HeartScore

For the online interactive HeartScore - you can play Doctor and add your own details.

Intervention

Systolic blood pressure
is 130 mmHg, and that is above the normal range.

Raised blood pressure increases your risk for cardiovascular diseases.
It would be beneficial if your blood pressure was lowered from the present 130 mmHg to a level around xx mmHg.

You can contribute to this by choosing a diet rich on vegetables and fibres and by avoiding excessive intake of salt and animal fat.

If you increase your level of physical activity, it will also lead to a substantial reduction in your blood pressure.

In some cases, however, it is necessary to treat a high blood pressure with medicine.


Cholesterol

Your cholesterol is 5 mmol/L, and that is above the normal range.

The lower the cholesterol value gets, the lower the risk of cardiovascular disease.

I therefore recommend that your present cholesterol value of 5 mmol/L is lowered to a value around 5 mmol/L or less. This can be obtained by increasing the intake of vegetables and by eating less animal fat.

In severe cases, drugs may be needed to reduce a high cholesterol level.

GUIDELINES

Systolic Blood Pressure

Your patients blood pressure has been measured to 130 mmHg, 'and that is above the normal range.

The risk of cardiovascular diseases increases continuously as blood pressure rises from levels that are considered to be within the normal range.

The decision to start treatment, however, depends not only on the level of blood pressure, but also on an assessment of total cardiovascular risk and the presence or absence of target organ damage.

In patients with established CVD the choice of antihypertensive drugs depends on the underlying cardiovascular disease.

The decision to lower blood pressure with drugs depends not only on the total cardiovascular risk but also on presence of target organ damage.

Drug therapy should be initiated promptly in individuals with a sustained systolic blood pressure (SBP) > 180 mmHg and/or a diastolic blood pressure (DBP) > 110 mmHg regardless of their total cardiovascular risk assessment.

Individuals at high risk of developing CVD with sustained SBP of higher than 140 mmHg and/or DBP higher than 90 mmHg also require drug therapy.

For such individuals, drugs should be used to lower blood pressure to <140/90mmhg.>

• diuretics,
• betablockers,
• ACE inhibitors,
• calcium-channel blockers and
• angiotensin II antagonists.

In many clinical trials, blood pressure control has been achieved by the combination of two or even three drugs, and drug combination therapy is often also necessary in routine clinical practice.

In patients with several diseases requiring drug therapy, polypharmacy can become a major problem and good clinical management is required to resolve it.

In all patients, blood pressure reduction should be obtained gradually.
For most patients, the goal of therapy is blood pressure less than 140/90 mmHg, but for patients with diabetes and individuals at high total CVD risk, the blood pressure goal should be lower.

Cholesterol Guidelines
our patients cholesterol has been measured to 5 mmol/L, and that is above the normal range.

In general, total plasma cholesterol should be below 5 mmol/l (190 mg/dl), and LDL cholesterol should be below 3 mmol/l (115 mg/dl).

For patients with clinically established CVD and patients with diabetes the treatment goals should be lower:total cholesterol <4.5mmol/l(175mg/dl)>1.7mmol/l(150mg/dl),serve as markers of increased cardiovascular risk.

Values of HDL cholesterol and triglycerides should also be used to guide the choice of drug therapy.

Asymptomatic people at high multifactorial risk of developing cardiovascular disease, whose untreated values of total and LDL cholesterol are already close to 5 and 3 mmol/l, respectively, seem to benefit from further reduction of total cholesterol to <>8mmol/l (320mg/dl) and LDL-cholesterol>6mmol/l (240mg/dl) by definition places a patient at high total risk of CVD.

If the 10 year risk of cardiovascular death is >5%, or will become >5% if the individuals´ risk factor combination is projected to age 60, a full analysis of plasma lipoproteins should be performed, and intensive lifestyle advice, particularly dietary advice, should be given .

If values of total and LDL cholesterol fall below 5 mmol/l (190 mg/dl) and 3 mmol/l (115 mg/dl), respectively, and the total CVD risk estimate has become <>5%, lipid lowering drug therapy should be considered to lower total and LDL cholesterol even further.

The goals in such persistently high-risk individuals are to lower total cholesterol to < style="font-weight: bold;" size="4">Diet
General recommendations:

• foods should be varied, and energy intake must be adjusted to maintain ideal body weight
• the consumption of the following foods should be encouraged: fruits and vegetables, whole grain cereals and bread, low fat dairy products, fish and lean meat.
• oily fish and omega-3-fatty acids have particular protective properties
• total fat intake should account for no more than 30% of energy intake, and intake of saturated fats should not exceed a third of total fat intake. The intake of cholesterol should be less than 300 mg/day
• in an isocaloric diet, saturated fat can be replaced partly by complex carbohydrates, partly by monounsaturated and polyunsaturated fats from vegetables and marine animals
  Patients with arterial hypertension, diabetes, and hypercholesterolemia or other dyslipidemias should receive specialist dietary advice.

Priorities
The priorities for CVD prevention in clinical practice are :

• Patients with established coronary heart disease, peripheral artery disease and cerebrovascular atherosclerotic disease
• Asymptomatic individuals who are at high risk of developing atherosclerotic cardiovascular disease because of
• multiple risk factors resulting in a 10 year risk of 5% now (or if extrapolated to age 60) for developing a fatal CVD event
• markedly raised levels of single risk factors: cholesterol 8 mmol/l (320 mg/dl), LDLcholesterol 6 mmol/l (240 mg/dl), blood pressure 180/110 mmHg
• diabetes type 2 and diabetes type 1 with microalbuminuria
• Close relatives of
• patients with early onset atherosclerotic cardiovascular disease
• symptomatic individuals at particularly high risk
• Other individuals encountered in your clinical practice

Strategies
Strategies to make behavioural counselling more effective include:

• develop a therapeutic alliance with the patient
• gain commitments from the patient to achieve lifestyle change
• ensure the patient understands the relationship between lifestyle and disease
• help the patient overcome barriers to lifestyle change
• involve the patient in identifying the risk factor(s) to change
• design a lifestyle modification plan
• use strategies to reinforce the patients´ own capacity to change
• monitor progress of lifestyle change through followup contacts
• involve other health care staff wherever possible

SCORE
This new model for total risk estimation based on the SCORE (Systematic Coronary Risk Evaluation) system is now recommended and has several advantages.

The SCORE risk assessment is derived from a large dataset of prospective European studies and predicts fatal atherosclerotic CVD events over a ten year period.

This risk estimation is based on the following risk factors: gender, age, smoking, systolic blood pressure and total cholesterol.

The threshold for high risk based on fatal cardiovascular events is defined as "higher than 5%" , instead of the previous "higher than 20%" using a composite coronary endpoint.

This SCORE model has been calibrated according to each European country´s mortality statistics. In other words, if used on the entire population aged 40-65, it will predict the exact number of fatal CVD-events that eventually will occur after 10 years.

Using HeartScore total CVD risk can also be projected to age 60 which may be of particular importance for guiding young adults, at the age of 20 or 30, at low absolute risk, but already with an unhealthy risk profile, which will put them at much higher risk when they grow older.

Relative risk can also be estimated from the pie charts.

You can read more about the SCORE project in European Heart Journal, 2003, 24; 987-1003.