cvd

1. CPG ON PRIMARY &
SECONDARY PREVENTION
OF CARDIOVASCULAR
DISEASE 2017

2. OBJECTIVES
The objectives of this CPG are to:
• look critically at the available evidence on the effectiveness of
strategies for the primary and secondary prevention of CVD.
• educate healthcare workers on methods of assessing and
stratifying CV risk in our local population.
• suggest appropriate preventive steps against cvd at the individual,
community and governmental level

3. INTRODUCTION
• Epidemiology :
CVD – main cause global mortality
In Malaysia , CVD has been the leading cause of morbidity and mortality for more
than a decade
Data from the 2011-2013 registry indicated that Malaysians developed ACS at a
younger age than that seen in neighbouring countries.
The mean age was 58.5 years and the peak incidence was in the 51-60 year age
group

4. INTRODUCTION
• from the NATIONAL HEALTH AND MORBIDITY SURVEYS (NHMS),
The malaysian adult population (≥18 years) has high levels of CV risk factors.
• 63.6% of men, and 64.5% of women are either overweight or obese.
• 43% of men smoke, 59% of men between the ages 21-30 smoke.
• 43.5% of men, and 52.2% of women have hypercholesterolemia.
• 30.8% of men, and 29.7% of women have hypertension.
• 16.7% of men, and 18.3% of women have diabetes mellitus.
**Data from NHMS V 2015 showed that the prevalence of these CV risk factors
begin to increase from the age of 30 years

5. PREVENTION OF CVD
•The healthy general
population
•Individuals with
multiple CV risk
factors. Individuals
who are at a high risk
for a CV event
• Individuals who are at
a high risk for a CV
event
Primary
Prevention
Strategies
• Already have an index
CV event
Secondary
Prevention
Strategies

6. The following information should be obtained for CV risk assessment:
History of
smoking
(and
vaping)
Lipid
profile
(TC,
LDL-C,
HDL-C,
TG)
Blood
glucose
/
BMI and waist
circumference
BP

7. • The committee advocates opportunistic rather than mass screening

11. Based on the 10-year CV risk, individuals may be classified as:
• >30% - Very High CV Risk
• >20% - High CV Risk
• 10-20 % - Intermediate (or Moderate) CV risk
• <10% - Low CV risk

12. • Most individuals who are at low and intermediate (or moderate)
risk can be managed by lifestyle changes alone.
• Those at high risk and high lifetime risk may require
pharmacotherapy in accordance with the cpgs.

13. Lifestyle changes involves:
These individuals should be assessed and counseled appropriately at
regular intervals to ensure adherence to a healthy lifestyle and to
determine if treatment goals are achieved.
Diet low in
saturated fats,
high in fiber
and low in
sodium
Regular
exercise
Smoking
cessation
•Maintaining
an ideal body
weight

14. • Individuals with established CVD are at a high risk of a recurrent
CV event.
• All CV risk factors in these patients should be treated to target via
lifestyle modification and drug therapy as indicated

15. • TYPES OF CVD :
• CHD : stable angina ACS non-obstructive coronary artery disease
• cerebrovascular accident (CVA) - this has a heterogeneous aetiology and
includes:
atrial fibrillation (AF) with embolization carotid artery and proximal aortic
atherosclerosis and thromboembolism intracranial haemorrhage (including
intracerebral and subarachnoid haemorrhage)
• Peripheral Arterial Disease including aortic aneurysm
• Asymptomatic individuals with:
“silent” myocardial ischemia detected by non-invasive testing
 significant atheromatous plaques detected in any vascular tree by imaging

16. • Risk factors for CVD :
Non-modifiable risk factors
Increasin
g age
Gende
r
Family
history
Ethnicity

17. • MODIFIABLE risk factors :
Hypertensi
on
Physical
inactivity
Diabetes
mellitus
Dyslipidem
ia
Obesity/
Overweight
Smokin
g
Diet/Dietar
y patterns
Cardio
Metabolic
Risk

18. Conditions that are associated with increased CV risk are:
• Chronic kidney disease
• Certain infections like HIV infection
• Certain cancers and its treatment (chemotherapy and
radiotherapy)
• Connective tissue diseases
• Obstructive sleep apnoea
• Psychosocial stress/ depression

19. • Gender specific issues:
Erectile dysfunction: ED is an indicator for generalized
vasculopathy. Lifestyle modifications reduces the prevalence of
CVD and also improves sexual health
Pre-eclampsia/ Pregnancy
Combined oral contraceptives
Sex hormone therapy – menopausal hormone therapy and
testosterone replacement therapy

20. • Risk markers that may be used to refine CV risk assessment beyond the
traditional risk factors found in the Framingham Risk Score include:
Resting ECG
Echocardiography- more sensitive to detect LVH (routine use of echocardiogram
as a screening tool in the asymptomatic population has not been proven
beneficial)
Biochemical – hs CRP if >3ng/ml – higher risk CVD
Subclinical vascular damage
- Ankle brachial index (<0.9 indicates arterial stenosis/PAD)
- Coronary Artery Calcium
• They are most useful in further risk stratifying individuals at Intermediate (or

21. The Malaysian Healthy Eating
Recommendations is the
#QuarterQuarterHalf plate which
consists of:
• Quarter of the plate being CHO
– rice, noodles, bread, cereals
and other cereal products and/or
tubers
• Quarter of the plate being
protein – fish, poultry, meat
and/or legumes
• Half of the plate being fruits
and vegetables
• Drinking plain water
Interventions to
prevent CVD :

23. • The five key recommendations that accompanies the malaysian healthy plate
guideline are:
1. consume 3 regular healthy main meals everyday
2. consume 1-2 servings of healthy snacks when necessary
3. consume at least half of your grains from whole grains
4. consume non – fried & santan free dishes everyday
5. consume home cooked foods more often.

24. PHYSICAL ACTIVITY
• It is beneficial in both primary and secondary prevention.
• This includes:
• Leisure-time physical activities
• Occupational activities
• Commuting activities
• Exercise: a subset of PA that is planned and structured, involving repetitive
bodily movement done with a goal to improve or maintain physical fitness

28. SMOKING INTERVENTION
• Cigarette smoking is a major cause of CVD
• Tobacco smoking and exposure to secondhand smoke together are responsible
for about 6.3 million annual deaths worldwide.
• Smoking accounted for 33% of all deaths from CVD and 20% of deaths from
IHD in persons ≥35 years old
• In the INTERHEART study, a dose response relationship was demonstrated
between the number of cigarettes and MI, where smokers who smoked >40
cig/day were found to have a 9-fold relative risk of MI compared with non-
smokers

29. SMOKING CESSATION PROGRAMME
• Nicotine replacement therapy (NRT)
• Varenicline – reduce relapse
• Bupropion – sustained release (risk of seizures 1:1000)
• The use of e-cigarettes and shisha are not recommended.

30. OBESITY MANAGEMENT
• Overweight and obese individuals should be counselled that lifestyle changes
can produce a 5-10% rate of weight loss that can be sustained over time and
that this can be associated with clinically meaningful health benefits.
• Bariatric surgery may be considered as a treatment option for obesity if BMI:
>35 kg/m2 with or without co morbidities.
>32 kg/m2 with co-morbidities.
>30 kg/m2 if central obesity + 2 CV risk factors
• Bariatric surgery has been shown to improve CV risk factors, CV events and
mortality.
• Recommendation: • For weight loss, in addition to dietary intervention, adults
should engage in 150–420 minutes of moderate-intensity physical activity per
week.

31. OBESITY MANAGEMENT
• Drug therapy should be considered for overweight and obese people with:
• BMI >25.0 kg/m2 plus 2 CV risk factors or
• BMI ≥ 27.0 kg/m2 after failing to lose weight despite 6 months of lifestyle
modification.
• Two anti-obesity drugs that are available locally are:
 Sympathomimetic (Phentermine) – this drug should not be used continuously
for longer than 6 months at any one time.
Lipase Inhibitor - Orlistat
Glucagon-like peptide 1 Receptor Agonist - Liraglutide479

32. OBESITY MANAGEMENT
• anti-obesity drugs may enhance weight loss by an additional 3-5%.
• in addition, the use of orlistat in obese individuals had shown a reduction in
diabetes incidence by 37.3% with a mean weight reduction of 5.8 vs 3.0 kg
compared to placebo

33. ANTICOAGULANTS