobic and, where possible, continuous allowing for a steady progression in effort, e.g. walking programmes, cycling, jogging, swimming.
- The time spent exercise training contributes to meeting the 150 minutes per week physical activity recommendation (as above).
Patients with established CVD and those considered at higher risk of CVD:
- A more structured approach is needed in managing patients and in all cases, assessment and specific goal setting, with risk stratification, delivered by professionals skilled in health-related exercise is preferable.
- Exercise on referral and community-based exercise initiatives are recommended for patients at risk of CVD.
- Cardiac rehabilitation programmes are recommended for patients with established CVD and in those following a CVD event.
3. Childhood and Adult Obesity Recommendations
- Multidisciplinary approaches to obesity management in children and young people are required with a 'lifetime risk' message. These include interventions during the early post-partum period as well as regular monitoring of childhood weight and family counselling.
- With appropriate training all health care professions should be able to Ask and Assess adiposity and Advise appropriate adult patients on evidence based ways to target weight change.
4. Lipid Recommendations
- Non-fasting blood samples should be taken to measure total cholesterol (TC) and HDL-cholesterol. The JBS3 risk calculator enables entry of these two measures and it is expected that non-HDL-c (TC minus HDL-c = non-HDL-c) will gradually replace LDL-c in clinical practice as well as in clinical trials.
- All high risk people should receive professional lifestyle support to reduce total and LDL-c, raise HDL-c, and lower triglycerides to reduce their CVD risk.
- Cholesterol-lowering drug therapy is recommended in:
- Patients with established CVD
- Individuals at particularly high risk of CVD: diabetes age > 40 years, patients with CKD stages 3-5, or FH
- Individuals with high 10-year CVD risk (threshold to be defined by NICE guidance)
- Individuals with high lifetime CVD risk estimated from heart age and other JBS3 calculator metrics, in whom lifestyle changes alone are considered insufficient by the physician and person concerned
- Statins are recommended as they are highly effective at reducing CVD events with evidence of benefit to LDL-c levels <2 mmol/L which justifies intensive non-HDL-c lowering.
- Statins are safe with trial evidence showing no effects on non-cardiovascular mortality or cancer. There is a small increase in risk of developing diabetes but the benefits of cholesterol lowering greatly exceed any risk associated with diabetes. If statin intolerance develops a stepwise strategy involving switching agents and re-dosing is recommended.
- Despite low HDL-c levels contributing to CVD risk, drug therapy to raise HDL has not been shown to reduce CVD risk and is not currently indicated.
5. Blood Pressure Recommendations
- Hypertension should be suspected when office BP is persistently elevated, i.e. ≥140/90mmHg.
- Ambulatory BP monitoring (ABPM) is recommended to confirm the diagnosis of hypertension (Daytime mean ABPM ≥135/85mmHg).
- All high risk people should receive professional lifestyle support to reduce their blood pressure which may avoid the need for, or complement the use of, drug therapy for hypertension and reduce CVD risk.
- People with an office BP >160/100 mmHg, an 24-hour day time ABPM average or home APBM average of >150/95 mmHg (stage 2 hypertension) should be offered pharmacological therapy to reduce BP.
- People with an office BP >140/90 mmHg, but <160/100 mmHg, a 24-hour daytime ABPM average or home APBM average of >135/85 mmHg (stage 1 hypertension) and established CVD, hypertensive target organ damage, diabetes, CKD, or a high lifetime risk assessed by JBS3 calculator, should be offered pharmacological therapy to reduce BP.
- People with stage 1 hypertension without established CVD, hypertensive target organ damage, diabetes, CKD, or a significant increase in lifetime risk assessed by JBS3 calculator, should receive advice on lifestyle interventions and be scheduled for annual BP and lifetime risk assessment to inform future need for therapy.
- Pharmacological treatment for patients with hypertension should follow the current NICE guidance (CG127) treatment algorithm:
- Patients <55 years of age should be offered an ACE inhibitor or ARB as preferred initial therapy
- Patients aged ≥55 years should be offered a Calcium Channel Blocker (CCB) as preferred initial therapy
- Combinations of drug treatment are usually required to optimise BP control for the majority of patients.
- Thiazide-like diuretics are an alternative to CCB and are preferred for patients intolerant of CCBs, or with heart failure or at high risk of heart failure.
- Beta-blockers are not preferred unless there are specific indications for use, i.e. in patients with symptomatic angina or chronic heart failure.
- For pregnant women or women planning pregnancy, when BP treatment is being considered, the recommendations of the NICE guideline CG107 Hypertension in pregnancy should be followed.