Primary prevention of cardiovascular disease: new guidelines, technologies and therapies

A trend in primary prevention of cardiovascular disease (CVD) has been a move away from managing isolated risk factors, such as hypertension and dyslipidaemia, towards assessment and management of absolute CVD risk. In Australian guidelines, absolute CVD risk is calculated as the probability of a stroke, transient ischaemic attack, myocardial infarction, angina, peripheral arterial disease or heart failure occurring within the next 5 years. Absolute CVD risk should be regularly assessed in patients aged 45 years or older (35 years or older in Aboriginal and Torres Strait Islander people) using the Australian absolute CVD risk calculator (http://www.cvdcheck.org.au). For patients currently taking a blood pressure (BP)-lowering or lipid-lowering agent, pretreatment values should be used to calculate risk. Patients at high absolute risk of CVD (>15% over 5 years) should be treated with both BP-lowering and lipidlowering agents, unless contraindicated or clinically inappropriate. For patients at moderate absolute risk of CVD (10%-15%) treatment with a BP-lowering and/or a lipid-lowering agent should be considered if the risk remains elevated after lifestyle interventions, BP is ≥160/100mmHg, there is a family history of premature CVD, or the patient is of South Asian, Middle Eastern, Maori, Pacific Islander, Aboriginal or Torres Strait Islander ethnicity. BP measurements taken using an oscillometric device can be used to approximate mean daytime ambulatory BP

External validation and comparison of four cardiovascular risk prediction models with data from the Australian Diabetes, Obesity and Lifestyle study

OBJECTIVES: To evaluate the performance of the 2013 Pooled Cohort Risk Equation (PCE-ASCVD) for predicting cardiovascular disease (CVD) in an Australian population; to compare this performance with that of three frequently used Framingham-based CVD risk prediction models. DESIGN: Prospective national population-based cohort study. SETTING: 42 randomly selected urban and non-urban areas in six Australian states and the Northern Territory. PARTICIPANTS: 5453 adults aged 40-74 years enrolled in the Australian Diabetes, Obesity and Lifestyle study and followed until November 2011. We excluded participants who had CVD at baseline or for whom data required for risk model calculations were missing. MAIN OUTCOME MEASURES: Predicted and observed 10-year CVD risks (adjusted for treatment drop-in); performance (calibration and discrimination) of four CVD risk prediction models: 1991 Framingham, 2008 Framingham, 2008 office-based Framingham, 2013 PCE-ASCVD. RESULTS: The performance of the 2013 PCE-ASCVD model was slightly better than 1991 Framingham, and each was better the two 2008 Framingham risk models, both in men and women. However, all four models overestimated 10-year CVD risk, particularly for patients in higher deciles of predicted risk. The 2013 PCE-ASCVD (7.5% high risk threshold) identified 46% of men and 18% of women as being at high risk; the 1991 Framingham model (20% threshold) identified 17% of men and 2% of women as being at high risk. Only 16% of men and 11% of women identified as being at high risk by the 2013 PCE-ASCVD experienced a CV event within 10 years. CONCLUSIONS: The 2013 PCE-ASCVD or 1991 Framingham should be used as CVD risk models in Australian. However, the CVD high risk threshold for initiating CVD primary preventive therapy requires reconsideration

Identified health concerns and changes in management resulting from the Healthy Kids Check in two Queensland practices

Design, setting and participants: A medical records audit from two Queensland general practices, identifying 557 files of children who undertook an HKC between January 2010 and May 2013.Objectives: To determine how many children had health problems identified by the Healthy Kids Check (HKC) and whether this resulted in changes to clinical management.Main outcome measures: Child health problems identified in the medical records before, during and after the HKC.Results: Most children in our sample had no problems detected in their medical record (56%), 21% had problems detected during the HKC assessment, 19% had problems detected before, and 4% after. Most frequent health concerns detected during the HKC were speech and language (20%), toileting, hearing and vision (15% each), and behavioural problems (9%). Of the 116 children with problems detected during the HKC, 19 (3% of the total sample) had these confirmed, which resulted in a change of management. No further action was recorded for 9% of children. Missing data from reviews or referral outcomes for 8% precluded analyses of these outcomes. We estimated that the change in clinical management to children with health concerns directly relating to the HKC ranged between 3% and 11%.Conclusions: Overall, data suggest that general practitioners are diligent in detecting and managing child health problems. Some of these problems were detected only during the HKC appointment, resulting in change of management for some children. Further studies are required to estimate the full benefits and harms, and particularly the false negatives and true positives, of the HKC

“What should happen before asymptomatic men decide whether or not to have a PSA test?” A report on three community juries

Objectives: To elicit the views of well informed community members on the ethical obligations of general practitioners regarding prostate-specific antigen (PSA) testing, and what should be required before a man undergoes a PSA test. Design and setting: Three community juries held at the University of Sydney over 6 months in 2014. Participants: Forty participants from New South Wales, of diverse social and cultural backgrounds and with no experience of prostate cancer, recruited through public advertising: two juries of mixed gender and ages; one all-male jury of PSA screening age. Results: In contrast to Royal Australian College of General Practitioners guidelines, the three juries concluded that GPs should initiate discussions about PSA testing with asymptomatic men over 50 years of age. The mixed juries voted for GPs offering detailed information about all potential consequent benefits and harms before PSA testing, and favoured a cooling-off period before undertaking the test. The all-male jury recommended a staggered approach to providing information. They recommended that written information be available to those who wanted it, but eight of the 12 jurors thought that doctors should discuss the benefits and harms of biopsy and treatment only after a man had received an elevated PSA test result. Conclusions: Informed jury participants preferred that GPs actively supported individual men in making decisions about PSA testing, and that they allowed a cooling-off period before testing. However, men of screening age argued that uncertain and detailed information should be communicated only after receiving an elevated PSA test result

“What should happen before asymptomatic men decide whether or not to have a PSA test?” A report on three community juries

Objectives: To elicit the views of well informed community members on the ethical obligations of general practitioners regarding prostate-specific antigen (PSA) testing, and what should be required before a man undergoes a PSA test. Design and setting: Three community juries held at the University of Sydney over 6 months in 2014. Participants: Forty participants from New South Wales, of diverse social and cultural backgrounds and with no experience of prostate cancer, recruited through public advertising: two juries of mixed gender and ages; one all-male jury of PSA screening age. Results: In contrast to Royal Australian College of General Practitioners guidelines, the three juries concluded that GPs should initiate discussions about PSA testing with asymptomatic men over 50 years of age. The mixed juries voted for GPs offering detailed information about all potential consequent benefits and harms before PSA testing, and favoured a cooling-off period before undertaking the test. The all-male jury recommended a staggered approach to providing information. They recommended that written information be available to those who wanted it, but eight of the 12 jurors thought that doctors should discuss the benefits and harms of biopsy and treatment only after a man had received an elevated PSA test result. Conclusions: Informed jury participants preferred that GPs actively supported individual men in making decisions about PSA testing, and that they allowed a cooling-off period before testing. However, men of screening age argued that uncertain and detailed information should be communicated only after receiving an elevated PSA test result