This year’s EPCCS Meeting dedicated much time to discussion and identifying gaps in the evidence, aimed at composing practical recommendations for CV risk management in general practice.
This year’s annual EPCCS meeting was held at Prague, Czech Republic. In response to audience feedback at previous meetings, the format was changed towards more room for debate. In separate sessions, key cardiovascular risk factors and management of established CV diseases were covered. The evidence base of each of the topics was outlined first. Areas of uncertainty exist, however, as well as gaps in the evidence. It was discussed how to deal with these, in an attempt to reach consensus. The shared views and experiences will be combined for each session and EPCCS will make an effort to prepare documents summarising the key points and consensus recommendations for publication on the website and/or in clinical journals.
Main CVD risk factors: Health behaviour changes
One of the key messages in the session on health behaviour modification was that it is surprisingly well-accepted by patients if a doctor intervenes with health behaviour. Important when discussing strategies to improve lifestyle with a patient is to acknowledge to change alone is not enough. It helps if concrete steps and targets are discussed and appointments made. Taking a positive approach by focussing on what can be done is helpful, thus it is advantageous if a GP is aware of existing health programmes in their region. Involving family members, or enrolling a patient in a group intervention may also enhance motivation and success.
Another important realisation is that even if for instance weight reduction is only achieved temporarily, the benefit on other health markers (eg blood pressure, HbA1c) has a more lasting effect.
Importantly, ten years ago efforts to reduce smoking may have been considered useless. Incremental small effects have, however, accumulated to a large net effort. The same should be aimed for with weight loss and other risk factors.
Main CVD risk factors: Elevated lipids
In the session on elevated lipids, the implications of the recent IMPROVE-IT trial were highlighted. This study showed lower event rates with lower LDL-cholesterol levels, achieved with a non-statin agent (ezetimibe). Thus, lowering LDL-c levels per se is central to risk reduction, rather than the pleiotropic effects attributed to statins. These results underscore the LDL hypothesis, which states that LDL-c lowering is central to CV event reduction, rather than the statin hypothesis, which said that the CV benefit obtained is specific to statins.
Although lower LDL-c levels in general appear beneficial, the study results do not suggest specific targets. No randomised clinical trial has been performed to compare treating to different LDL-c targets, thus the often recommended goal of
With respect to risk assessment, consensus was reached in that traditional risk scores currently preform as well as any other biomarker. Coronary artery calcium is the only exception, but it is not feasible to subject everybody to a CT scan and expose them to radiation.
Lipid management in frail elderly patients with comorbidities was noted as an underexplored area that deserves more attention in future research.
Main CVD risk factors: Elevated blood pressure
On the second day of the meeting, several aspects of management of elevated blood pressure (BP) were topic of discussion. For instance what should GPs do about masked hypertension, is it worth screening for? Treating it did not seem very beneficial in low-risk patients, so awareness is possibly mostly important in patients at high risk.
Evidence exists that nurses consistently measure lower systolic BP than GPs, in the same patient (difference: 7 mmHg). In addition to ambulatory BP measurement to exclude white collar hypertension, 30-minute office BP measurement also seems informative, according to a Dutch study.
Also in this session, treatment targets were topic of debate. In the European Society of Hypertension guideline update, limited evidence is presented for a benefit of targeting BP lower than 140/90 mmHg. A recent press release on results of the SPRINT trial, however, stated that mortality was reduced by almost a quarter and CVD by almost a third during 2-3 ears of follow-up. When patients reached 120 mmHg with 3 medications instead of 140 mmHg on 2 drugs.
Established vascular disease: Heart failure diagnosis and management
Heart failure (HF) was the last topic of this meeting. It is important due to its poor prognosis, but difficult to diagnose. Many questions were discussed on how case-finding may best be performed. If HF is suspected, based on clinical decision rules, BNP may be measured. But other factors that can raise BNP should be taken into account; it may for instance be challenging to interprete BNP results in diabetic patients. Moreover, it is not always clear what to do with results of open access tests.
Differences exist between HF management guidelines of the ESC and for instance those of the United Kingdom, with regard to the tests that should be performed.
Concerning treatment, symptom relief with diuretics is important, to act on the fluid overload. ACE-inhibitors, mineralocorticoid receptor antagonists and angiotensin-receptor blockers can improve prognosis. Ivabradine and devices may be beneficial, as well as the new angiotensin receptor neprilysin-inhibitor (ARNI, sacubitril/valsartan), although probably not yet in primary care in the near future.
It is important to identify HF patients on a downward path, to offer palliative care. It should be noted, however, that this is very difficult to predict, as individual variation in the course of disease is very large. Whether the clinical picture worsens of improves; the GP has a central responsibility in this trajectory.
