|GUIDELINE AND CONSENSUS
|Year : 2017 | Volume
| Issue : 4 | Page : 26-37
Guidelines for comprehensive prevention and treatment of cardiovascular diseases in community populations (The Trial)
Yong Huo1, Junbo Ge2
1 Department of The first Hospital of Peking University, Beijing, China
2 Department of Zhongshan Hospital, Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
|Date of Web Publication||12-Mar-2018|
Dr. Junbo Ge
Zhongshan Hospital, Institute of Cardiovascular Diseases, Fudan University, Shanghai
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Huo Y, Ge J. Guidelines for comprehensive prevention and treatment of cardiovascular diseases in community populations (The Trial). Cardiol Plus 2017;2:26-37
|How to cite this URL:|
Huo Y, Ge J. Guidelines for comprehensive prevention and treatment of cardiovascular diseases in community populations (The Trial). Cardiol Plus [serial online] 2017 [cited 2018 Mar 24];2:26-37. Available from: http://www.cardiologyplus.org/text.asp?2017/2/4/26/227172
Pilot project committee of Chinese adult dyslipidemia health management service and Editorial Committee of Guidelines for the management of cardiovascular diseases in community populations (The Trial)
<Chinese cardiovascular disease report 2015> indicated that the prevalence of cardiovascular disease is on the rise in china. In 2014, the death rate of cardiovascular diseases in rural and urban areas was the first. Therefore, it is particularly important and urgent for screening and prevention of major cardiovascular disease risk factors of hypertension, dyslipidemia, overweight/obesity, diabetes, smoking, and major cardiovascular diseases (coronary heart disease and stroke) in the community.
- Major risk factors
1.1.1 The objective of prevention and treatment of hypertension
- Screening population: Individuals who have headache, dizziness, and/or have the risk factors of hypertension (high-sodium and low-potassium diet, overweight and obesity, drinking, mental stress, lack of exercise, as well as those 35 years of age or older, and have family history of premature hypertension and lack of sleep,)
- Hypertension population: The blood pressure (BP) is ≥140/90 mmHg at different dates and different time of consulting room measuring BP more than 3 times; or 24 h ambulatory BP mean value is ≥130/80 mmHg, ≥135/85 (mmHg) at the day (awake), ≥120/70 mmHg during night sleep.
1.1.2 Community management of hypertension
- To establish the community hypertension electronic health record and carry out the education of therapeutic lifestyle [Appendices 1 and 2]
- The target BP: BP <140/90 mmHg for individuals <65 years; BP <150/90 mmHg for individuals >65 years
- Selection of antihypertensive drugs: Calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonist (ARB), diuretics, beta blockers (BBs), and fixed compound preparation. The specific use of drugs and drug safety [Appendix 3]
- The risk stratification, regular monitoring of BP, standardized follow-up [Appendices 4 and 5].
1.1.3 Indication of referral to higher level hospital
- With new-onset heart disease or new onset stroke
- Sustained BP ≥ 180/110 mmHg or hypertensive crisis
- Suspected secondary hypertension
- Children, adolescents, pregnant women, and lactating women
- Refractory hypertension (after a reasonable combination of lifestyle modification and diuretics including diuretics, at least 3 antihypertensive drugs were administered, and the BP was not up to standard)
- There cannot be explained or difficult to deal with adverse reactions after taking antihypertensive drugs, as shown in Appendix 3
- Hypertension associated with multiple risk factors or target organ damage and difficult to deal with.
1.1.4 Evaluation index of hypertension community management
- Hypertension screening rate = number of BP screening/community resident population × 100% in over 18 years
- Ambulatory BP utilization = ambulatory BP utilization/number of hypertensive patients with electronic records × 100% in hypertension management population
- The coincidence rate of referral index of patients with hypertension management = the number of patients with referral indications/hypertension referral cases × 100%.
1.2.1 The objective of prevention and treatment of dyslipidemia. Community physicians assessed dyslipidemia among people in the district according to [Table 1]. All patients diagnosed with atherosclerotic cardiovascular disease (ASCVD) and those whose blood lipids were not up to standard were all the subjects of prevention and treatment of dyslipidemia. Target of intervention of dyslipidemia is shown in [Table 1].
|Table 1: Targets of dyslipidemia intervention for combined clinical disease or risk factors|
Click here to view
1.2.2 Community management of dyslipidemia. Community doctors divide patients with dyslipidemia into different management levels and implement classified management as well as the annual evaluation and adjustment of management level for patients within the jurisdiction according to the goal of lipid lowering.
For low-density lipoprotein cholesterol (LDL-C) as the intervention target, statins are preferred. Statin therapy should be initiated for patients with clinically diagnosed ASCVD regardless of their baseline LDL-C levels and if LDL-C is <1.8 mmol/L, with more than 50% decline as a therapeutic target. Statins of different dosages and dosages descending LDL-C amplitude reference [Table 2].
Moderate or high intensity statin therapy should be selected unless the patient cannot be tolerated. If LDL-C failed to reach the target after statin therapy, one can choose ezetimibe combination (10 mg × 1/day). For pure triglycerides (≥G e mmol/L), fibrates or nicotinic acid drugs should be the first choice to prevent the occurrence of acute pancreatitis.
1.2.3 Indication of referral to higher level hospital
- After 3–6 months of strict lifestyle intervention and standard drug treatment, LDL-C has not yet reached the target value
- Severe adverse reactions occurred when taking lipid regulating drugs
- Untreated LDL-C > 4.9 mmol/L and suspected familial hypercholesterolemia
- Secondary dyslipidemia.
1.2.4 Evaluation indexes of community management of dyslipidemia
- Dyslipidemia detection rate = dyslipidemia number/number of screening × 100%
- The treatment rate of dyslipidemia patients = the number of treatment cases/the number of patients with dyslipidemia × 100%
- The coincidence rate of referral index of patients with dyslipidemia = the number of referral cases/dyslipidemia × 100%.
1.3 Overweight and obesity
1.3.1 The objective of prevention and control. Overweight and obesity were assessed with body mass index (BMI), BMI = weight (kg)/height2 (m2). Overweight: BMI 24–27.9 kg/m2; obesity: BMI ≥28 kg/m2. If the individual muscle is highly developed, BMI is not suitable as a diagnostic standard for.
1.3.2 Community management
- Control target: weight reduction at least 5%–10% or BMI <25 kg/m2
- To carry out the treatment of lifestyle education, regular monitoring of weight waist and circumference
- Drug therapy for weight loss: Under the guidance of a specialist, you can consider orlistat and other weight loss drugs.
1.3.3 Indication of referral to higher level hospital
- Secondary obesity was suspected, especially in children and adolescents
- Combined with heart disease, new stroke, diabetes, hypertension, and sleep apnea–hypopnea syndrome
- BMI ≥32 kg/m2, lifestyle, and drug intervention were ineffective.
1.3.4 Assessment index of overweight community management
- Overweight and obesity detection rate = overweight or obesity number/number of visits × 100%
- Receive health education with weight control at least once a year.
1.4.1 The objective of prevention and treatment of diabetes
- Diagnosed diabetes: Meet any one of the following can be diagnosed:
- The typical symptoms of diabetes, polydipsia, polyuria, polyphagia, and weight loss, random plasma glucose detection ≥11.1 mmol/L
- Fasting blood glucose ≥7 mmol/L (not on the same day)
- Hours after glucose load, blood glucose level ≥11.1 mmol/L (2 time not on the same day)
- Fasting blood glucose ≥7 mmol/L and 1 time glucose ≥11.1 mmol/L 2 h after glucose load.
- Patients with impaired glucose regulation: Impaired fasting glucose refers to the fasting blood glucose was 6.1–6.9 mmol/L, 2 h postprandial blood glucose <7.8 mmol/L. Impaired glucose tolerance refers to the 2 h blood glucose after glucose load is 7.8–11.1 mmol/L and fasting blood glucose <6.1 mmol/L.
1.4.2 Community management of diabetes prevention and control
- The blood glucose control objectives: Most nonpregnant adult patients with type 2 diabetes fasting blood glucose level is 4.4–7 mmol/L, 2 h postprandial blood glucose <10 mmol/L, glycosylated hemoglobin (HbA1c 7.0%). To formulate individual goals based on the patient's age, course of disease, life expectancy, complications, the severity of the disease and so on
- To establish community population diabetes electronic health records and to carry out education and intervention on therapeutic lifestyle of diabetes mellitus, regular monitoring of blood glucose and standardized follow-up
- The principle of choosing hypoglycemic drugs:
- Patients with type 1 diabetes mellitus should be treated with insulin or insulin analogs and to avoid hypoglycemia (blood glucose level is ≥3.9 mmol/L).
- The type 2 diabetes: Individual control objectives and treatment options are used; the current commonly used oral hypoglycemic drugs including metformin and insulin secretagogues, alpha glucosidase inhibitors and two dipeptidyl peptidase-4 inhibitor, thiazolidine two ketones, can be used when necessary insulin or insulin analogs treatment.
1.4.3 Indication of referral to higher level hospital
- Newly diagnosed children and adolescents with diabetes mellitus
- Suspected of diabetic ketoacidosis, hyperosmolar nonketotic diabetic syndrome, lactic acidosis, and severe hypoglycemia and other acute complications of diabetes, transfer immediately after emergency treatment
- New symptoms or target organ damage occurred during follow-up, such as lower limb pain and intermittent claudication, acral gangrene, paresthesia or pain of the skin, coronary heart disease, ischemic cerebrovascular disease, and renal damage
- Serious adverse reactions were observed or standard medication for 3 months, blood sugar is still not up to standard
- Diabetes mellitus complicated with infection or surgical treatment is needed
- Women during pregnancy and lactation.
1.4.4 Diabetes community management assessment index
- ≥18-year-old diabetes screening rate = number of screening/community resident population × 100%
- The number of patients with HbA1c <7%/the number of patients with diabetes mellitus × 100%
- Coincidence rate of referral indication = the number of diabetic patients with referral indications/diabetic patient referral number × 100%.
1.5.1 Smoking prevention and control personnel: All smokers should quit smoking. Cardiovascular patients with special needs for smoking cessation include hypertension, coronary heart disease, peripheral vascular disease, diabetes, and stroke patients.
1.5.2 Community management of smoking: Refer to the “5A” model of smoking cessation intervention: “Ask, Advice, Assess, Assist, and Arrange.”
1.5.3 Indication of referral to higher level hospital: Require the use of varenicline smoking cessation treatment groups, etc.
1.5.4 Smoking community management assessment indicators. (1) The rate of smoking cessation education among smokers = smoking education number/number of smokers attending × 100%. (2) More than 2 times quit smoking related health education every year.
- Major cardiovascular diseases
2.1 Coronary heart disease
2.1.1 The objective of prevention and treatment of coronary heart disease
- Confirmed patients
- Patients with typical clinical symptoms, but difficult to diagnose.
2.1.2 Community management of coronary heart disease
- Objective: To control the risk factors, reduce the incidence of acute coronary syndrome (ACS) and sudden cardiac death, improve and maintain the cardiac function, and improve the treatment compliance of patients
- Treatment measures: Coronary heart disease secondary prevention program [Table 3]
- Coronary heart disease health education, regular review, standardized follow-up.
2.1.3 Referral to higher hospitals
- Angina pectoris occurred for the first time
- ACS: unstable angina, non-ST-segment elevation myocardial infarction (STEMI) and STEMI
- There were no typical chest pain episodes, but the electrocardiogram ST-T had dynamic abnormal changes
- Old myocardial infarction found for the first time
- Recent or worsening heart failure
- Patients need to adjust the treatment plan or regular specialist follow-up
- Patients need further examination: Treadmill exercise test, radionuclide imaging, echocardiography, coronary computed tomography, coronary angiography, and so on.
2.1.4 Management of STEMI patients before referral
- Should immediately call the emergency contact referral, and timely transmit pre hospital information
- If no contraindications, patient should be immediately chewing aspirin 300, 300–600 mg of clopidogrel or ticagrelor 180 mg, early oral atorvastatin 20–40 mg or rosuvastatin 10–20 mg
- Close monitoring of vital signs.
2.1.5 Community management assessment index of coronary heart disease
- The secondary prevention rate of coronary heart disease = the number of patients treated with antiplatelet drugs + statins + ACEI + BB/the number of patients diagnosed with coronary heart disease × 100%,
- Referral index compliance rate = the number of patients with coronary heart disease according to referral indications/coronary heart disease patients referral number × 100%.
2.2.1 The subjects of stroke prevention and control
- The subjects have been diagnosed with stroke (including transient ischemic attack [TIA])
- Stroke should be considered if the patient suddenly shows any of the following symptoms [Appendix 6]:
- Weakness or numbness of one limb (with or without facial)
- Facial numbness or angular deviation on one side
- Unclear speech or understanding of language difficulties
- Eyes gaze sideways
- The unilateral or bilateral visual loss or fuzzy
- The dizziness and vomiting
- Severe headache, vomiting, previously rare
- The disturbance of consciousness and/or twitch
- Risk factors: Hypertension, dyslipidemia, diabetes mellitus, hyperhomocysteinemia, smoking, atrial fibrillation, overweight or obesity, lack of exercise, family history of stroke.
2.2.2 Community management of stroke
184.108.40.206 Target: The primary, secondary, and third prevention (rehabilitation) of stroke and reduce the incidence and recurrence rate of stroke.
220.127.116.11 Treatment measures
- Primary prevention
- The control of risk factors: Control of BP (<65 years, BP <140/90 mmHg; ≥65 years, BP < 150/90 mmHg). Blood lipid regulation: long-term statin therapy (LDL-C <1.8 mmol/L or drop over 50%). Blood glucose control (HbA1c <7%). Patients with hypertension complicated with hyperhomocysteinemia (>10 mmol/L): folic acid supplementation is recommended
- Antiplatelet aggregation therapy: Benefits and risk assessments are needed, and medication is appropriate
- Anticoagulation therapy: Atrial fibrillation in rheumatic valvular heart disease is a definite indication of warfarin anticoagulation. Nonvalvular atrial fibrillation patients with CHA2DS2-VASc score ≥2 points to warfarin anticoagulation, international normalized ratio (INR) must be monitored (target value: 2–3), The new oral anticoagulants, such as dabigatran, Shaaban, and Shaaban, do not need to monitor INR, so they can be used.
- Secondary prevention
- Control risk factors
- TIA and light stroke treatment. TIA and light stroke are serious and urgent intervention stroke warning events
- Patients with noncardiogenic ischemic stroke may receive oral antiplatelet therapy such as aspirin and/or clopidogrel
- Ischemic stroke of cardiogenic (atrial fibrillation): Anticoagulant therapy is the first choice.
- Third prevention: Rehabilitation therapy in community (acupuncture, physiotherapy, functional recovery training)
18.104.22.168 Health education for stroke patients with therapeutic lifestyle, regular review, standardized follow-up.
2.2.3 Indication of referral to higher level hospital:
- Patients with suspected stroke (include TIA)
- Patients with previous history of stroke and poor control of these risk factors
- Patients who took warfarin anticoagulation, INR <2 or INR >3
- Patients with atrial fibrillation and/or rheumatic valvular disease who cannot be treated with anticoagulation.
2.2.4 Treatment before referral:
- Stroke patients need immediate referral to a hospital with thrombolytic qualification
- Keep the vital signs stable as much as possible
- Timely delivery of patient information before referral.
2.2.5 Evaluation index of stroke prevention and treatment
- The referral rate of the first diagnosed stroke patients = the number of referral cases in the first diagnosis stroke patients/the number of patients with first diagnosed stroke × 100%
- Standardized treatment rate of stroke (include antiplatelet aggregation, statin therapy, BP control) = number of patients with standardized treatment of stroke/number of patients diagnosed with stroke × 100%.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chen W. Chinese Cardiovascular Disease Report 2015. Encyclopaedia of Chinese Publishing House; 2014.
Hypertension League (China), National Cardiovascular Disease Center. Cardiovascular disease branch of Chinese Medical Association, and so on Chinese education guidelines for patients with hypertension. China Med J Front (Electron Ed) 2014;6:78-110.
Guidelines for the Prevention and Control of Hypertension in China. Guidelines for the prevention and treatment of hypertension in China 2010. Chin J Fron Med (Electron Ver) 2011;3:42-93.
Chinese Blood Pressure Measurement Working Group. Chinese guideline for blood pressure measurement. Chin J Hypertens 2011;19:1101-15.
Rabar S, Harker M, O'Flynn N, Wierzbicki AS; Guideline Development Group. Lipid modification and cardiovascular risk assessment for the primary and secondary prevention of cardiovascular disease: Summary of updated NICE guidance. BMJ 2014;349:g4356.
Joint Committee on the Prevention and Treatment of Dyslipidemia in Chinese Adults. Guidelines for the prevention and treatment of dyslipidemia in Chinese adults (Revised Edition 2016). Chin J Circ 2016;31:937-50.
Cardiology Evidence-based Medicine Expert Review Group of the Chinese Medical Association, Specialized Committee Chinese Gerontological Society of Cardiovascular and Cerebrovascular Disease. Prevention and treatment of hypertriglyceridemia in dyslipidemia Chinese. China Med Expert Consens J Front (Electron Ed) 2011;3:115-20.
People's Republic of China Ministry of Health Department of Disease Control. Chinese Adult Overweight and Obesity Prevention and Control Guidelines. Beijing: People's Medical Publishing House; 2003. p. 4.
Handelsman Y, Bloomgarden ZT, Grunberger G, Umpierrez G, Zimmerman RS, Bailey TS, et al.
American Association of Clinical Endocrinologists and American College of Endocrinology – Clinical practice guidelines for developing a diabetes mellitus comprehensive care plan-2015 – Executive summary. Endocr Pract 2015;21:413-37.
Diabetes Society of Chinese Medical Association. Guidelines for the prevention and treatment of type 2 diabetes in China (2013 Edition). Chin J Diabetes Mellit 2014;6:447-98.
Gratziou C. Respiratory, cardiovascular and other physiological consequences of smoking cessation. Curr Med Res Opin 2009;25:535-45.
Wang C. 2007 Version of Chinese Clinical Smoking Cessation Guidelines (Trial Version). Beijing: People's Health Press; 2007. p. 12.
Chinese Society of Cardiology, Editorial Committee of Chinese Journal of Cardiology. Guidelines for the diagnosis and treatment of chronic stable angina pectoris. Chin J Cardiovasc Dis 2007;35:195-206.
Chinese Society of Cardiology, Editorial Committee of Chinese Journal of Cardiology. Guidelines for the diagnosis and treatment of acute ST segment elevation myocardial infarction. Chin J Cardiovasc Dis 2015;43:380-93.
Chinese Society of Cardiovascular Diseases, Editorial Committee of Chinese Journal of Cardiology. Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndromes. Chin J Cardiovasc Dis 2012;40:353-67.
Neurology Branch of Chinese Medical Association, Chinese Medical Association Neurology Branch of Cerebrovascular Disease Group. Acute ischemic stroke diagnosis and treatment guidelines China 2014. Chin J Neurol 2015;48:246-57.
Neurology Branch of Chinese Medical Association, Chinese Medical Association Neurology Cerebrovascular Disease Study Group. The secondary prevention guide 2014. Chin J Neurol China Ischemic Stroke Transient Ischemic Attack 2015;48:258-73.
European Association for Cardiovascular Prevention and Rehabilitation, Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, et al.
ESC/EAS guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 2011;32:1769-818.
Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al.
Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 2010;12:1360-420.
Chinese Society of Cardiology, Chinese Medical Association. Chinese expert consensus on warfarin anticoagulation therapy. Chin J Intern Med 2013;52:76-82.
Chinese Expert Consensus Group for Transient Ischemic Attack. Chinese experts consensus on antiplatelet therapy for transient ischemic attack and light stroke (2014). Chin Med J 2014;94:2092-6.
Neurology Branch of Chinese Medical Association Neurorehabilitation Group, Neurology Cerebrovascular Disease Study Group of the Chinese Medical Association, the Ministry of Health Stroke Screening and Prevention Engineering Committee Office. Chinese stroke rehabilitation treatment guidelines (2011 full version). Chin Rehabil Theory Pract 2012;18:301-18.
Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al.
2013 ESH/ESC guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159-219.
Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK, et al.
Effects of alcohol reduction on blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-7.
Chalmers J, MacMahon S, Mancia G, Whitworth J, Beilin L, Hansson L, et al.
1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization. Clin Exp Hypertens 1999;21:1009-60.
Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, et al.
Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 2014;32:3-15.
Daskalopoulou SS, Rabi DM, Zarnke KB, Dasgupta K, Nerenberg K, Cloutier L, et al.
The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2015;31:549-68.
Ministry of Health and Other 15 Ministries and Commissions. China Chronic Disease Prevention and Control Work Plan (2012-2015). Health and Family Planning Commission, Center for Disease Prevention and Control 2012. No. 34; 08 May 2015.
Revision Committee on Guidelines for the Management of Hypertension in China. Guidelines for the management of hypertension in China (Revised Edition 2014). Chin J Front Med (Electron Ver) 2015;7:18-40.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]