Professor John Deanfield explains how the JBS3 approach to CVD risk reduction encompasses the whole population rather than just those individuals at high short-term risk

Despite the stunning improvement in clinical outcomes from cardiovascular disease (CVD), there is no room for complacency. Indeed, CVD remains the major cause of morbidity and mortality in developed countries such as the UK, and the situation is much worse in developing nations, where an increase in premature disability and death from CVD has already occurred and is likely to accelerate.

In contrast to many other diseases, the major risk factors that drive the development of CVD and its clinical complications, such as heart attack and stroke, have been identified. For example, in the INTERHEART study, which was conducted in 52 countries, nine risk factors (mostly modifiable) accounted for more than 90% of heart attacks.1 Despite the wealth of evidence from clinical trials on the benefit of reducing levels of risk factors, few people lead healthy lifestyles and a disappointing number do not adhere with medication when it is prescribed. This represents a major opportunity for CVD prevention at both the individual and population levels and is the focus of the new Joint British Societies’ third CVD prevention consensus guideline (JBS3), which was published in March of this year.2

What is new about JBS3?

Previous prevention strategies have focused on patients at high short-term risk of CVD.3 Tables have been developed to calculate patients’ 10-year absolute risk of CVD and to set specific thresholds for prescription of cardioprotective drugs such as statins.3 This approach appropriately directs treatment to individuals at highest risk of CVD, who stand to gain the largest short-term benefit. However, recognition is increasing that many people have CVD risk factor profiles that put them at high lifetime risk of events despite a low short-term risk. Those affected in this way, who are predominantly younger people and particularly women, so far have largely been excluded from CVD risk-reduction strategies based on the ‘high-risk’ approach, even when they have modifiable risk factors such as high blood pressure and abnormal cholesterol levels. The JBS3 guideline is unique in emphasising the importance of not only treating patients at high risk but also promoting strategies to reduce lifetime CVD risk and delay cardiovascular events.2

This change in approach is based on several lines of evidence. Atherosclerosis begins many years before clinical manifestations of CVD occur, and exposure to CVD risk factors from early life has been shown to promote progression of ‘preclinical’ arterial disease.4 Furthermore, the emergence of clinical CVD seems to be related to long-term exposure to risk factors that are potentially modifiable; smoking is a classic example of damage caused by exposure over time and also of the benefits of early cessation.5 Recent evidence from genetic studies and trials shows, similarly, that a longer period of exposure to low levels of low-density lipoprotein (LDL) cholesterol could leverage larger reductions in later CVD risk.6 This suggests that prevention efforts need to begin much earlier. With clear analogies between health and wealth planning, the JBS3 approach has been described as ‘investing in your arteries’.

JBS3 risk calculator supports communication of short-term and lifetime risk

A new calculator has been developed to estimate and communicate CVD risk for all patients,7 except those with established CVD and those with high-risk diseases such as diabetes (aged >40 years), chronic kidney disease (stages 3–5), and familial hypercholesterolaemia, in whom intensive risk-factor reduction rather than risk estimation is required.2 The JBS3 risk calculator displays both the 10-year risk of CVD and a range of novel measures designed to communicate the concept of risk over a person’s lifetime and the benefits that may be achieved by sustained, long-term reduction of risk factors. It aims to empower patients and the public to take ownership of their personal cardiovascular health and to make appropriate decisions about their lifestyle and drug treatment. A person’s ‘heart age’, which is easily understood, is also estimated, as a ‘heart age’ greater than the chronological age is a good motivator to change behaviour. The age at which an individual can expect, with their current risk profile, to have their first CVD event is also prominently displayed. This represents ‘event-free survival’ and is also easily understood. Importantly, the impact of lowering risk factors on these measures is demonstrated in several graphic presentations to facilitate patients’ understanding. Use of the JBS3 calculator should change the nature of the conversations between healthcare professionals and their patients in primary care. Some key messages come across, including:

  • the long-term harm from traditional risk factors such as blood pressure, smoking, and cholesterol
  • the lifetime benefits of even small reductions of multiple risk factors, such as can be achieved by lifestyle improvements
  • the greatly reduced ‘lifetime’ gain when appropriate reduction of risk factors is delayed
  • it is never too late to gain benefit from lowering risk factors.

For most people, the strongest message is the potential gain from an early and sustained change to a healthier lifestyle rather than prescription of drugs.2 A clear management algorithm is presented (see Figure 1) based on levels of short- term (10-year) risk, as well as risk over the patient’s lifetime.

As cardioprotective drugs have become cheaper and have been shown to be safe and efficacious when used in the long term, there is an opportunity to broaden their use beyond previous recommendations. It is important to appreciate that there is no conflict between the JBS3 guideline2 and the recent NICE lipid guideline, which recommends reducing the threshold of 10-year risk required to prescribe statins.8 The JBS3 calculator puts the ‘statin conversation’, which is currently so controversial, into a personalised context to inform and facilitate patient choice.7 The JBS3 approach extends efforts to reduce the risk of CVD to encompass the whole adult population rather than just those at high short-term risk.

Figure 1: JBS3 management algorithm2
JBS3 management algorithm
  • * Current NICE guidance www.nice.org.uk JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014; 100: ii1–ii67. Reproduced with kind permission.

Recommendations

The JBS3 guideline makes recommendations for a broad range of practice issues that are frequently encountered in primary care.2 Of great value is the guidance to use non-high-density lipoprotein (non-HDL) cholesterol rather than LDL cholesterol. This represents the cholesterol in both LDL cholesterol and other atherogenic particles and can be calculated simply by subtraction of HDL from total cholesterol in a non-fasting sample. Evidence is accumulating that this better predicts risk and response to treatment than the level of LDL cholesterol,9 which is particularly relevant for the increasing number of patients who have metabolic derangement as a result of obesity.

The JBS3 guideline provides clear approaches for the management of individuals with diseases that increase the risk of CVD, as well as those who have established CVD, including peripheral artery disease and stroke.2 Guidance is given on the use of genetic testing, novel biomarkers, and imaging techniques to refine estimates of the risk of CVD based on current evidence of their value. The document is easy to follow and refers, when appropriate, to existing guidelines (e.g. for antihypertensive drugs). It would take only a few minutes to read and understand the key recommendations in the JBS3 summary!

Next steps

The JBS3 approach should change the interaction between healthcare professionals and their patients in primary care. It aims to improve the communication of a patient’s personal risk of CVD and their own potential for benefit from early and sustained lowering of risk factors, usually by lifestyle changes. This should be more motivational than just a conversation about statins!

The JBS3 risk calculator complements the NHS Health Check programme in England, which offers measurements of risk factors for CVD from the age of 40 years.10 A 10-year risk estimate at this age is of limited value, as CVD events are rare in people younger than 50 years. The JBS3 calculator is available online (www.jbs3risk.com) and in a new app—JBS3 Heart Risk—designed for use in primary care, which can be accessed from the same webpage. A ‘patient-friendly’ version is also under development. The impact of widespread use of the JBS3 recommendations will need to be tested formally, and local and national evaluation programmes are being discussed.

Excitingly, the concept of lifetime risk and leveraged health gains from early and sustained reduction of risk factors for CVD can be extended to other important non-communicable diseases, such as dementia. The impact of smoking, diabetes, high blood pressure, and abnormal levels of cholesterol on cognitive function is becoming clear,11 and reductions in these largely modifiable factors may be valuable beyond the benefit for CVD. Delaying the development of both CVD and dementia, which is now the public’s greatest health concern, through similar healthy lifestyle changes could have a big impact on behaviour and adherence to treatments.

Conclusion

The third iteration of the JBS recommendations provides the basis for renewed efforts to reduce the burden of CVD in the population, as well as its impact for patients. It emphasises the need to treat people at high risk with an intensive approach but also to empower the public to ‘invest’ in their future cardiovascular health by making early improvements to their personal CVD risk profile, which, for most people, can be achieved through lifestyle changes. The new calculator is simple and intuitive and should be used to achieve consensus with each patient on the best strategy for them to avoid or delay CVD events. Success will depend on the patients’ understanding of lifetime risk and their consequent adherence to the strategy agreed with their primary care doctor.

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
  • This new guidance emphasises the importance of risk factor reduction and moves this emphasis into groups at lower immediate risk but substantial lifetime risk of CVD
  • JBS3 also recommends an individualised approach to personal risk factors and extends beyond the management of lipids and statins into avoidable lifestyle interventions:
    • CCGs should liaise with local public health colleagues to incorporate these recommendations and also the recent NICE guidance on statins into the NHS Health Check programme
    • these public health colleagues will be instrumental in commissioning local schemes to aid risk factor reduction (e.g. through smoking cessation and weight reduction programmes)
  • Community interventions to reduce population risk factors through promoting exercise (e.g cycling to work) and education through programmes in schools will also be important and can be included in the health and well-being plan.

CCG=clinical commissioning group

  1. Yusuf S, Hawken S, Ounpuu S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364 (9438): 937–952.
  2. JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014; 100: ii1–ii67.
  3. JBS2 Board. Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91: v1–v52.
  4. Raitakari O, Juonala M, Kähönen M et al. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study. JAMA 2003; 290 (17): 2277–2283.
  5. Jha P, Ramasundarahettige C, Landsman V et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013; 368: 341–350.
  6. Ference B, Yoo W, Alesh I et al.Effect of long-term exposure to lower low-density lipoprotein cholesterol beginning early in life on the risk of coronary heart disease. A Mendelian randomization analysis. J Am Coll Cardiol 2012; 60 (25): 2631–2639.
  7. JBS3 website. JBS3 Risk Calculator. www.jbs3risk.com (accessed 23 July 2014).
  8. NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 181. NICE, 2014. Available at: nice.org.uk/cg181
  9. Boekholdt S, Hovingh G, Mora S et al. Very low levels of atherogenic lipoproteins and the risk for cardiovascular events: a meta-analysis of statin trials. J Am Coll Cardiol 2014; 64 (5): 485–494.
  10. NHS Health Checks website. www.healthcheck.nhs.uk (accessed 23 July 2014).
  11. Lincoln P, Fenton K, Alessi C et al. The Blackfriars Consensus on brain health and dementia. Lancet 2014; 383 (9931): 1805–1806. G