Pocket guidelines for assessment and management of cardiovascular risk

A new book of pocket-charts that will help health workers to identify people at risk of heart attacks and strokes and save lives by prescribing the most appropriate treatment is published today by the World Health Organization (WHO). The charts can be adapted for use in any setting, in any country, with any patient.

The "Pocket Guidelines for Assessment and Management of Cardiovascular Risk" can be carried and used by any health care worker and is available in six languages. The guide contains easy-to-use charts that can predict the risk of a heart attack or a stroke and could help health workers to save and improve the lives of people in all countries.

"This is a real breakthrough. Now, health care workers everywhere - whether they are in a high-tech medical center in a big city, or riding a bicycle to visit patients in the countryside - can use a simple assessment and treatment tool to prevent heart attacks and strokes," said the WHO Director-General, Dr Margaret Chan. "Primary health care workers now have a new tool to assess and manage people at risk of heart attacks and strokes. This brings cardiovascular care to the places and people who need it most."

This is the first cardiovascular disease risk-prediction system that can be used worldwide and is also specially designed for use with people everywhere, including in low-resource settings. It is an important innovation that will help health workers to target limited health care resources at people who are at higher risk of developing heart attacks and strokes.

These guidelines will be distributed to health workers in the form of pocket guides that have been produced for each of the WHO regions (risk profiles are different for different parts of the world).

"We are never prepared for the sudden death of a family member or a friend from a heart attack or stroke", said Dr Catherine Le Galès-Camus, WHO Assistant Director-General for Noncommunicable Diseases and Mental Health. "Cardiovascular diseases are increasing towards epidemic proportions in developing countries - they already account for one-third of global deaths, and almost 10 percent of the global burden of disease, and are likely to become the developing world's leading cause of death in 2010. There is reason for hope, however, given that huge potential exists to control this emerging epidemic. These risk charts are a major new tool for providing the best health care to all the world’s people".

To ensure that the pocket guide gets into the hands of the health care workers who should use it, WHO will be collaborating with national Ministries of Health and health-focused nongovernmental organizations to organize 'training of trainers' workshops and distribution of the pocket guide.

The risk-prediction charts integrate the following risk factors when predicting the risk of a heart attack or stroke in the 10 year period following the patient assessment:

• age
• sex
• tobacco use
• blood pressure
• diabetes status
• blood cholesterol.

The pocket guide also incorporates management recommendations, based on the risk of developing heart attacks and strokes, in the following areas:

• smoking cessation
• dietary changes
• physical activity
• weight control
• alcohol intake
• antihypertensive drugs
• lipid-lowering drugs
• hypoglycaemic drugs
• antiplatelet drugs
• anticoagulant treatment
• revascularization surgery
• drugs that are not recommended.

Background

Cardiovascular disease (CVD) is the number one cause of death globally, causing one third of all deaths. In 2005, 11.8 million people died of heart attacks and other heart diseases, and 5.7 million died of stroke. Around 80% of these deaths were in low- and middle-income countries. By 2015, an estimated 20 million people will die from CVD annually, mainly from heart attacks and strokes. Socioeconomic costs of premature deaths and disability, and escalating costs of medical care make it all the more urgent to take measures to prevent and control this burgeoning epidemic in low- and middle-income countries where health care resources are limited.

Urbanization and globalization promote tobacco use, unhealthy diet and physical inactivity. These risk factors result in increased risk of people developing heart attacks and strokes because the result is raised levels of blood pressure, blood glucose, blood cholesterol and body weight. These, in addition to increasing age, are major risk factors that determine an individual's chances of having a heart attack or stroke. This is known as the cardiovascular risk.

Until now, individuals have often been assessed and treated based on a single cardiovascular risk factor such as high blood pressure, high blood lipids or diabetes. This approach can result in committing a patient who has only a small cardiovascular risk to many years of drug therapy or, conversely, neglecting to treat those with an overall higher cardiovascular risk. Most importantly, the single risk factor approach is not cost effective and is not affordable for many low-income and middle-income countries.

For successful prevention and control of the CVD epidemic, the combination of population-based and individual-based strategies are needed to lower the cardiovascular risk of populations and individuals. Population-wide strategies such as tobacco control and promotion of a healthy diet and physical activity are very cost effective in all countries. Cost effective interventions are also available to treat those who have survived heart attacks and strokes. However, treating risk factors such as high blood pressure and blood lipids is cost effective for low-income and middle-income countries only if interventions are targeted at high risk individuals.

In many low-income and middle-income countries, national and state health care budgets and per capita health expenditures are suboptimal. It is imperative, therefore, to use the limited resources that are available as effectively and efficiently as possible. This requires the prioritization of cost-effective approaches and the targeting of those patients who are most likely to benefit from interventions. In any population, those people who are most likely to benefit from cost-effective CVD interventions are the people with the highest cardiovascular risk.

The World Health Organization, in collaboration with the International Society of Hypertension (ISH), has developed cardiovascular risk prediction charts that enable cardiovascular risk assessment and prediction in non-western populations.

Many health care systems in low-income countries do not have the basic infrastructure facilities to support resource intensive risk prediction tools, particularly in primary health care. The WHO/ISH charts use easily measurable indicators of risk to quantify the 10-year risk of developing heart attacks and strokes. These indicators of risk include gender, age, systolic blood pressure, smoking status, diabetes and total blood cholesterol. For use in low-resource settings, where blood cholesterol measurement is not routinely available, alternative charts have been developed that predict risk without blood cholesterol. Also, in many low-resource settings, urine sugar levels may be used as a surrogate marker for diabetes.

Although the risk-prediction charts and pocket guides are simple to use, short training sessions will be required to introduce the charts into regular health care practice. The charts are ready for use now, and will be updated over time. Like all risk-prediction tools, the accuracy of this tool for specific populations can be improved over the long term by making minor adaptations as data are collated for individual populations. Technical assistance will be provided, through the WHO-ISH collaboration, to compare this new tool with other risk prediction methods, to further improve accuracy, and to adapt the CVD risk-prediction charts to suit very specific country contexts.

For further information, please contact:

Shanthi Mendis
Senior Adviser, Cardiovascular diseases
Chronic Disease and Health Promotion
WHO Geneva
Tel.: +41 22 791 3441
Mobile: +41 79 505 7455
E-mail: [email protected]