Improve your cardiovascular risk assessment Currently cardiovascular risk management is mainly based on a review of traditional risk factors such as blood pressure, lipid levels cholesterol , HbA1c and family history. An increased blood pressure leads the heart to work harder, which makes the heart and arteries more susceptible to injury. There are a number of anti-hypertensive drugs available to lower the blood pressure. High levels of triglycerides and LDL cholesterol in combination with low levels of HDL cholesterol are associated with atherosclerosis the buildup of fatty deposits in artery walls that increases the risk for heart attack and stroke.
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Assessing the cardiovascular risk of a patient typically uses these traditional risk factors. Although these risk factors are very important determinants of cardiovascular risk, they do not always explain the increased cardiovascular risk in diabetes and renal failure patients. These risk scores use multiple clinical measurements blood tests and calculate the cardiovascular risk of patient based on that.
In daily practice these risk scores are rarely used by physicians because it requires a number of time consuming and expensive laboratory tests and the clinical performance is moderate. The AGE Reader. Sociodemographics included age, sex and smoking habit. Drug history included the number of antihypertensive drugs prescribed and the use of lipid lowering agent. To avoid the impact of ageing on CVD risks, we applied the age at baseline to calculate the CVD risks at both baseline and 12 months. The BP at baseline was defined as the averages of all available BP readings within 6 months before baseline, whereas the BP at 12 months was defined as the averages of all BP measurements between 6 and 18 months after baseline.
All other biometric data at baseline and 12 months were defined as the latest available reading until 3 months and between 6 and 18 months after baseline, respectively. Descriptive statistics were used to report the characteristics of sociodemographics, drug history, biomedical data, predicted year CVD risk and the stage of hypertension of each patient in RAMP-HT group and usual care groups at baseline and after 12 months.
Differences in baseline and month characteristics between groups were tested using independent t tests for continuous variables or chi-square tests for categorical variables. Paired t tests were used to evaluate the mean within-patients changes in the outcomes of interest at 12 months compared with baseline. Unadjusted difference-in-difference estimation in the outcomes between groups was performed by independent t tests.
Adjusted difference-in-difference estimations between groups were assessed using multiple linear regressions by the adjustment of confounding factors sociodemographics, drug history, biomedical data, predicted year CVD risk and the stage of hypertension. Similarly, for the evaluation of the rate of target achievement and improvement in the outcomes, chi-square test was used to test the unadjusted difference-in-difference in the proportion of target achievement rate and improvement between groups. Adjusted difference-in-difference estimations between groups were assessed using multiple logistic regressions by the adjustment of confounding factors mentioned above.
All significance tests were two-tailed and findings with a P value less than 0. Due to propensity score matching, the sociodemographics, drug history, biomedical data, predicted year CVD risk and the stage of hypertension between the two groups were similar at baseline. Significant differences were observed in the use of antihypertensive drugs and lipid-lowering agent between RAMP-HT participants and usual care patients. Table 2 and Fig. To the best of our knowledge, this is the first study to evaluate the effectiveness of a structured CVD- risk stratification and risk-guided management programme building on existing clinical resources and available multidisciplinary interventions, as an added-on service to usual care for patients with hypertension in the real-world primary care setting.
Our results demonstrated that RAMP-HT led to greater proportion of patients achieving target BP and LDL-C and greater reduction in predicted year CVD risk after 12 months of intervention among primary care patients with suboptimal BP control compared with the usual care; the difference reached statistical significance. The RAMP-HT interventions are evidence based  and multifaceted, aiming to address four inter-related components of the chronic care model  using a multidisciplinary team approach. In contrast to traditional doctor-led idiosyncratic clinical care, the RAMP-HT nurse acts as the care manager for each RAMP-HT participant and is responsible for providing patient assessment and education, and coordinating frontline doctors care and allied health professionals services according to protocol.
In addition to ensuring the delivery of appropriate treatment tailored to individual patient's needs and risks, these organizational changes allow focused yet coordinated interventions according to the expertise of each team members and are time-saving. Moreover, an electronic clinical data entry platform is available to enhance relay of information among the different team members. This feedback system prompts frontline doctors of the assessment results, enables them to review the process of care delivered to the respective patients and to adjust drug prescription as indicated.
From the patient's perspective, multiple contacts with different team members help to reinforce knowledge, adherence and self-management. Both Rudd et al. Our findings further supported that algorithm-driven, multidisciplinary CVD risk assessment and risk-guided management involving patient education and drug titration was an effective way to improve BP control and was superior to lifestyle intervention or drug titration alone.
CVD risk assessment and management
Significantly, although the RAMP-HT encompassed more interventions compared with these previous studies, an additive effect on BP reduction was not apparent. This could be explained by the study design and the absence of an algorithm for hypertension drug titration by frontline doctors.
Our study was an observational cohort study on the implementation of RAMP-HT as an additional but integrated component to usual GOPC care in the real-world primary care setting, as opposed to a randomized controlled trial . Because of this arrangement, a specific algorithm for antihypertensive drug titration only for RAMP-HT participants would neither be practical nor feasible. Nevertheless, considering that a significantly greater proportion of RAMP-HT patient achieved target BP than usual care group, which was a more meaningful outcome than mean BP reduction for healthcare providers, the clinical benefit of having the additional RAMP-HT services in addition to usual care and the use of feedback loop was still evident and important.
Although hyperlipidaemia often coexists with hypertension and assessment of total CVD risk has been strongly advocated, very few hypertension intervention studies evaluated LDL-C or predicted year CVD risk as outcomes of their interventions [14,15]. Together with improved BP, the improved lipid profile contributed to a significantly greater reduction in the predicted year CVD risks in the RAMP-HT group compared with usual care after 12 months of intervention. Nevertheless, it was not yet certain if the observed benefits could be extrapolated to patients with stable control hypertension.
Therefore, a longer term follow-up is required to evaluate whether the intervention can lead to actual reduction in CVD events and to validate the effectiveness of RAMP-HT among different risk groups over a longer time span. The long-term impact of RAMP-HT on noncardiovascular complications such as renal failure and on healthcare resources and service utilization is yet to be evaluated.
To attain the desired health benefits of the RAMP-HT in the real-world clinical setting, one must also ensure that the intended care has been provided; annual evaluation of quality of care and feedback on possible areas of improvement are essential. Our study had several limitations. First, evaluation of the RAMP-HT was designed as a population-based matched cohort study as opposed to an experimental randomized control study. The aim of RAMP-HT is to improve population BP control through an optimized, coordinated use of existing resources in the public primary care setting; such set-up requires concerted efforts from various stakeholders including health policy-makers, frontline healthcare providers and patients with continual feedback from the research team to ensure its implementation in the real-world clinical setting.
Therefore, conducting a participatory-action research instead of randomized control trial is the most appropriate, although it is well aware that unobserved potential confounders may affect the results, and blinding of healthcare providers and patients is not possible. Moreover, literatures had shown that similar results could be obtained from observational studies and RCTs.
Conversely, patients older than 80 years were excluded because BP and LDL-C targets for the elderly group remain controversial. Lastly, the predicted year CVD risk, but not the incidence of CVD events, was evaluated in this study because a month follow-up period was too short to observe CVD events.
Yet, there is currently no CVD-risk prediction function available for Chinese hypertension patients. Thus, the estimated benefit in CVD-risk reduction may not be accurate. Further study with a longer follow-up period e. In conclusion, among patients with suboptimal hypertension control, such structured, protocol-driven multidisciplinary RAMP-HT was more effective than usual care in achieving satisfactory control of BP and LDL-C, and reducing predicted year CVD risk after 12 months of intervention.
Long-term evaluation should be conducted to assess whether improvement in the clinical outcomes can be translated into actual reduction in CVD complications and mortalities in the real-world clinical setting, and whether the intervention is cost-effective.
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
The authors wish to acknowledge the contributions of the multidisciplinary risk-stratification based hypertension management programme teams at the Hospital Authority head office, chief of service in primary care and programme coordinator in each cluster and Statistics and Statistics and Workforce Planning Department at the Hong Kong Hospital Authority. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
The Risk-Assessment-and-Management-Programme for patients with Hypertension RAMP-HT study tested the potential effects of a protocol-driven multidisciplinary risk assessment and management program in a large cohort of hypertensive patients at low-moderate risk without diabetes or other comorbidities , who did not achieve optimal control of blood pressure and low-density lipoprotein cholesterol levels.
The study demonstrated that this approach was more effective than usual care in achieving satisfactory control of BP and LDL-C levels, and reducing predicted years cardiovascular risk at month follow-up observation. Such educational and therapeutic strategy can be effectively applied in a setting of real practice, although in some selected Countries several economic limitations and regulatory rules may at least, in part, limit the clinical effectiveness of this approach. The authors successfully implemented a nonrandomized multidisciplinary assessment-and-management program RAMP-HT for treated but uncomplicated hypertension with suboptimal BP control in primary care.
A much richer set of information on factors that may have influenced decision making would also have been ideal. The conclusions of the study rely heavily on complex statistical models that are not easily confirmable by the reader. We hope that the graphical information will provide a more intuitive approach that supports the conclusions provided by the modelling. The study also has several important strengths. Secondly, it reports on actual behaviour rather than hypothetical behaviour as in clinical vignette studies, 18—22 and may have stronger generalisability.
Thirdly, it is a large study including over 76, first CVD first assessments, and therefore has sufficient power to investigate hypothesised decision-making processes. We believe that this study provides some useful lessons for organisations implementing absolute CVD risk assessment programmes. While a threshold may provide useful guidance, the reality for clinicians is a complex array of information on a patient that will modify decisions based upon CVD risk. Treatment decisions are made in consultation with a patient, who will bring other information and values to the decision.
In New Zealand, the next version of the CVD risk management guidelines are being developed and it is likely that the current thresholds will be replaced by risk score ranges within which treatment should be discussed with patients based upon their individual circumstances. This is perhaps a better reflection of clinical reality and is consistent with the principle underpinning the New Zealand risk-based guidelines, which has always been that the intensity of interventions should be proportional to the estimated CVD risk.
Combined risk score and lipids.
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There is little information on how this information is used by doctors and their patients. This paper suggests that the latter approach is more likely, but that the decision process is complex and takes into account other factors. Cardiovascular disease CVD risk assessment is commonly recommended in guidelines, but there is uncertainty about how clinicians use this information. Our objective was to understand how New Zealand primary care clinicians use CVD risk assessment estimates to inform new statin prescribing.
We used a cohort of patients seen in primary care who have had a CVD risk estimated on the basis of a New Zealand modified Framingham risk equation. These patients were linked to national pharmaceutical dispensing records to determine new statin use in the following six months. There were 76, patients aged 35 to 75 who were not on a statin, had a first recorded CVD risk assessment between July and June , and for whom national guidelines recommended management on the basis of estimated CVD risk. Statin dispensing increased with increasing CVD risk. A logistic regression model using the CVD risk score predicted statin initiation better than models using lipid measures Area Under the Curve 0.
However, further modelling and graphical analysis suggested clinicians were using a range of other information to inform the initiation of statins. However, other factors are associated with increased statin dispensing independent of CVD risk score. Dr Kerr reports grants from HRC during the conduct of the study. Abstract Aim Cardiovascular disease CVD risk assessment is commonly recommended in guidelines, but there is uncertainty about how clinicians use this information.
The Assessment and Management of Cardiovascular Risk summary | Ministry of Health NZ
Method We used a cohort of patients seen in primary care who have had a CVD risk estimated on the basis of a New Zealand modified Framingham risk equation. Results There were 76, patients aged 35 to 75 who were not on a statin, had a first recorded CVD risk assessment between July and June , and for whom national guidelines recommended management on the basis of estimated CVD risk. Correspondence Email tomrobnz gmail. References JBS Board. Systematic review of guidelines on cardiovascular risk assessment: Which recommendations should clinicians follow for a cardiovascular health check?
Arch Intern Med. European Guidelines on cardiovascular disease prevention in clinical practice version Eur Heart J. New Zealand Guidelines Group. New Zealand Primary Care Handbook Wellington: New Zealand Guidelines Group; National Vascular Disease Prevention Alliance. Guidelines for the management of Absolute cardiovascular disease risk. Melbourne: National Stroke Foundation; Management of raised blood pressure in New Zealand: a discussion document. Evidence-based best-practice guideline.
The assessment and management of cardiovascular risk. Int J Epidemiol. Ministry of Health. Health Targets. How is my DHB performing? Eur J Prev Cardiol. Regression discontinuity designs: an approach to the evaluation of treatment efficacy in primary care using observational data. Evaluating disease management programme effectiveness: an introduction to the regression discontinuity design.
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