Prevention of cardiovascular disease: Guideline for assessment and management of cardiovascular risk

The World Health Organization released three publications on the guidelines for the assessment and management of cardiovascular risk. The first publication provides guidance on reducing disability and premature deaths from coronary heart disease, cerebrovascular disease and peripheral vascular disease in people at high risk, who have not yet experienced a cardiovascular event. The accompanying pocket guidelines provide evidence-based guidance and the WHO/International Society of Hypertension risk prediction charts allow treatment to be targeted according to simple predictions of absolute cardiovascular risk.

Reviewer: Carlos Mendoza Montano, PhD, ProCor contributing editor, APRECOR, Guatemala, e-mail: projhouse@intelnet.net.gt

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.

For successful prevention and control of the CVD epidemic, the combination of population-based and individual-based strategies is needed to lower the cardiovascular risk of populations and individuals.

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.

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.

Guidelines for assessment and management of 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. Several forms of therapy can prevent coronary, cerebral and peripheral vascular events. Decisions about whether to initiate specific preventive action, and with what degree of intensity, should be guided by estimation of the risk of any such vascular event. But 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. Therefore, 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.

The risk prediction charts allow treatment to be targeted according to simple predictions of absolute cardiovascular risk. The risk prediction charts indicate 10-year risk of a fatal or nonfatal major cardiovascular event (myocardial infarction or stroke), according to age, sex, blood pressure, smoking status, total blood cholesterol and presence or absence of diabetes mellitus for 14 WHO epidemiological sub-regions. There are two sets of charts. One set (14 charts) can be used in settings where blood cholesterol can be measured. The other set (14 charts) is for settings in which blood cholesterol cannot be measured. Both sets are available in color and shades of black on a CD. Each chart can only be used in countries of the specific WHO sub-region.

The guidelines include recommendations for management of major cardiovascular risk factors through changes in lifestyle and prophylactic drug therapies. The guidelines provide a framework for the development of national strategies for prevention of cardiovascular disease that take into account the particular political, economic, social and medical circumstances.

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.

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).

More information on the three publications is available at:
www.who.int/cardiovascular_diseases/resources/publications

Some of the guidelines are available to download in PDF format or may be purchased through www.who.int/bookorders, by e-mailing bookorders@who.int or writing to: WHO Press, World Health Organization, 1211 Geneva 27, Switzerland.

Prevention of Cardiovascular Disease: Guideline for Assessment and Management of Cardiovascular Risk
Cost is US$27.00/CHF30.00, CHF21.00 in developing countries. Order number 11500703.
PDF (2.4 MB): www.who.int/cardiovascular_diseases/guidelines/Full%20text.pdf

Prevention of Cardiovascular Disease: Pocket Guidelines for Assessment and Management of Cardiovascular Risk
Cost is US$ 13.50/CHF15.00, CHF10.50 in developing countries. Includes WHO/ISH Cardiovascular Risk Prediction Charts for:
African Region: order number 11502713
Americas Region: order number 11504713
Eastern Mediterranean Region: order number 11505713
European Region: order number 11503713
South-East Asia Region: order number 11501713
Western Pacific Region: order number 11500713

Date Posted: 2 October 2007