Cardiovascular Risk Cardiovascular Risk AssessmentAssessment

Dr Farhan Ali&

Dr Ramesh Mehay

Cardiovascular Risk Cardiovascular Risk Assessment GoalsAssessment Goals

The clinical goals of cardiovascular risk assessment The clinical goals of cardiovascular risk assessment and management are to:and management are to: Reduce the incidence of cardiovascular disease, Reduce the incidence of cardiovascular disease, including:including:

Coronary heart disease (including angina and Coronary heart disease (including angina and myocardial infarction)myocardial infarction)Stroke and transient ischaemic attacksStroke and transient ischaemic attacksPeripheral arterial diseasePeripheral arterial diseaseAtherosclerotic aneurysm of a major arteryAtherosclerotic aneurysm of a major artery

Improve the quality of lifeImprove the quality of life

Improve life expectancyImprove life expectancy

What should we look for?What should we look for? Risk assessment should include Risk assessment should include

Ethnicity, Ethnicity, Smoking habit history, Smoking habit history, Family history of CVD and Family history of CVD and Measurements of weight, waist circumference, Measurements of weight, waist circumference, Blood pressure, Blood pressure, Lipids (total cholesterol and high-density lipoprotein (HDL) Lipids (total cholesterol and high-density lipoprotein (HDL)

cholesterol)cholesterol) Glucose. Glucose. The American Heart Association (AHA) guidelines also The American Heart Association (AHA) guidelines also

recommend recording the pulse rate and rhythm to screen recommend recording the pulse rate and rhythm to screen for atrial fibrillation for atrial fibrillation

Once all risk factors have been identified, cardiovascular Once all risk factors have been identified, cardiovascular risk charts or calculator should be used to estimate the total risk charts or calculator should be used to estimate the total risk of developing CVD over the following 10 years. A total risk of developing CVD over the following 10 years. A total CVD risk of over 20% over 10 years is defined as high-risk. CVD risk of over 20% over 10 years is defined as high-risk.

What blood tests are What blood tests are recommended for recommended for

cardiovascular disease risk?cardiovascular disease risk? When an individual has been prioritized for When an individual has been prioritized for

formal risk assessment, they will need the formal risk assessment, they will need the following tests:following tests: Total cholesterol and HDL cholesterol (average of at Total cholesterol and HDL cholesterol (average of at

least two tests, at least one of which should be on a least two tests, at least one of which should be on a fasting sample).fasting sample).

Blood glucose.Blood glucose. Renal function with an estimated glomerular filtration Renal function with an estimated glomerular filtration

rate (eGFR) to screen for chronic kidney disease.rate (eGFR) to screen for chronic kidney disease. Creatine kinase may be useful before starting statin Creatine kinase may be useful before starting statin

treatment if the person is at increased risk for muscle treatment if the person is at increased risk for muscle toxicity.toxicity.

Which Risk calculator Which Risk calculator should I use?should I use?

NICE recommends that the modified Framingham 1991 10-NICE recommends that the modified Framingham 1991 10-year risk equations (as used in the JBS 2 risk calculator) year risk equations (as used in the JBS 2 risk calculator) should be used to assess CVD risk. should be used to assess CVD risk.

The JBS 2 tool is based on the following risk factors: age, The JBS 2 tool is based on the following risk factors: age, sex, smoking habit, systolic blood pressure, left ventricular sex, smoking habit, systolic blood pressure, left ventricular hypertrophy, and the ratio of total cholesterol to HDL hypertrophy, and the ratio of total cholesterol to HDL cholesterol. Recent versions can adjust risk on the basis of cholesterol. Recent versions can adjust risk on the basis of central obesity, South Asian ethnic origin, and impaired central obesity, South Asian ethnic origin, and impaired fasting glucose. fasting glucose. www.bhsoc.org..

The JBS 2 calculator is less accurate for certain population The JBS 2 calculator is less accurate for certain population groups, e.g. women, ethnic minority groups andsocial groups, e.g. women, ethnic minority groups andsocial deprivation. The QRISK®2 calculator adjusts for some of deprivation. The QRISK®2 calculator adjusts for some of these factors (e.g. deprivation - using postcode), and is these factors (e.g. deprivation - using postcode), and is gaining increased acceptance in the UK (as it uses UK gaining increased acceptance in the UK (as it uses UK rather than Framingham (USA) data); rather than Framingham (USA) data); http://qrisk.org..

For Scotland, the Scottish Intercollegiate Guidelines For Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) recommend use of the ASSIGN calculator Network (SIGN) recommend use of the ASSIGN calculator ((www.assign-score.com))

Who needs a cardiovascular Who needs a cardiovascular risk assessment?risk assessment?

Primary care is ideally placed for primary Primary care is ideally placed for primary prevention, and this should be done in patients prevention, and this should be done in patients at increased risk:at increased risk: Hypertensives, Hypertensives, Diabetics, Diabetics, Familial hyperlipidaemiaFamilial hyperlipidaemia Strong family history of CVDStrong family history of CVD Opportunistically - The Joint British Societies' (JBS 2) Opportunistically - The Joint British Societies' (JBS 2)

guidelines recommend that all adults from age 40 guidelines recommend that all adults from age 40 years onwards should be considered for an years onwards should be considered for an opportunistic comprehensive CVD risk assessment in opportunistic comprehensive CVD risk assessment in primary careprimary care

Who does not need a Who does not need a cardiovascular risk cardiovascular risk

assessment? assessment? Risk assessment is not required in those Risk assessment is not required in those

whose 10-year risk can be assumed to be at whose 10-year risk can be assumed to be at least 20%least 20%

People 75 years of age or older, People 75 years of age or older, or withor with Established cardiovascular disease, Established cardiovascular disease, or withor with Peripheral vascular disease, Peripheral vascular disease, or withor with Familial hypercholesterolaemia, Familial hypercholesterolaemia, or withor with Polycythaemia vera, Polycythaemia vera, or withor with Type 2 diabetes mellitus and older than 40 years of Type 2 diabetes mellitus and older than 40 years of

age, with or without any additional risk factor.age, with or without any additional risk factor.

How do we reduce the risk How do we reduce the risk of CVD?of CVD?

Lifestyle modificationsLifestyle modifications

Drug treatments Drug treatments

Effective management of any Effective management of any underlying medical condition underlying medical condition Diabetes Diabetes HypertensionHypertension Hyperlipidaemia.Hyperlipidaemia.

Lifestyle ModificationLifestyle Modification Advise about a healthier diet:Advise about a healthier diet:

Total fat intake is 30% or less of total energy intake.Total fat intake is 30% or less of total energy intake. Saturated fats are 10% or less of total energy intake.Saturated fats are 10% or less of total energy intake. Dietary cholesterol is less than 300 mg/day.Dietary cholesterol is less than 300 mg/day. Saturated fats are replaced by monounsaturated and polyunsaturated fats.Saturated fats are replaced by monounsaturated and polyunsaturated fats. Advise eating at least:Advise eating at least:

Five portions of fruit and vegetables per day.Five portions of fruit and vegetables per day. Two portions of fish per week, including a portion of oily fish.Two portions of fish per week, including a portion of oily fish.

Do not routinely recommend omega-3 fatty acid supplements or plant Do not routinely recommend omega-3 fatty acid supplements or plant sterols and stanols for primary prevention.sterols and stanols for primary prevention.

Physical activity:Physical activity: Advise people to take 30 minutes of at least moderate-intensity exercise a Advise people to take 30 minutes of at least moderate-intensity exercise a

day, at least 5 days a week. such as brisk walking, using stairs and cycling.day, at least 5 days a week. such as brisk walking, using stairs and cycling. Tell people that they can exercise in bouts of 10 minutes or more Tell people that they can exercise in bouts of 10 minutes or more

throughout the day.throughout the day. Take into account the person's needs, preferences and circumstances.Take into account the person's needs, preferences and circumstances. Agree goals and provide written information about the benefits of activity Agree goals and provide written information about the benefits of activity

and local opportunities to be active.and local opportunities to be active.

Lifestyle factors 2Lifestyle factors 2 Weight management:Weight management:

Offer people who are overweight or obese advice and Offer people who are overweight or obese advice and support to work towards achieving and maintaining a support to work towards achieving and maintaining a healthy weight.healthy weight.

Alcohol consumption:Alcohol consumption: Advise men to limit their alcohol intake to 3-4 units a day.Advise men to limit their alcohol intake to 3-4 units a day. Advise women to limit their alcohol intake to 2-3 units a Advise women to limit their alcohol intake to 2-3 units a

day.day. Advise everyone to avoid binge drinking.Advise everyone to avoid binge drinking.

Smoking cessation:Smoking cessation: Advise all people who smoke to stop.Advise all people who smoke to stop. If people want to stop:If people want to stop: Provide structured advice and support, with use of Provide structured advice and support, with use of

medication to help smoking cessation when appropriate.medication to help smoking cessation when appropriate.

Drug treatmentDrug treatment Hypertension: screen for hypertension and treat appropriately Hypertension: screen for hypertension and treat appropriately

according to British Hypertension Society (BHS) guidelinesaccording to British Hypertension Society (BHS) guidelines

Aspirin: although use of aspirin is widely accepted for secondary Aspirin: although use of aspirin is widely accepted for secondary prevention, results in primary prevention are inconclusive. prevention, results in primary prevention are inconclusive. Recent studies have found that aspirin doubles the risk of Recent studies have found that aspirin doubles the risk of gastrointestinal bleeding and current opinion is that this gastrointestinal bleeding and current opinion is that this outweighs any benefits which might be conferred in reducing the outweighs any benefits which might be conferred in reducing the onset of CVD.onset of CVD.

Lipid-lowering drugs: Statin treatment is recommended as part of Lipid-lowering drugs: Statin treatment is recommended as part of primary prevention for adults with a 10-year risk of 20%. primary prevention for adults with a 10-year risk of 20%. Usual treatment should be with simvastatin 40 mg. Higher-dose Usual treatment should be with simvastatin 40 mg. Higher-dose

statins should not be used as there are no RTCs comparing high and statins should not be used as there are no RTCs comparing high and low dose statins in relation to cardiovascular outcomes in people low dose statins in relation to cardiovascular outcomes in people without CVD. without CVD.

Do not set a target concentration for total cholesterol or low-density Do not set a target concentration for total cholesterol or low-density lipoprotein (LDL) cholesterol in primary prevention.lipoprotein (LDL) cholesterol in primary prevention.

Once a patient has started taking a statin, repeat lipid measurement Once a patient has started taking a statin, repeat lipid measurement is unnecessary. Clinical judgment and the patient's preference should is unnecessary. Clinical judgment and the patient's preference should guide the review of drug treatment and whether to review the lipid guide the review of drug treatment and whether to review the lipid profile.profile.

Any QuestionsAny Questions