SIGN CHD In Scotland in the year ending 31 March 2006 over 10,300 patients died from CHD and 5,800 from cerebrovascular disease, with almost 49,000 hospital admissions for CHD and a further 22,050 for cerebrovascular disease. www.isdscotland.org Coronary Heart Disease SIGN CHD SIGN is a collaborative network of healthcare professionals and SIGN guidelines are developed by multidisciplinary groups using a standard methodology based on a systematic review of the evidence. SIGN levels of evidence 1+ + High quality meta analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta analyses, systematic reviews of RCTs, or RCTs with a low risk of bias 1 Meta analyses, systematic reviews of RCTs, or RCTs with a high risk of bias 2+ + High quality systematic reviews of case-control or cohort studies High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal 2 Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal 3 Non-analytic studies, e.g. case reports, case series 4 Expert opinion SIGN grades of recommendation A At least one meta analysis, systematic review, or RCT rated as 1+ + , and directly applicable to the target population; or A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+ , directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2+ + , directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1+ + or 1+ C A body of evidence including studies rated as 2+ , directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2+ + D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ SIGN Coronary Heart Disease SIGN CHD • • • • • PREVENTION STABLE ANGINA ACUTE CORONARY SYNDROMES ARRHYTHMIAS CHRONIC HEART FAILURE SIGN: Prevention SIGN CHD: prevention Prevention of CHD - Risk Estimation • Individuals with symptomatic manifestations of cardiovascular disease or diabetes should be considered at high risk (≥ 20% risk over 10 years) of cardiovascular events D • All adults over the age of 40 who have no history of cardiovascular disease or diabetes and who are not being treated for blood pressure or lipid reduction should have their cardiovascular risk estimated at least once every five years D SIGN CHD : prevention Simvastatin 40 mg/day recommended as part of the management in those patients over age 40 with a 10 year risk of CVS events of > 20% A Potential events avoided and related resources saved from treating 435,000 asymptomatic individuals at high CVD risk with a statin Event Clinical benefit over 4.3 years Major vascular 6,217 All cause mortality 2,303 Total 8,520 Annual bed days saved ASCOT-LLA/CARDS Annual cost savings (million) 17,050 £5.9 17,050 £5.9 Potential events and resources saved from treating 95,000 symptomatic individuals with a statin Events Major vascular All cause mortality Total Events avoided Annual bed days saved 9,437 Annual cost savings (million ) 19,770 £6.8 19,770 £6.8 718 10,155 HPS SIGN has commissioned the development of a score to include social deprivation as a risk variable. ASSIGN tends to classify more people with a positive family history and who are socially deprived as being at high risk. When used in its own host population, it abolished a large social gradient in future CVD victims not identified for preventative treatment by the Framingham score: it therefore improved social equity. http://assign-score.com Heart 2007;93:172-176 SIGN: chronic stable angina SIGN CHD: Stable Angina • Patients with left main stem disease should undergo coronary artery bypass grafting to improve coronary heart disease prognosis A • Patients with triple vessel disease should be considered for coronary artery bypass grafting to improve coronary heart disease prognosis but where unsuitable be offered percutaneous coronary intervention A • Patients with single or double vessel disease where optimal medical therapy fails to control symptoms should be offered percutaneous intevention or where unsuitable, be considered for coronary bypass surgery A SIGN: acute coronary syndromes SIGN CHD: ACS • Patients with ST elevation acute coronary syndrome should be treated immediately with primary percutaneous coronary intervention A • Where primary percutaneous coronary intervention cannot be provided within 90 minutes of diagnosis, patients with ST elevation acute coronary syndrome should receive immediate thrombolytic therapy D • Patients with ST elevation acute coronary syndrome within 6 hours of symptoms who fail to reperfuse following thrombolysis should be considered for rescue percutaneous coronary intervention B SIGN CHD: ACS • A • ABA In addition to long term aspirin, clopidogrel therapy should be continued for three months in patients with nonST elevation acute coronary syndromes B SIGN: Arrhythmias SIGN CHD: arrhythmias • Patients with impaired LV ejection fraction in NYHA Class I – III after previous myocardial infarction should be considered for ICD therapy A • Patients with spontaneous non-sustained ventricular tachycardia, severely depressed ejection fraction (<0.25) or prolonged QRS duration (>0.12 sec) should be prioritized for ICD implantation B SIGN Heart Failure SIGN CHD : heart failure BNP should be checked prior to commencing therapy for suspected heart failure A SIGN CHD: Heart failure Heart Failure - Interventional procedures In patients in sinus rhythm with drug refractory symptoms of heart failure due to left ventricular systolic function (LVEF < 35%) and who are in NYHA Class III and IV and who have a QRS duration of > 120 m/s, cardiac resynchronisation therapy (CRT) should be considered A SIGN CHD: Heart failure Heart Failure - Discharge planning • Comprehensive discharge planning to ensure links with post discharge services should be available to all those with symptomatic heart failure. A nurse-led, home based element should be included A • Telephone follow-up by specialised heart failure nurses should be considered for patients with stable heart failure. Nurses should have the ability to alter diuretic dose, telephone schedules and recommend emergency/non-scheduled medical contact A SIGN CHD What are the potential clinical events avoided by implementation? SIGN CHD implementation benefits 7,229 Bed days saved per year 17,052 Saving s per year (£ million) 5.9 718 9,437 19,770 6.8 950 2,761 9,108 2.5 750 2,672 5,414 2.0 5,096 22,099 51,344 17.2 Acute Coronary Syndromes guideline 896 2,176 2,394 1.2 Arrhythmia and Heart Failure guidelines 1,232 2,851 7,074 2.3 Total events 7,224 27,126 60,812 20.7 Recommendati on by guideline Mortality avoided over 5 years Events avoide d over 5 years 2,678 Statins – secondary prevention Antihypertensive drugs Statins – primary prevention Prevention other Prevention - total Estimated annual cost of implementing key recommendations by guideline Cost (£ million) Year 1 Year 6 ACS 5 (5) 5 (5) Arrhythmias 4 (5) 4 (5) Heart Failure 7 (7) 7 (7) Prevention 25 (27) 54 (62) Total 41 (44) 70 (79) SIGN CHD The recommendations on statins and hypertension account for over 90% of the costs and the savings SIGN CHD Over the next five years, it is estimated that over 7,200 premature deaths from CVD and over 27,000 vascular events could be avoided. This is equivalent to a 9% reduction from the current CVD mortality rate and an 8% reduction from the current CVD event rate.