Prof. Andrew Nicolaides, MS, FRCS, PhD (Hon)
Prof. Nicolaides was the Professor of Vascular Surgery at the Imperial College School of Medicine and Consultant Vascular Surgeon at St Mary’s Hospital from 1983–2000. He is now Honorary Professor of Surgery at St George’s University of London / University of Nicosia Medical School, Nicosia, Cyprus. His research is now directed towards the genetic risk factors for cardiovascular disease, identification of individuals at risk and the development of effective methods of prevention of stroke and chronic venous disease. He is Past-President of the International Union of Angiology, Past-President of the Section of Measurement in Medicine of the Royal Society of Medicine and currently Chairman of the Board of the European Venous Forum.
Summary of his IUA 2020 Session – The New ESC/EAS 2019 guidelines on lipid therapy
Instead of calculating the 10-year risk of MI or stroke, the guidelines now recommend that physicians calculate total cardiovascular risk (CV risk). For this calculation they provide new tables based on several conventional risk factors. This total CV risk approach allows flexibility. If optimal control cannot be obtained with one risk factor, trying harder with other risk factors can still reduce risk.
The guidelines no longer distinguish between symptomatic and asymptomatic patients either. This is because many asymptomatic patients have sub-clinical atherosclerosis to such an extent that places them in the high-risk group.
The guidelines now include a new statement that stipulates certain conditions are markers of such a high risk that individuals do not require scoring. “Those with documented cardiovascular disease (CVD), familial hypercholesterolemia, presence of carotid or femoral plaques (on ultrasound), or coronary calcium score > 100 are at high risk etc.
In the past, aggressive risk factor modification was not recommended to individuals or patients with asymptomatic carotid stenosis because they were not considered at high risk. This has now changed with the new guidelines. The finding of an ACS > 50% (or even plaques producing ACS < 50%) carries a new message: it identifies individuals at very high risk who can benefit from aggressive risk factor modification resulting in a 30% reduction in stroke and 50% reduction in risk of myocardial infarction.
However, to achieve this we need to educate both doctors and patients, and we need to screen asymptomatic individuals at low Framingham cardiovascular risk with ultrasound to identify those with atherosclerotic plaques because those at high Framingham risk are already being treated.