The new JBS 2 guidelines state that all people at high risk of atherosclerotic cardiovascular disease should be identified and treated, says Professor David Wood

The aim of the new Joint British Societies' guidelines (JBS 2) on cardiovascular disease prevention, published in December 2005 in Heart, is to promote a consistent multidisciplinary approach to the management of people with established atherosclerotic cardiovascular disease (CVD) and those at high risk of developing symptomatic atherosclerotic disease.1 These guidelines, developed by the British Cardiac Society, the British Hypertension Society, Diabetes UK, HEART UK, the Primary Care Cardiovascular Society and the Stroke Association, update the original Joint British Societies' recommendations published in 1998 (JBS 1).2,3

Why new guidelines were needed

Since JBS 1, a wealth of new scientific evidence has emerged on lipid lowering in patients with atherosclerosis and high-risk individuals, blood pressure management, and risk factor control in medically diagnosed diabetes, and prevention of diabetes. There is also new clinical trial evidence on indications for some cardioprotective drug therapies.

Therefore, a second joint working party was convened and the original four professional societies were joined by the Stroke Association, because of the importance of addressing all aspects of atherosclerotic disease, and the Primary Care Cardiovascular Society.

The latter is particularly important because general practitioners and other healthcare professionals working in primary care organisations have the lead responsibility, and best clinical opportunity, for delivering preventive strategies to all priority groups.

The scope of JBS 2

JBS 2 now encompasses the whole of atherosclerotic CVD – that is acute coronary syndromes, exertional angina, cerebrovascular disease (transient cerebral ischaemia and non-haemorrhagic atherosclerotic stroke and haemorrhagic stroke) and peripheral atherosclerotic disease – rather than highlighting coronary heart disease (CHD).

It is now more appropriate to address atherosclerotic CVD as a whole because new scientific evidence provides greater justification for the prevention of other forms of atherosclerotic disease. Any symptomatic manifestation of atherosclerosis in any vascular territory puts a person at high risk of dying from CVD, mainly from coronary artery disease.

Therefore it is now necessary to offer the same lifestyle and risk factor management to all people with atherosclerotic disease.

For asymptomatic individuals at high total risk of developing symptomatic CVD the objective is the same, namely to reduce the risk of developing coronary disease, stroke (including transient cerebral ischaemia), aneurysm of a major artery or lower limb claudication.

What's new in JBS 2?

Priorities for CVD prevention

CVD prevention in clinical practice should focus equally on people with established atherosclerotic CVD, people with diabetes and asymptomatic individuals at high total risk (CVD risk of ?20% over 10 years) of developing symptomatic atherosclerotic disease.This is because they are all high-risk people.

The biology of atherosclerotic disease and its complications makes the traditional separation of 'secondary' from 'primary' prevention illogical. All high-risk people have some degree of vascular dysfunction or atherosclerosis, whether symptomatic or not; in other words they all have the same underlying disease process.

Therefore, the clinical priorities are:

  • people with any form of established atherosclerotic CVD
  • asymptomatic people without established CVD but who have a combination of risk factors which puts them at high total risk (estimated multifactorial CVD risk ?20% over 10 years) of developing atherosclerotic CVD for the first time
  • people with diabetes mellitus (type 1 or 2). People with diabetes are now all considered to be at high risk and therefore formal cardiovascular risk assessment is not required.

These three groups of people all require professional lifestyle and multifactorial risk factor management to defined lifestyle and risk factor targets. They should also receive appropriate cardioprotective drug therapy.

In addition, people with the following single risk factors also require CVD prevention because they too are at high cardiovascular risk, regardless of the presence of other risk factors:

  • raised blood pressure ?160 mmHg systolic or ?100 mmHg diastolic, or lesser degrees of blood pressure elevation with target organ damage
  • elevated total cholesterol to high density lipoprotein (HDL) cholesterol ratio ?6.0
  • familial dyslipidaemia, such as familial hypercholesterolaemia or familial combined hyperlipidaemia.

People with a family history of premature CVD should be assessed for their cardiovascular risk and then managed appropriately.

All adults from 40 years onwards who have no history of CVD or diabetes and who are not already on treatment for blood pressure or lipids should be considered for an opportunistic comprehensive cardiovascular risk assessment in primary care.The new JBS 2 cardiovascular risk prediction charts (Figures 1 and 2) should be used to estimate the total risk of developing CVD. People with a total CVD risk ?20% over 10 years (red areas in charts) should receive professional lifestyle and risk factor management and appropriate cardioprotective drug therapies.

Figure 1: JBS 2 CVD risk prediction charts - men



Reproduced by kind permission of Paul Durrington, University of Manchester

Figure 2: JBS 2 CVD risk prediction charts - women



Reproduced by kind permission of Paul Durrington, University of Manchester

Thresholds for treatment
The thresholds in Table 1, are recommended for more intensive lifestyle intervention and appropriate drug therapies to reduce overall cardiovascular risk.

Table 1: Thresholds for treatment
  • Clinical evidence of atherosclerotic CVD
  • Diabetes mellitus (type 1 or 2)
  • A total CVD risk ?20% over 10 years
  • Elevated blood pressure ?160 mmHg systolic or ?100 mmHg diastolic, or lesser degrees of blood pressure elevation with target organ damage
  • Elevated total cholesterol to HDL-cholesterol ratio ?6.0
  • Diagnosis of a familial dyslipidaemia, e.g. familial hypercholesterolaemia or familial combined hyperlipidaemia

Lifestyle and risk factor targets
Lifestyle and risk factor targets have been reinforced and lower blood pressure (in selected high-risk people) and lower lipid targets are now recommended (Table 2).

Table 2: Lifestyle and risk factor targets
  • Discontinue smoking, make healthier food choices, increase aerobic physical activity and achieve optimal weight (BMI <25 kg/m2) and weight distribution (waist circumference <102 cm in men [Asians <90 cm] and <88 cm in women [Asians <80 cm])
  • Blood pressure target of <140 mmHg systolic and <85 mmHg diastolic. In selected higher risk people (established atherosclerotic disease, diabetes and chronic renal failure) a new lower blood pressure target of <130 mmHg and <80 mmHg may be more appropriate
  • A new lower total cholesterol target of <4.0 mmol/l and a new lower low density lipoprotein (LDL) cholesterol <2.0 mmol/l, or a 25% reduction in total cholesterol and a 30% reduction in LDL cholesterol, whichever gets the person to the lowest absolute level
  • The optimal fasting glucose is ?6.0 mmol/l for all high risk people.The optimal target for glycaemic control in people with diabetes is a fasting or pre-prandial glucose value of 4.0–6.0 mmol/l and a HbA1c <6.5 %

Anti-thrombotic therapy
Aspirin 75 mg daily is recommended for life for all people with coronary or peripheral atherosclerotic disease. If aspirin is contraindicated, or there are side-effects, then clopidogrel 75 mg daily is appropriate.

For all people with a history of cerebral infarction, or transient ischaemic attack, and who are in sinus rhythm, aspirin 75–150 mg daily plus dipyridamole M/R (modified release) 200 mg twice daily is recommended for 2 years following the initial event to prevent stroke recurrence as well as other vascular events.

If aspirin is contraindicated, or there are side-effects, clopidogrel 75 mg daily is an alternative.

For those who have a further ischaemic cerebrovascular event while taking aspirin and dipyridamole M/R, changing aspirin for clopidogrel 75 mg daily should be considered.

Aspirin 75 mg daily is recommended for all people over the age of 50 years who have a total CVD risk ?20 %, and in selected people with diabetes (i.e. those aged 50 years or older, or people who are younger but have had the disease for more then 10 years, or who are already receiving treatment for hypertension), once the blood pressure has been controlled to at least the audit standard of <150 mmHg systolic and <90 mmHg diastolic.

Blood pressure lowering therapy
A beta blocker is recommended for all people following myocardial infarction unless there are contraindications.

An angiotensin converting enzyme (ACE) inhibitor is recommended for people with symptoms or signs of heart failure at the time of myocardial infarction, or those with persistent left ventricular systolic dysfunction (ejection fraction <40%) following infarction.

An ACE inhibitor should be considered for other people with coronary artery disease, especially if the blood pressure is not below the target of <130 mmHg systolic and <80 mmHg diastolic.

An angiotensin II receptor blocker is an alternative to an ACE inhibitor if the latter is associated with side-effects.

A calcium channel blocker and/or a diuretic should be considered in all high-risk people if the blood pressure is not below the target.

Lipid lowering therapy
A statin is recommended for all high-risk people with established atherosclerotic disease, for most people with diabetes (see below), and others at high total risk of developing CVD.

In people with diabetes statin therapy is recommended for:

  • all those who are aged 40 years or more with either type 1 or 2 diabetes
  • for people aged 18–39 years with either type 1 or 2 diabetes and who have at least one of the following:
    – retinopathy (pre-proliferative, proliferative, maculopathy)
    – nephropathy, including persistent microalbuminuria
    – poor glycaemic control (HbA1c >9.0)
    – elevated blood pressure requiring antihypertensive therapy
    – raised total blood cholesterol (?6.0 mmol/l)
    – features of metabolic syndrome (central obesity and fasting triglyceride >1.7 mmol/l [non-fasting >2.0 mmol/l] and/or HDL cholesterol < 1.0 mmol/l in men or <1.2 mmol/l in women)
    – family history of premature CVD in a first degree relative.

     

In asymptomatic people who are at high total risk of developing CVD a statin is recommended if the total cholesterol and low density lipoprotein (LDL) cholesterol targets have not been achieved.

Other classes of lipid lowering drugs (fibrates, bile acid sequestrants, cholesterol absorption inhibitors, nicotinic acid) should be considered in addition to a statin if the total and LDL cholesterol targets have not been achieved.

The challenge facing primary care

The challenge of caring for people with atherosclerotic disease is considerable and there is a pressing need for a national comprehensive preventive cardiology strategy.

In the 1998 Health Survey for England the prevalence of CHD (angina and heart attack) was 7.1% in men and 4.6% in women.4 When stroke was included the CVD prevalence was 8.5% and 6.2% respectively. From age 65 onwards, between one-quarter and one-third of men reported having had coronary disease or a stroke – the prevalence rising with age.

The EUROASPIRE surveys show that a majority of these cases are still not achieving the recommended lifestyle, blood pressure and lipid targets.5,6

For apparently healthy people who are at high risk of developing CVD because of elevated blood pressure, dyslipidaemia, impaired glucose regulation, or a combination of these and other risk factors, the standard of clinical management is also a cause for concern.

In the most recent Health Survey for England (2003) the prevalence of smoking in those without CVD was 28% in men and 25% in women;4 64% of men and 55% of women were overweight (BMI > 25kg/m2); 29% of men and 27% of women had hypertension (BP ?140/90 mmHg) and 68% of men and 67% of women had an elevated cholesterol (total cholesterol >5 mmol/l). The overall prevalence of diabetes, including those with established CVD, was 4.3% of men and 3.4% of women.4

Audits of clinical practice have shown a failure to detect many such high-risk individuals in the community.7Among those found to be at high risk there are still many who are not being managed effectively to contemporary risk factor targets.

Conclusion

The new JBS 2 guidelines will help GPs and other health professionals working in primary care to define their daily priorities for providing preventive cardiovascular care, the thresholds at which to consider treatments, and treatment targets.

The overall aim of JBS 2 is to continue to promote a consistent multidisciplinary approach to the personalised management of people with established atherosclerotic CVD, diabetes and other people at high risk of developing symptomatic CVD. It emphasises a total risk approach to CVD risk assessment and management reflecting the growing scientific evidence base for the effective care of all high-risk people.

All high-risk people should be managed by clinicians who are able to address all aspects of CVD prevention. Other health professionals, such as nurses, dieticians and physiotherapists, also have a central role in delivering professional preventive care in hospitals and general practice.

By achieving the lifestyle and risk factor targets defined in these guidelines the risk of cardiovascular disease will be reduced by at least half, or more for some individuals.

References

  1. JBS 2: Joint British Societies' Guidelines on Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; 91 (suppl v): v1-v52.
  2. Wood DA, Durrington P, Poulter N et al. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998; 80 (suppl 2): S1-S29.
  3. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, British Diabetic Association. Joint British recommendations on prevention of coronary heart disease in clinical practice: summary. Br Med J 2000; 320: 705-8.
  4. Health Survey for England www.dh.gov.uk
  5. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries: principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J 2001; 22: 554-72.
  6. EUROASPIRE I and II Group. Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001; 357: 995-1001.
  7. Primatesta P, Brookes M, Poulter NR. Improved hypertension management and control: results from the Health Survey for England 1998. Hypertension 2001; 38: 827-32.

Guidelines in Practice, March 2006, Volume 9(3)
© 2006 MGP Ltd
further information | subscribe