KISS - A Cardiometabolic Risk Assessment

Transcription

1 KISS - A cardiometabolic risk assessment tool to identify dyslipidemic highrisk cardiovascular patients in daily routine W. Ramlow 1, H. Prophet 1,2, P. Lansberg 1, W. Kähler 2, C. Peter 3, and T. Zimmermann 3 1 Apheresis Center Rostock (ACR), Germany 2 Cardiology Practice Dr. Kähler, Rostock, Germany 3 B.A.P. GmbH, Rostock, Germany

2 Medical Service Network Rostock Dialysis Apheresis Nephrology Apheresis treatment Various indications Cardiology Gastroenterology Lipidology Internal medicine Family medicine Biomedical research QM IT Solutions Event management Apheresis services Patient shuttle Logistics Financing

3 OpeningStatements LDL-cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) are independent rsik factors for early development and progression of cardiovascular diseases (CVD) Apheresis is an effective treatment option in patients where LDL-C / Lp(a) cannot be adequately lowered by life style changes, diet and medication alone

4 Treatment Options LDL-hypercholesterolemia Life style changes Diet Physical activity Medication Statins Cholesterin absorption inhibitors Bile acid sequestrants Nicotinic acid analogues Apheresis (Liver transplantation) HLp(a) Medication Nicotinic acid analogues Apheresis

5 Statin-Intoleranz Source: CUCHEL et al., Eur.Heart.J. 2014

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7 What is the best way to identify dyslipidemic high-risk CVD patients??? Standard procedures: Routine lab (TC, LDL-C, Lp(a)) FH scores (*DLCN, *SB, *MEDPED criteria) Genetic testing Clinical diagnoses / procedures (ICD coding; OPS coding) Premature CVD Progressive CVD CVD risk scores *DLCN = Dutch Lipid Clinic Network; SB = Simon Broome; MEDPED = Make early diagnosis, prevent early disease

8 MEDPED and Simon Broome Criteria for the Identification of FH* Patients FH* = familial Hypercholesterolemia

9 Dutch Lipid Clinics Network Criteria for the Identification of FH* Patients *FH = familial Hypercholesterolemia

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17 The distribution of risk from 10-year cardiovascular disease (CVD) and coronary heart disease (CHD) risk calculators for 10 sample patients (evenly distributed from highest to lowest average risk). Allan G et al. Circulation 2013;127: Copyright American Heart Association

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19 Cardiometabolic Risk Assessment (Diabetes, Renal Disease, Dyslipidemia, Atherosclerosis, Obesity, Hypertension)

20 Source: Lp(a) handbook of the European Society for Atherosclerosis

21 Difficulties in identifying dyslipidemic high-risk CVD individuals??? LDL-C no real disease burden Neither for patients nor for physicians GP s see responsibilty at cardiologists / angiologists site Cardiologists prefer apparative diagnostics and therapies Lp(a) nobody cares Heterogeneity of Lp(a) more thrombogenic than atherogenic? Genetic testing still too expensive Appr LDL-R mutations; many mild mutations clinical relevance? Identical PCSK9 GOF mutations variation in LDL-C levels clinical relevance? Other than standard mutations (LDL-R, ApoB, PCSK9) involved Synergistic action of multiple risk factors / co-morbidities Too complex (time-consuming) during clinical routine work

22 Without systematic screening activities matching laboratory results (including genetics) with clinical findings many high-risk patients remain unidentified who could certainly benefit from better treatment!

23 Effective screening programs must be easy to handle for patients and medical staff time efficient unexpensive suitable for electronic (web based) documentation

24 S-crea MAU Cardiometabolic and Renal Risk Assessment (Simple, time-efficient, inexpensive) KISS (Keep It Simple Screening) program: Gender, age Family history (simple questionnaire) Patient s history (simple questionnaire) Smoking status (current smoker or smoking for more than 5 yrs) Medication Height, weight, hip and waist circumference Blood pressure Glucose, HbA1c S-creatinine,GFR, microalbuminuria TC, LDL-C, TG, Lp(a) (Uric acid), (hs-crp) The missing links Renal function Lp(a) MAU = microalbuminuria

25 Whom to screen? Cost-benefit ratio of screening procedures Any adult? Average annual patient numbers: GP practice 3,000 6,000 Cardiology practice 4,000 6,000 Average screening costs Does not include project development costs, technical maintenance, service and analyzing procedures Time for explanation and examination, lab, documentation Estimated costs per patient ~ 15 25

26 Pre-selection for KISS: - - Patients with very high LDL-C levels (Lp(a) usually not measured) - Patients with premature CVD

27 Lab Screening Patients with hichol Top Convert and analyze lab database Find hichol patients and contact them via central lab / practice Down CVD status by KISS Optimize LLT Patients with hichol AND premature CVD?

28 Lab data from Rostock + Greater Rostock* Total population covered: appr. 410,000 inhabitants Evaluation period: 2009, 2010, 1011, 2012, 2013 Data source: encrypted data from all subjects with lab results during the above period requested by more than 500 medical institutions (mainly private practices; 1 hospital) *Source: Pseudonymized data from Medical Laboratory Rostock

29 Rostock and Greater Rostock (ca. 360,000 adults) Individuals with TC > 8.5 (330) / 6.5 (250) Appr % of individuals without parallel LDL-C measurements Appr. 30% of individuals without parallel TG measurements TC: total cholesterol, LDL-C: LDL-cholesterol, TG: triglycerides

30 Rostock and Greater Rostock (ca. 360,000 adults) Individuals with TC > 8,0 (310) AND TG <4 (350)

31 Screening in private practices Patients with hichol / hilp(a) AND premature CVD? Up Bottom Optimize LLT KISS Identify active patients? Screening for CVDrelated ICD codes in private practices Search for patients with premature CVD (age range?)

32 ICD-Codes to search for CVD H34.*-Retinal vascular occlusions I20.*- Angina pectoris I21.*- Acute myocardial infarction I22.*- Subsequent myocardial infarction I24.*- Coronary thrombosis not resulting in myocardial infarction I25.*- Old myocardial infarction I44.*- Atrioventricular and left bundle-branch block I45.*- Other conduction disorders I46.*- Cardiac arrest I47.*- Paroxysmal tachycardia I48.*- Atrial fibrillation and flutter I49.*- Other cardiac arrhythmias I63.*- Cerebrovascular diseases I64.*- cerebral infarction or stroke I65.*- Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction I66.*- Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction I68.8- Other cerebrovascular disorders in diseases classified elsewhere I69.3- Sequelae of cerebral infarction I Sequelae of stroke, not specified as haemorrhage or infarction I69.8- Sequelae of other and unspecified cerebrovascular diseases I70.*-Atherosclerosis I73.0- Raynaud syndrome I73.9- Peripheral vascular disease, unspecified I74.*- Arterial embolism and thrombosis I77.9- Disorder of arteries and arterioles, unspecified I78.9- Disease of capillaries, unspecified I79.2- Peripheral angiopathy in diseases classified elsewhere I79.8- Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere

33 - GP practice 01 : Analysis of patient data from (Aug.): Total number of patients: 4,284 - GP practice 02 : Analysis of patient data from (Sep.): Total number of patients: 5,387

34 ICD Codes SelectiveICD Codes (CVD) I67.4 I12.0 I12.9 I13.0 I13.1 I13.2 I13.9 I20.0 I20.1 I20.8 I21.0 I21.1 I21.2 I21.03 I21.4 I21.9 I22.0 I22.1 I22.8 I22.9 I23.0 I23.1 I23.2 I23.3 I23.4 I23.5 I23.6 I23.8 I25.11 I25.12 I25.13 I25.14 I25.16; I25.20 I25.21 I25.22 I25.29; I25.3;I25.4;I25.4 I35.0; I35.2 I42.0, I42.1, I42.5 I43.1 I44.0;I44.1;I44.2;I44.3;I44.4;I44.5;I44.6 I45.2; I45.3 I46.0; I46.1; I46.9 I47.0; I47.2 I48.3; I48.4 I49.0 I63.0; I63.1; I63.2; I63.3; I63.4; I63.5; I63.6; I63.7; I63.8; I63.9 I64.. I65.0; I65.1; I65.2; I65.3; I65.8; I65.9 I66.0; I66.1; I66.2; I66.3; I66.4; I66.8; I66.9 I69.3; I69.4 I70.1; I70.21; I70.22; I70.23; I70.24 I71.00 bis I71.07,I71.1; I71.3; I71.5; I71.8 I72.0 bis I72.9 I73.0 I74.0 bis I74.5, I74.8 Bezeichnung der Obergruppe Patienten mit hypertensiver Enzephalopathie Patienten mit hypertensiver Nierenkrankheit Diagn. gesamt mit I20% Ischämischer Herzinfarkt Diagn. mit I21% akuter Herzinfarkt Diagn. mit I22% rezidivierend Herzinfarkt Diagn. mit I23% Komplikation nach Infarkt Diagn. mit I25% chronische ischämischer Herzinfarkt Diagn. mit I35% Nichtrheumatische Aortenklappenkrankheit Diagn. mit I42% Kardiomyopathie Diagn. mit I43% Kardiomyopathiebei anderorts klassifizierten Krankheiten Diagn. mit I44% Arterioventrikulärer Block, Linksschenkelblock Diagn. mit I45% Sonstige kardiale Errregungsleitungsstörg. Diagn. mit I46% Herzstillstand Diagn. mit I47% Paraoxymale Tachykardie Diagn. mit I48% Vorhofflimmern- flattern Diagn. mit I49% Kammerflattern - flimmern Diagn. mit I63% Hirninfarkt Schlaganfall, nicht als Blutung oder Infarkt bezeichnet I64.. Verschluss/Stenose präzerebraler Arterien ohne result. Hirninfarkt I66% Verschluss u. Stenose zerebr. Arterien ohne result. Hirninfarkt Diagn. mit I69% Folgen einer zerebrovaskulärer Krankheit Krankeiten der Arterien, Arteriolen und Kapillaren I70 Aortenaneurysma und dissektion Sonstiges Aneurysma und sonstige Dissektion I72.0 bis I72.9 Raynaud-Syndrom I73.0 Embolie und Thrombose der Arterien I74.0 bis I74.5, I74.8

35 Premature CVD Main Diagnosis* (GP practice 01; pts 55 yrs; data only from 2013) (Cardiac death AMI CHD (stents) Third degree AV block Stroke PAVD Renal artery stenosis 2 patients) 11 patients 6 patients 2 patients 12 patients 4 patients 1 patient 36 patients with premature CVD eligible for KISS in only one general practice - How many patients with dyslipidemia? - How many patients will not reach the target values after optimization of LLT? (Acc. to EUROASPIRE III 50% of CVD patients with dyslipdemia stll not on target despite statin treatment in about 90% of cases; see REINER et al., 2013) *after validation using patient records

36 KISS Database ready to go

37 KISS Database ready to go

38 KISS database ready to go Web based no software required