Enfoque de riesgo para la prevención de enfermedades cardiovasculares

Objectives

Chile’s 2014 consensus establishes a national, risk-based framework for preventing and controlling cardiovascular disease, addressing the country’s leading cause of death through integrated management of modifiable risk factors and identification of people requiring more intensive intervention.[1][2]It contributes to the 2011–2020 Health Objectives, which seek improved survival after acute myocardial infarction and stroke, more effective hypertension and type 2 diabetes coverage, reduced renal replacement therapy incidence in people under 65, and stronger protective health factors.[3][4]

• Apply global cardiovascular-risk assessment, recognising that coexisting risk factors have combined and multiplicative effects and that overall risk should guide prevention rather than isolated abnormalities.[5][6]
• Classify adults as low risk below 5%, moderate risk at 5–9%, or high risk at 10% or above for estimated 10-year coronary risk, while treating documented atherosclerotic cardiovascular disease, diabetes mellitus, chronic kidney disease, resistant hypertension and severe dyslipidaemia as independent high-risk conditions.[7][8]
• Increase the risk category where premature cardiovascular disease in a first-degree relative or metabolic syndrome is present, and consider lifetime risk, particularly among younger adults with low short-term risk but important risk factors.[9][10]
• Promote healthy lifestyles at every risk level, including smoking cessation, regular physical activity, healthy eating, moderate alcohol consumption and weight reduction where appropriate.[11][12]
• Set risk-specific therapeutic targets for low-density lipoprotein cholesterol, blood pressure and glycated haemoglobin, while individualising targets for older people and people with chronic kidney disease and albuminuria.[11][13]
• Achieve 2011–2020 national targets, including raising first-year projected survival after acute myocardial infarction from 78.5% to 91% and after cerebrovascular attack from 70.5% to 89.7%, increasing effective hypertension coverage from 16.8% to 25.2% and type 2 diabetes coverage from 29.8% to 35.8%, and reducing tobacco use and risky alcohol consumption.[4]

Implementation

The consensus is intended principally for health professionals caring for adults, especially primary-care doctors, nurses and nutritionists in the Cardiovascular Health Programme, alongside relevant specialists and health-sector students.[14]It combines systematic risk assessment, lifestyle support, pharmacological management, reassessment and specialist referral, and was developed by the Ministry of Health through review of international guidance, expert comments and consensus meetings involving multidisciplinary contributors.[15][16]

• Assess cardiovascular risk for people attending a health centre for the first time and during a Preventive Medicine Examination; obtain medical history, examination findings and relevant investigations, then first identify high-risk clinical conditions before using risk tables.[17][18]
• Estimate risk in eligible adults aged 35–74 using Chilean Framingham-derived tables incorporating sex, age, blood pressure, total cholesterol and smoking status, with high-density lipoprotein cholesterol adjustment where available.[8][19]Use the online simulator and Cardiovascular Health Programme smartphone application as supporting tools.[20][19]
• Provide intensive and immediate intervention for high-risk people, consider more intensive treatment for moderate-risk people, and avoid unnecessary medication in low-risk people while encouraging lifestyle change and efficient use of available resources.[6]
• Deliver lifestyle support through routine tobacco-use assessment and the Ask, Brief advice and Cessation support model, exercise prescription, dietary guidance and sex-specific alcohol limits.[12][21][22]
• Initiate and adjust antihypertensive, lipid-lowering, glucose-lowering, renal-protective and antiplatelet therapies according to cardiovascular risk, clinical conditions and treatment targets; complement, rather than delay, indicated medicines with lifestyle measures.[23][24][25]
• Classify chronic kidney disease by cause, glomerular filtration level and albuminuria, confirm persistent albuminuria or proteinuria, and refer people with stage 3b–5 disease for specialist assessment.[26][25][27]
• Review people starting antihypertensive treatment frequently during the first month, with early dose adjustment and adherence support; after targets are reached, schedule medical follow-up every three months for high-risk people, every six months for moderate-risk people and annually for low-risk people.[20][28]
• Reassess cardiovascular risk periodically according to initial risk classification, document tobacco status at least annually for smokers and recent ex-smokers, and use clinical records and reminders to support consistent assessment and follow-up.[18][21]

Monitoring & Evaluation

The framework combines national outcome and coverage targets for 2011–2020 with clinical risk assessment, periodic follow-up and safety monitoring. It does not set out a comprehensive reporting, surveillance, audit or accountability architecture, nor identify responsible monitoring institutions.[3][4][18]

• Measure national progress against 2020 targets to increase first-year projected survival after acute myocardial infarction from 78.5% to 91% and after cerebrovascular attack from 70.5% to 89.7%; increase effective hypertension-treatment coverage from 16.8% to 25.2% and type 2 diabetes-treatment coverage from 29.8% to 35.8%; and reduce renal replacement therapy incidence among people under 65 from 8.2 to 6.8 per 100,000.[4]
• Track protective and behavioural factors through targets to increase the prevalence of at least five protective factors among people over 15 from 35.6% to 42.7%, reduce last-month tobacco use among 12–64-year-olds from 40.9% to 35.6%, and reduce risky alcohol use among 15–24-year-olds from 15.1% to 14.8%.[4]
• Use first-year survival, effective treatment coverage, projected incidence or prevalence, renal replacement therapy incidence, and prevalence of protective factors as the principal measurement concepts for the Health Strategy targets.[4]
• Assess cardiovascular risk for people attending a health centre for the first time and during a Preventive Medicine Examination, then categorise and treat people enrolled in the public Cardiovascular Health Programme according to their risk.[18]
• Reassess cardiovascular risk periodically, with the interval determined by the initial risk category, because risk changes over time.[18]
• Apply a sequential classification process by first confirming or excluding clinical conditions that automatically place a person at high cardiovascular risk before using risk tables.[18][8]
• Use Chilean Framingham-derived tables, online tools or the Cardiovascular Health Programme smartphone application to estimate 10-year coronary risk among eligible adults without established high-risk conditions.[8][20][19]
• Classify estimated 10-year risk as low below 5%, moderate at 5–9%, and high at 10% or above, while recognising diabetes, chronic kidney disease, resistant hypertension and severe dyslipidaemia as independent clinical high-risk criteria.[8]
• Recognise that the Chilean risk tables were validated in 2013 for prediction of coronary and cerebrovascular events, although variation between risk calculators supports use of models developed or adapted for the local population.[29]
• Review people starting antihypertensive treatment frequently during the first month to assess target attainment and reduce therapeutic inertia, including weekly professional blood-pressure checks and medical review where dose adjustment or treatment intensification is required.[20]
• Schedule initial treatment reviews after 7–14 days to adjust doses, identify adverse effects and reinforce adherence; after achieving targets, review high-risk people every three months, moderate-risk people every six months and low-risk people every 12 months.[28]
• Monitor blood-pressure reduction in older adults progressively, including seated and standing measurements to identify orthostatic hypotension, and ensure diastolic pressure does not fall below 60 mmHg when systolic pressure is lowered.[30][31]
• Use glycated haemoglobin and blood-pressure targets as clinical treatment measures, while individualising targets for older people, people with recurrent hypoglycaemia, limited life expectancy or advanced complications.[13][32]
• Assess chronic kidney disease through estimated glomerular filtration rate and albuminuria or proteinuria, using cause, filtration category and albuminuria category to support prognosis and treatment planning.[33][27][34]
• Confirm persistent albuminuria or proteinuria with at least two positive results from three samples over three to six months after excluding transient causes, and classify albuminuria as A1 below 30 mg/g, A2 at 30–300 mg/g and A3 above 300 mg/g.[27]
• Monitor plasma potassium one week after initiating an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker in people with high-risk chronic kidney disease.[25]
• Monitor statin safety through baseline creatine phosphokinase and hepatic transaminases, reassessing creatine phosphokinase if muscle symptoms occur and monitoring transaminases within three months of treatment initiation.[35]
• Record tobacco-use status for every person attending a health service and update the status of current smokers and recent ex-smokers at least annually, supported by clinical-record prompts and reminders.[21][22]
• Use clinical documentation, scheduled reviews and adherence reinforcement as practical monitoring mechanisms, while recognising that no formal programme-wide indicator set, reporting schedule, surveillance process, audit mechanism or accountability system is specified in the supplied material.[18][28][21]

Costing & Financing

No explicit budget, costed implementation plan, financing source, resource allocation, funding gap, resource-mobilisation mechanism or quantified economic assumption is specified.[36][4][33]

• Recognise optimisation of available resources as an intended benefit of global cardiovascular-risk assessment, particularly through targeting intensive treatment towards people at higher risk and avoiding unnecessary medication for those at low risk.[6]
• Note that the ABC tobacco-cessation intervention is characterised as cost-effective, but no cost, budget allocation or financing arrangement is provided.[12]
• Use protein-to-creatinine ratio monitoring rather than albumin-to-creatinine ratio monitoring for diagnosed chronic kidney disease with substantial proteinuria where appropriate; it is described as less costly, without a monetary estimate.[27]
• Recognise that fixed-dose combinations of cardiovascular medicines may reduce treatment costs and potentially cardiovascular morbidity and mortality, although the referenced combinations were not available in Chile and no price or budget estimate is supplied.[37]
• Record that declarations of interest mention non-quantified pharmaceutical-industry support, honoraria, research funding and sponsored education, but these disclosures do not constitute programme financing information.[38][39]