CARDIOVASCULAR DISEASE RISK ASSESSMENT & PREVENTION CLINIC

Cardiovascular disease (CVD) is a term that describes a group of disorders of the heart and blood vessels caused by atherosclerosis and thrombosis, which includes coronary heart disease, stroke, peripheral arterial disease, and aortic disease.

The risk of CVD is greater in men, patients with a family history of CVD, and in certain ethnic backgrounds such as South Asians. CVD risk is also greater in patients aged over 50 years and increases with age; patients aged 85 years and over are at particularly high risk. CVD has several important and potentially modifiable risk factors such as hypertension, abnormal lipids, obesity, diabetes mellitus, and psychosocial factors such as depression, anxiety, and social isolation. Low physical activity, poor diet, smoking, and excessive alcohol intake are also modifiable risk factors.

CVD is the most common cause of death in Europe accounting for 4.1 million deaths (2.2 mio in females, 1,9 mio in males) each year; corresponding to 47% of all deaths among women and 39% among men. IHD and cerebrovascular disease are the most common causes of cardiovascular death and IHD accounts for 1.67 million deaths corresponding to 17% and 18% of all deaths in men and women, respectively. Notably, more than twice as many men as women under the age of 70 years die from IHD

The age-adjusted CVD incidence has declined rapidly in almost all Western European countries with up to 30-50% reduction in the last 10-15 years in some countries. The decline is seen in both men and women and the majority can be attributed to improvements in primary and secondary prevention. However, not all risk factors show a beneficial trend. While smoking rates and population cholesterol levels have gone down, obesity and diabetes are increasing, causing some concern of whether the beneficial development seen in recent decades may not continue or even be reversed. Psychosocial stress, such as depression, anxiety and burn-out, which are now recognized as important contributors to CVD incidence and prognosis, are not declining. Also, disparities in CVD mortality regional, as well as national socioeconomic and other disparities remain high and even increasing [1]. According to the World Health Organization, CVD is responsible for the majority of the global loss of disability adjusted life-years. The most important modifiable risk factors responsible for global CVD burden are – in order of ranking – systolic blood pressure, diet, LDL-cholesterol, smoking, obesity, and plasma glucose but also environmental risks linked to climate changes are among the top-ranking modifiable risk factors [2].

Aims of treatment

Dr Ubaid’s and his team aim in this dedicated clinic is to help prevent the occurrence of cardiovascular events by reducing modifiable risk factors, life style changes and drug treatment. To help achieve this aim, Dr Ubaid uses specific and validated risk assessment tools to estimate the individual’s risk of developing cardiovascular diseases and based on the result of these risk assessment tools and after a careful clinical assessment, he provides individualised advise accordingly.

The National Institute of Clinical Excellence NICE recommends that priority for a full formal risk assessment should be given to patients with an estimated 10-year risk of 10% or more. Patients aged over 40 years should have their estimate of CVD risk reviewed on an ongoing basis. As well as to patients with a first-degree relative who has premature atherosclerotic CVD or familial dyslipidaemia, regardless of their age.
Cardiovascular risk assessment calculators are used to predict the approximate likelihood of a cardiovascular event occurring over a given period of time. Standard risk scores may be underestimated in patients with additional risk due to existing conditions or medications that can cause dyslipidaemia (e.g. antipsychotics, corticosteroids, or immunosuppressants). CVD risk may also be underestimated in patients who are already taking antihypertensives or lipid-regulating drugs, or who have recently stopped smoking. Interpretation of risk scores as well as the need for further management of risk factors in those who fall below the CVD risk threshold, should always reflect informed clinical judgement.
All patients at any risk of CVD should be advised to make lifestyle modifications that may include beneficial changes to diet (such as increasing fruit and vegetable consumption, reducing saturated fat and dietary salt intake), increasing physical exercise, weight management, reducing alcohol consumption, and Smoking cessation. An annual review should be considered to discuss lifestyle modification, medication adherence and risk factors. The frequency of review may be tailored to the individual.

Further preventative measures with drug treatment should be taken in individuals with a high risk of developing CVD (primary prevention), and to prevent recurrence of events in those with established CVD (secondary prevention).

Antiplatelet therapy

Aspirin is not recommended for primary prevention of CVD due to the limited benefit gained versus risk of side-effects such as bleeding.

Antihypertensive therapy

Antihypertensive drug treatment should be offered to patients who are at high risk of CVD and have sustained elevated systolic blood pressure and/or diastolic blood pressure. For further guidance on prescribing antihypertensive drugs in patients without symptomatic CVD and for specific groups at high cardiovascular risk, see Hypertension.

Lipid-lowering therapy

A statin is recommended as the lipid-lowering drug of choice for primary prevention of CVD. All modifiable risk factors, comorbidities and secondary causes of dyslipidaemia (e.g. uncontrolled diabetes mellitus, hepatic disease, nephrotic syndrome, excessive alcohol consumption, and hypothyroidism) should be managed before starting treatment with a statin. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy.

Antiplatelet therapy

Antiplatelet therapy with low-dose daily aspirin should be offered to patients with established atherosclerotic disease. Alternatively, clopidogrel can be considered in patients who are intolerant to aspirin or in whom it is contraindicated.

Clopidogrel or a combination of dipyridamole with aspirin should be considered to prevent recurrence of stroke and other vascular events in all patients with a history of stroke or transient ischaemic attack who are in sinus rhythm. For further information, see Stroke.

For guidance on the use of antiplatelet agents in patients with acute coronary syndrome, see Acute coronary syndromes.

Antihypertensive therapy

Antihypertensive drug treatment is recommended in patients with established CVD and sustained elevated systolic blood pressure and/or diastolic blood pressure. For further guidance on prescribing antihypertensive drugs in patients with CVD, see Hypertension.

Lipid-lowering therapy

A statin is recommended as the lipid-lowering drug of choice for secondary prevention of CVD. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy.

Treatment with high-dose atorvastatin should be offered to patients with established atherosclerotic CVD. However, a lower dose can be used if the patient is at an increased risk of side-effects or drug interactions. NICE (2016) recommend that low-dose atorvastatin be offered to patients with established CVD and chronic kidney disease.

High-dose simvastatin is generally avoided due to the risk of myopathy, unless the patient has been stable on this regimen for at least one year. Furthermore, the MHRA advise that high-dose simvastatin only be considered for patients who have not achieved their treatment goals with lower doses and have severe hypercholesterolaemia and high risk of cardiovascular complications; benefits should outweigh risks.

Patients taking statins should have an annual medication review to discuss medication adherence, lifestyle modification, CVD risk factors, and non-fasting, non-HDL-cholesterol concentrations (if testing deemed appropriate). Total cholesterol, HDL-cholesterol, and non-HDL-cholesterol concentrations should be checked 3 months after starting treatment with a high-intensity statin. Patients who are stable on a low or medium-intensity statin should discuss the benefits and risks of switching to a high-intensity statin at their next medication review.

Aiming for a reduction in non-HDL-cholesterol concentration of greater than 40% is recommended.

DON’T LET OTHERS DIE NEEDLESSLY

Psychological risk factors

Psychological treatment should be considered in patients with mood and anxiety disorders and comorbid CVD; complex patients may require referral to mental health services for assessment and delivery of high-intensity or specialist treatments. Selective serotonin re-uptake inhibitors (SSRIs) should be considered for treatment in patients with depression and coronary heart disease. For guidance on prescribing of antidepressant drugs see Antidepressant drugs.

Heart Disease in Women

The death rate from cardiovascular diseases has decreased among men, but continues to increase in women. Cardiovascular disease is the number 1 killer of women causing 1 in 3 deaths each year.

Unfortunately, only 1 in 3 women are unaware that heart disease is the greatest health problem facing women today.

MEET SALAHADDIN

OTHER DEDICATED CLINICS

General/Interventional Cardiology
SPORTS CARDIOLOGY CLINIC
Cardiac Rehabilitation Clinic

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    Your kindness and good humour were very much appreciated and certainly put me at ease throughout the procedure, which on other ocassions has been quite daunting, your relaxed approach to my problem was very calm and professional.

    In Dr Salahaddin Ubaid I had a medical genius who also contributed significantly to aiding me overcome all of the negative worries and emotions I was feeling. The care he provided to me, his attention to detail, his personal knowledge, expertise, experience and skills was outstanding.

    Dr Ubaid works well with all the staff. His approach to his fellow workers is both patient and respectful. His easy going manner makes him very approachable to ask advice and he accommodates any delays graciously. I personally look forward to working with him.

    A great team player, all of the nursing staff are very happy to work with Salahaddin as he is polite, efficient, and has a great aura of calmness and competence and appreciates the time to be light-hearted.

    What I valued as much as his erudition was his people skills, he related to everyone as an individual, his understanding, communications, interactions and personable nature were exceptional. Dr Ubaid was quite simply staggering, he is somebody that has had a significant impact on me, not just for giving me my life back and for his medical genius but for being the person that he is.

    In life we all need role models, if I was in training to be a doctor you would certainly fit that role for me. I thank you so much for what you have done to allow me to continue with my fitness regime and wish you well in the life ahead of you.

    His presence radiates a warmth, he instils confidence in all those around him, he sets an example for others to follow and is a role model for others to aspire to be like. He was kind, courteous, professional, understanding, caring and highly approachable and relatable as well as the medical guru we all benefit from and rely on to give us our lives back.

    Meet Dr Salahaddin Ubaid

    General & Interventional Cardiology

    Risk Assessment & Prevention Clinic

    Sports Cardiology Clinic

    Cardiac Rehabilitation Clinic