New CVD, Diabetes and Stroke guidelines issued
08 December 2003
New CVD, Diabetes and Stroke guidelines issued for health professionals
New guidelines to help treat cardiovascular disease (including stroke) and diabetes are being launched by the Minister of Health on Monday 8 December.
"Diabetes and cardiovascular disease are top government priority areas and these guidelines will provide important information for DHBs and PHOs to help them manage their populations" says Dr. Colin Feek Deputy Director General of Health, Ministry of Health.
The number of people diagnosed with diabetes in the next 20 years is expected to increase from 115,000 to over 160, 000. Cardiovascular disease, including heart disease and stroke, accounts for 40% of all deaths in New Zealand and most diabetics die of cardiovascular disease.
The three sets of guidelines offer recommendations for lifestyle changes as well as medical treatments on the assessment and management of cardiovascular disease, management of diabetes and management of people who have had a stroke.
Maori and Pacific peoples are more likely to have cardiovascular disease and diabetes than other population groups and the guidelines will help to reduce health inequalities as they provide specific information on the management of Maori and Pacific peoples.
For example, the cardiovascular guidelines recommend that men aged 45 and women aged 55 and above should have a cardiovascular disease risk assessment, but because of their higher risk Maori and Pacific men and women should have this assessment 10 years earlier.
The Stroke Guidelines provide information for DHBs on how to develop organised stroke services which clinical evidence has shown is the most important intervention for improving outcomes for people who have suffered a stroke.
The New Zealand Guidelines Group developed these guidelines with funding from the Ministry of Health.
Diabetes New Zealand, the National Heart Foundation, the Stroke Foundation and the Cardiac Society as well as large number of expert health professionals were invovled in the development of the guidelines.
All three guidelines will be sent to DHBs and health professionals for the management of these conditions.
The guidelines will be available on the New Zealand Guidelines Group website, www.nzgg.org.nz which consumers can access and the Stroke Guidelines will be available at www.stroke.org.nz.
CVD, Diabetes and Stroke guidelines Q&As
Where is the launch?
At the Beehive foyer between 4:30 and 6 p.m. on 8 December 2003, launched by The Hon. Annette King, and there will be other speakers including Dr Colin Feek, Deputy Director General of Health and Clinical Services Directorate, Ministry of Health; Dr Peter Didsbury, Chairperson of the Guidelines Group; Dr Jim Mann, Prof Human Nutrition and Medicine, University of Otago; Dr. Norman Sharpe, Medical Director of the Heart Foundation, Dr Paul Drury, Diabetes Specialist; Dr Harry McNaughton, Stroke Specialist.
How many guidelines are there?
There are three guidelines that cover the assessment and management of cardiovascular risk, the management of type 2 diabetes and the management of stroke.
Who developed these guidelines?
The guidelines have been developed by an independent group, the New Zealand Guidelines Group, over the last two years, in conjunction with National Heart Foundation and the Stroke Foundation, and a wide range of service providers, professional groups and consumer groups which reviewed the evidence and developed the key recommendations. The guideline development teams were chaired by:
- ·Dr. Jim Mann, Professor of Human Nutrition and Medicine, University of Otago and Chair CVD Screening and Risk Assessment Guideline Development Team.
- ·Dr. Patrick Manning, Diabetes Specialist.
- ·Dr. Jonathan Baskett, Gerontologist, and Dr. Harry McNaughton, Rehabilitation specialist and Honorary Medical Director of the Stroke Foundation and Co-Chairs of the Stroke Guideline Development Team
- ·Norman Sharpe, Medical Director of the National Heart Foundation and Chair Secondary Prevention Guideline Development Team.
The guideline teams reviewed hundreds of national and international research evidence to reach a series of recommendations for providing people after stroke, heart attack, and type 2 diabetes – and people at risk of those diseases, effective, timely and equitable.
What is new about these guidelines?
- These guidelines are thought to be the first internationally to have approached cardiovascular disease in a holistic way.
- They cover all aspects of the recommended management and self-care of people at risk of heart disease and stroke and those who already with heart disease, diabetes or stroke. They include an economic evaluation of the potential cost of the recommendations
- Recommendations have been developed that aim to reduce the current inequalities in health status of certain population groups in our society.
Who will use these guidelines?
These guidelines are intended for use by primary care practitioners involved in clinical management of risk factors, including general practitioners, nurse practitioners, practice nurses and dietitians. They will also be useful to people living with stroke or heart disease and their caregivers, families or whanau.
What is CV Risk?
The likelihood that a person will have a cardiovascular event (angina, heart attack, stroke or transient ischaemic attack) over 5 years. This can be estimated and forms the basis for all decisions and discussions about the treatment options for people who have cardiovascular risk factors or cardiovascular disease.
What are the major risk factors?
A personal history of cardiovascular disease, age, sex, smoking, lipids (cholesterol), blood pressure, diabetes, atrial fibrillation, obesity and physical inactivity.
Who should have their CVD risk assessed?
- Risk assessment for men without symptoms or risk factors is recommended from the age of 45.
- Risk assessment for women without symptoms or risk factors is recommended from the age of 55.
- People with risk factors should be assessed 10 years earlier - particularly people who are smokers or who have raised BP, raised cholesterol, diabetes or raised blood glucose.
- People with diabetes should have assessments every year.
- Mäori should be assessed 10 years earlier than non-Mäori. There is an urgent need to focus intervention programmes on Mäori, who bear the greatest burden of cardiovascular disease in New Zealand. The ‘outcome gap’ between Mäori and non-Mäori is widening.
What should be measured?
A comprehensive cardiovascular risk assessment includes measurement and recording of the following:
- Age • gender • ethnicity • smoking history • a fasting lipid profile
- A fasting plasma glucose • the average of two sitting blood pressures
- Family history • waist circumference • body mass index.
- People with diabetes will require additional tests
- HbA1c • albumin:creatinine ratio • creatinine • date of diagnosis.
What lifestyle advice is recommended?
- Lifestyle change and drug intervention should be considered together.
- A life free from cigarette smoke, eating a heart healthy diet and taking every opportunity to be physically active is recommended for people at less than 10% 5-year CV risk
- More intensive lifestyle change can be recommended for people at more than 10% 5-year CV risk and advice should be individualised and specific usually given by the primary carer team, relating to smoking cessation if relevant, a cardio protective diet and regular physical activity.
- Lifestyle change and drug therapy (aspirin, blood pressure lowering medication and lipid modifying therapy, statins) are advised for people at greater than 15% 5-year CV risk. More intense advice and treatment is suggested for higher risk people (more than 20 – 30%)
What is recommended for people after stroke?
- Organized stroke units save life, reduce morbidity, reduce length of stay in hospital and improve quality of life in people living with stroke.
- All District Health Boards should provide organised stroke services.
- Services must be responsive to the needs of Maori and Pacific peoples.
- All patients with stroke should receive information.
- Most people after stroke will be on low dose aspirin within 48 hours if CT rules out intracerebral haemorrhage and no contraindications exist.
- Most people after ischaemic stroke should be receiving additional blood-pressure lowering medication and statin treatment even when blood pressure or cholesterol are within previously accepted or borderline ranges.
- Follow-up should be by community based rehabilitation services, stroke clinics or family doctors according to continuing needs.
What is recommended for people with angina or after a heart attack?
- After myocardial infarction, comprehensive programmes that promote lifestyle change for people are best delivered by a cardiac rehabilitation team.
- Most people with angina or after myocardial infarction will be taking at least four standard drugs, low-dose aspirin (75 – 150 mg), a beta-blocker, a statin and an ACE-inhibitor.
What is recommended for people with diabetes?
- Involving families in diabetes management planning is of particular importance to Maori and pacific people with diabetes.
- Regular screening for renal, retinal and foot complications should occur from diagnosis of type 2 diabetes.
- Tight glycaemic control reduces the risk of and slows the progression of complications. A stepped approach is recommended to lower and maintain HbA1c to as close to physiological levels as possible, preferably less than 7%, without hypoglycaemia.
- Optimum blood pressure control, below 130/80 mm Hg, reduces the risk of and slows the progression of complications. Intensive blood pressure management is recommended in people with diabetes and overt nephropathy, microalbuminuria or other renal disease, with most requiring more than one blood pressure lowering agent and an ACE-inhibitor.
- Any sustained reduction in both HbA1c is worthwhile.
Summaries of the guidelines are available from the Guidelines Group.