New JBS3 recommendations for CVD prevention
Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3)
Heart 2014;100:ii1-ii67 doi:10.1136/heartjnl-2014-305693
The Joint British Societies (JBS) have published new consensus recommendations for the prevention of cardiovascular disease (CVD), today in a supplement to Heart .
Guidelines on reducing CVD have led to a large decline of CVD mortality. CVD is however still a leading cause of deaths worldwide. More patients survive their first CV event, and remain at high risk, and risk factors such as obesity and diabetes are more and more common. Hence, a focus on prevention remains crucial.
Current strategies focus on a 10-year risk, and use threshold risks for pharmacological therapy. In this way, those at highest risk who will likely benefit most from treatment, will receive treatment. A drawback of this approach is that a proportion of the population with a relatively low 10-year risk, but a high lifetime event risk, will not be treated. Especially younger patients and women may fall in this category.
The JBS3 addresses this issue, by acknowledging that there is a continuum of CVD risk in the population and that most CVD events occur in individuals who are at ‘intermediate risk’. According to 10-year risk assessment models, these patients would not receive risk factor lowering treatment. Since cardioprotective drugs are now know to be safe and efficacious over the longer term, and have become cheaper, their use may be extended beyond the current 10-year CVD risk threshold. JBS3 therefore supports a revaluation of indication for drug treatment, provided they are based on acceptability, cost effectiveness and practicality.
The most important change of JBS3 as opposed to JBS2 and other guidelines, is the focus on CVD risk over lifetime. Evidence is accumulating that long term exposure to CVD risk factors drives atherogenesis and that early treatment can modify disease progression and risk of future CVD events.
A new JBS3 risk calculator has been developed, based on QRISK Lifetime, which allows identification of individuals in the population who are at low short term risk but at high lifetime risk. The concept of ‘heart age’ is introduced, and this is presented next to 10-year risk and CVD event-free survival, which gives insight into the consequences of an individual’s lifestyle and associated risk factors.
The JBS3 risk calculator should empower individuals to understand why and when they should start CVD risk reduction, and what they should do. It should facilitate an informed discussion between a patient and the clinician, and should help in making decisions about lifestyle changes and, where indicated, pharmacological therapy.
The JBS3 is based on the latest clinical and scientific evidence. It recommends the use of traditional risk factors that are commonly and relatively easily measured, since newer approaches (e.g. biomarkers) to risk assessment have not been found to notably improve risk assessment, or since they may not be appropriate or necessary in the general population. The conclusion to not implement newer approaches in the risk assessment process is supported by the available scientific evidence to date.
Practical recommendations are given on the use of the JBS3 risk calculator, which uses total cholesterol and HDL-c from a non-fasting blood sample as an estimate of the lipid profile. Non-fasting non-HDL levels should be used as the treatment goal for lipid-lowering therapy, rather than LDL-c.
Diet and lifestyle interventions and pharmacological therapy are equally important for intensive risk factor modification, both in patients with existing CVD, and in patients at high short-term, or high lifetime risk of developing CVD.
The recommendations are clearly outlined in practical detail, including the underlying evidence.
Illustrated examples are given that guide the reader through the process and features of the JBS3 calculator. Distinct sections are dedicated to prevention of CVD, and how to deal with conditions with high risk of CVD.
Of note, the JBS3 should not be used for patients with known CVD, for whom treatment and clinician advice should be guided by established recommendations. The risk calculator may, however, be of use in this patient group to highlight the high risk and to emphasize the benefit of intervention.
As risk prediction is no exact science, efforts will need to be directed at continuing to refine this risk assessment tool. The NHS Health Checks programme and other large national registries of anonymised data provide an opportunity to study the JBS3 approach. This research will help understand how best to use the risk calculator in different populations as a tool to bring about beneficial behaviour change, in people who are at lower short term, but at potentially high lifetime CV risk.
Two separate editorials [2,3] in Heart compare this new JBS3 with other guidelines, including the recently published AHA/ACC guidelines on CV prevention. The authors conclude that the overlap between those and the JBS3 is substantial. This is not surprising, since the guidelines are based on the available scientific evidence, but reassuring nevertheless.
Find the Joint British Societies’ consensus recommendations online 
Access the JBS3 risk calculator
1. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). JBS3 Board. Heart 2014;100:ii1-ii67 doi:10.1136/heartjnl-2014-305693
2. Greenland P. British and American prevention guidelines: different committees, same science, considerable agreement. Heart heartjnl-2014-305651 Published Online First: 25 March 2014 doi:10.1136/heartjnl-2014-305651
3. Joep Perk J, Graham I, De Backer G. Prevention of cardiovascular disease: new guidelines, new tools, but challenges remain. Heart Published Online First: 25 March 2014 doi:10.1136/heartjnl-2014-305650