Remote Primary Health Care Manuals

Assessing and reducing cardiovascular risk ⚠️

             

  • Level of absolute cardiovascular risk is the chance of heart attack or stroke in the next 5 years. Looks at key risk factors together. Treat to reduce risk

  • Use risk calculators to assess new persons or to monitor others with ongoing low or moderate risk — can also be used to explain risk and help motivate lifestyle changes
  • Once a person has been assessed as high cardiovascular risk they remain at high cardiovascular risk – do not use risk calculators, do not stop medications

Assessing absolute cardiovascular risk

High cardiovascular risk

  • People with one or more items in Table 4.5 are at HIGH cardiovascular risk — do not use risk calculators for these people

Table 4.5 HIGH cardiovascular risk (if one or more present)  

  • Known cardiovascular disease (angina, heart attack, bypass surgery, stroke)
  • Diabetes AND kidney disease with urine ACR 5mg/mmol or more for males, 3.5mg/mmol or more for females
  • Diabetes AND age over 60 years
  • Chronic kidney disease with eGFR less than 45 or urine ACR more than 25 in males or more than 35 in females
  • Persistent high BP — systolic 180mmHg or more OR diastolic 110mmHg or more
  • Total cholesterol more than 7.5mmol/L
  • Familial hypercholesterolaemia (genetic disorder with high cholesterol)
  • 75 years or over

Cardiovascular risk calculators

  • If NOT at high risk according to Table 4.5 — use the appropriate risk calculator in your primary care patient management system to calculate risk for
    • Aboriginal adults aged 18–74 years
    • Non-Aboriginal adults aged 45–74 years
  • Use results from before person started any medication for BP or lipids

Risk categories

  • The risk category will be determined by the risk calculator
    • Low — medications usually not needed
    • Moderate — benefit from medication if unable to make lifestyle changes
    • High — this category has greatest benefit from ongoing medication

Reviewing absolute cardiovascular risk

  • Low — every year with Adult Health Check
  • Moderate — every year
  • High — continue to manage as high-risk
    • Treat to maximum tolerated doses regardless of targets
    • Do not stop medicines when they reach targets

Reducing absolute cardiovascular risk

Table 4.6 Reducing absolute cardiovascular risk    

Risk factor Goal / Action
Smoking
  • Quit smoking
Overweight/obesity
  • Waist circumference: men — 94cm or less, women — 80cm or less
  • More physical activity
  • Less processed and takeaway foods — See Healthy diet
Alcohol
  • No more than 2 standard drinks/day, no more than 10 standard drinks a week
Physical activity
  • 30 minutes moderate activity most days or every day
Hypertension (high BP)
  • Target BP less than 130/80
  • BP lowering medicine (ACE inhibitor or ARB)
High blood glucose levels
  • Aim for HbA1c 53mmol/mol (7%) or less — strict glucose control reduces cardiovascular risk events
Abnormal lipids (blood fats)
  • Treat to target
  • Statin recommended for high risk, consider for moderate list (below)
Kidney disease
  • Target BP less than 130/80
  • BP lowering medicine (ACE inhibitor or ARB)
Depression
  • Identify and treat depression
Absolute cardiovascular risk high (more than 15%)
  • Treat with statin AND ACE inhibitor or ARB
  • Aspirin recommended if known CVD — heart attack, angina, ischaemic stroke

Lipids (blood fats)


Abnormal lipids (blood fats) are a risk factor for cardiovascular disease — management based on level of cardiovascular risk not blood fat levels

 Do

  • If abnormal lipids
    • Take blood for TFT, CK, LFT (baseline tests only required)
  • If diabetes — good blood glucose control will improve abnormal lipids
  • Medical consult to prescribe statins according to risk factors — Table 4.7

Table 4.7   

Risk factors

Management with statins

  • Existing cardiovascular disease
  • High absolute cardiovascular risk
  • Give high dose statin even if lipids (blood fats) normal
  • Moderate absolute cardiovascular risk

 
  • May need statin even if lipids (blood fats) normal
  • Manage other risk factors
  • Low absolute cardiovascular risk
  • May not need statin even if lipids (blood fats) abnormal
  • Statins best medicines for lowering TC and LDL-C, have some effect on raising HDL-C
  • If statins not controlling lipids or not tolerated — medical follow up
  • Lipids and other cardiovascular risk factors should be managed with Active lifestyle management — see Lifestyle risk factors

Remember: Any lowering of TC or LDL-C or increase in HDL-C reduces CV risk even if target not reached

Follow-up

  • If LFT or CK abnormal at start — monitor on a regular basis and medical follow up