www.isdscotland.org

SIGN CHD

In Scotland in the year ending 31 March 2006 over 10,300 patients died from CHD and 5,800 from cerebrovascular disease, with almost 49,000 hospital admissions for CHD and a further 22,050 for cerebrovascular disease.

Coronary Heart Disease

SIGN CHD

SIGN is a collaborative network of healthcare professionals and SIGN guidelines are developed by multidisciplinary groups using a standard methodology based on a systematic review of the evidence.

SIGN levels of evidence

1++ High quality meta analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well conducted meta analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1 Meta analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High quality systematic reviews of case-control or cohort studies High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal

2 Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

SIGN grades of recommendation

A At least one meta analysis, systematic review, or RCT rated as 1++, and directlyapplicable to the target population;orA systematic review of RCTs or a body of evidence consisting principally ofstudies rated as 1+, directly applicable to the target population, and demonstratingoverall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the targetpopulation, and demonstrating overall consistency of results;orExtrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the targetpopulation and demonstrating overall consistency of results;or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4;orExtrapolated evidence from studies rated as 2+

SIGN Coronary Heart Disease

SIGN CHD

• PREVENTION

• STABLE ANGINA

• ACUTE CORONARY SYNDROMES

• ARRHYTHMIAS

• CHRONIC HEART FAILURE

SIGN: Prevention

SIGN CHD: prevention

Prevention of CHD - Risk Estimation

• Individuals with symptomatic manifestations of cardiovascular disease or diabetes should be considered at high risk (≥ 20% risk over 10 years) of cardiovascular events D

• All adults over the age of 40 who have no history of cardiovascular disease or diabetes and who are not being treated for blood pressure or lipid reduction should have their cardiovascular risk estimated at least once every five years D

SIGN CHD : prevention

Simvastatin 40 mg/day recommended as part of the management in those patients over age 40 with a 10 year risk of CVS events of > 20% A

ASCOT-LLA/CARDS

Potential events avoided and related resources saved from treating 435,000 asymptomatic

individuals at high CVD risk with a statin

Event Clinical benefit over 4.3 years

Annual bed days saved

Annual cost savings (million)

Major vascular 6,217 17,050 £5.9

All cause mortality

2,303    

Total 8,520 17,050 £5.9

HPS

Potential events and resources saved from treating 95,000 symptomatic individuals with a statin

EventsEvents avoided

Annual bed days saved

Annual cost savings (million

)

Major vascular 9,437 19,770 £6.8

All cause mortality

718    

Total 10,155 19,770 £6.8

Heart 2007;93:172-176

SIGN has commissioned the development of a score to include social deprivation as a risk variable. ASSIGN tends to classify more people with a positive family history and who are socially deprived as being at high risk. When used in its own host population, it abolished a large social gradient in future CVD victims not identified for preventative treatment by the Framingham score: it therefore improved social equity. http://assign-score.com

SIGN: chronic stable angina

SIGN CHD: Stable Angina

• Patients with left main stem disease should undergo coronary artery bypass grafting to improve coronary heart disease prognosis A

• Patients with triple vessel disease should be considered for coronary artery bypass grafting to improve coronary heart disease prognosis but where unsuitable be offered percutaneous coronary intervention A

• Patients with single or double vessel disease where optimal medical therapy fails to control symptoms should be offered percutaneous intevention or where unsuitable, be considered for coronary bypass surgery A

SIGN: acute coronary syndromes

SIGN CHD: ACS

• Patients with ST elevation acute coronary syndrome should be treated immediately with primary percutaneous coronary intervention A

• Where primary percutaneous coronary intervention cannot be provided within 90 minutes of diagnosis, patients with ST elevation acute coronary syndrome should receive immediate thrombolytic therapy

D

• Patients with ST elevation acute coronary syndrome within 6 hours of symptoms who fail to reperfuse following thrombolysis should be considered for rescue percutaneous coronary intervention B

SIGN CHD: ACS

• A• ABA

In addition to long term aspirin, clopidogrel therapy should be continued for three months in patients with non-ST elevation acute coronary syndromes

B

SIGN: Arrhythmias

SIGN CHD: arrhythmias

• Patients with impaired LV ejection fraction in NYHA Class I – III after previous myocardial infarction should be considered for ICD therapy A

• Patients with spontaneous non-sustained ventricular tachycardia, severely depressed ejection fraction (<0.25) or prolonged QRS duration (>0.12 sec) should be prioritized for ICD implantation B

SIGN Heart Failure

SIGN CHD : heart failure

BNP should be checked prior to commencing therapy for suspected heart failure A

SIGN CHD: Heart failureHeart Failure - Interventional procedures

In patients in sinus rhythm with drug refractory symptoms of heart failure due to left ventricular systolic function (LVEF < 35%) and who are in NYHA Class III and IV and who have a QRS duration of > 120 m/s, cardiac resynchronisation therapy (CRT) should be considered A

SIGN CHD: Heart failure

Heart Failure - Discharge planning

• Comprehensive discharge planning to ensure links with post discharge services should be available to all those with symptomatic heart failure. A nurse-led, home based element should be included A

• Telephone follow-up by specialised heart failure nurses should be considered for patients with stable heart failure. Nurses should have the ability to alter diuretic dose, telephone schedules and recommend emergency/non-scheduled medical contact A

SIGN CHD

What are the potential clinical events avoided by implementation?

SIGN CHD implementation benefits

Recommendation by guideline

Mortality

avoided over 5 years

Events avoided over

5 years

Bed days saved

per year

Savings per year(£

million)Statins –

primary prevention

2,678 7,229 17,052 5.9

Statins – secondary prevention

718 9,437 19,770 6.8

Antihypertensive drugs

950 2,761 9,108 2.5

Prevention - other

750 2,672 5,414 2.0

Prevention - total

5,096 22,099 51,344 17.2

Acute Coronary Syndromes guideline

896 2,176 2,394 1.2

Arrhythmia and Heart Failure guidelines

1,232 2,851 7,074 2.3

Total events 7,22427,12

660,81

220.7

 

Cost (£ million)

Year 1 Year 6

ACS 5 (5) 5 (5)

Arrhythmias 4 (5) 4 (5)

Heart Failure 7 (7) 7 (7)

Prevention 25 (27) 54 (62)

Total 41 (44) 70 (79)

Estimated annual cost of implementing key recommendations by guideline

SIGN CHD

The recommendations on statins and hypertension account for over 90% of the costs and the savings

SIGN CHD

Over the next five years, it is estimated that over 7,200 premature deaths from CVD and over 27,000 vascular events could be avoided. This is equivalent to a 9% reduction from the current CVD mortality rate and an 8% reduction from the current CVD event rate.