Conducting a comprehensive risk assessment

• In adults without known CVD, a comprehensive assessment of cardiovascular risk includes
• consideration of the following:
  • Modifiable risk factors
    • Smoking status
    • Blood pressure
    • Serum lipids
    • Waist circumference and Body Mass Index (BMI)
    • Nutrition
    • Physical activity level
    • Alcohol intake.
  • Non-modifiable risk factors
    • Age and sex
    • Family history of premature CVD
    • Social history including cultural identity, ethnicity and socioeconomic status.
  • Related conditions
    • Diabetes
    • Chronic Kidney Disease (albuminuria ± urine protein, eGFR)
    • Familial hypercholesterolaemia
    • Evidence of atrial fibrillation (history, examination, electrocardiogram).

Absolute cardiovascular disease (CVD) risk assessment 

• been developed based on New Zealand PREDICT equation
• calculator has been recalibrated and modified for the Australian population and health setting
• optional risk factors:
  • Geographical area (using residential postcodes as markers of area-level deprivation)
  • Atrial fibrillation.
  • People with type 2 diabetes, factoring
    • HbA1c
    • time since diagnosis of diabetes (measured in years)
    • urinary albumin-to-creatinine ratio (uACR)
    • eGFR
    • body mass index (BMI)
    • use of insulin in the previous 6 months.
  • People being treated with
    • BP lowering medications
    • Lipid modifying medications
    • antithrombotic medications
  • Risk estimates represent the chance of having a cardiovascular event in the next 5 years.
  • Risk categories :
    • high (≥10% risk over 5 years)
    • intermediate (5 to <10% risk over 5 years)
    • low (<5% risk over 5 years)
• The new categories are not directly interchangeable with previous 2012 Guidelines for the management of absolute cardiovascular disease risk equation categories.
• This difference has resulted in different risk percentile ranges for high, intermediate and low risk classifications.
• Aus CVD Risk Calculator is not validated for:
  • type 1 diabetes: may give an inaccurate risk estimate
• term ‘cardiovascular disease’ used in this guideline refers to the following conditions:
  • myocardial infarction (MI)
  • angina
  • other coronary heart disease (CHD)
  • stroke
  • transient ischaemic attack
  • peripheral vascular disease
  • congestive heart failure
  • other ischaemic CVD-related conditions

Risk category	Estimated  5‑year CVD riska	Management	Reassessment interval
High	≥10%	Encourage, support and advise a healthy lifestyle.b Prescribe ·        blood pressure-lowering ·        lipid-modifying pharmacotherapy.c	Formal reassessment of CVD risk is not generally required. High-risk status requires clinical management and follow up supported by ongoing communication.
Intermediate	5% to <10%	Encourage, support and advise a healthy lifestyle.b   Consider blood pressure-lowering and lipid-modifying pharmacotherapy, depending on clinical context.	Reassess risk every 2 years if not currently receiving pharmacotherapy to reduce CVD risk. Assess sooner if close to the threshold for high risk, if CVD risk factors worsen, or new CVD risk factors are identified. For First Nations people, reassess every year as part of an annual health check (or opportunistically) or at least every 2 years.
Low	<5%	Encourage, support and advise a healthy lifestyle.b   Pharmacotherapy is not routinely recommended.	Reassess risk every 5 years. Assess sooner if close to the threshold for intermediate risk, if CVD risk factors worsen, or new CVD risk factors are identified.   For First Nations people, reassess every year as part of an annual health check (or opportunistically) or at least every 2 years.

(a) Estimated probability of a cardiovascular event within the next 5 years, determined using the Australian cardiovascular disease risk calculator.

(b) This guideline refers to certain modifiable risk factors as ‘lifestyle’ factors. However, it is recognised that these behaviours are not necessarily an individual’s choice, but reflect the complex interplay of social, cultural, and environmental factors, which may be further influenced by clinical conditions. Use of the term ‘lifestyle’ does not attribute blame to a person

(c) Unless contraindicated or clinically inappropriate, and in discussion with the person on the benefits and harms of treatment. Encourage shared decision-making

Practice points

When communicating risk:

• Communicate risk as either a percentage or as a frequency (e.g. 15% or “15 out of 100 people like you will have a heart attack or stroke in the next 5 years”)
• Consider the person’s receptivity, understanding and acceptance of risk, health literacy, and learning preferences.
• Provide the information in multiple formats (e.g. numerical percentage, 100-person charts) suitable for the person’s receptivity and understanding.
• Use relevant decision aids to improve knowledge and guide management discussions. Repeat this discussion about risk over several consultations, where appropriate.
• Emphasise the relevance of the information by relating it to aspects of the person’s own experiences such as a recent illness, a new diagnosis in a friend or family member, the person’s life stage (e.g. adulthood, pregnancy), or family medical history.
• Discuss relevant CVD risk factors such as smoking, alcohol intake or obesity.

Target population

• not known to have CVD or to be at
• clinically determined high risk
• All people aged 45-79 years
• People with diabetes aged 35-79 years
• First Nations people aged 30-79 years
  • (First Nations people aged 18-29 years should have their individual risk factors assessed)

First Nations people aged 18-29 years  : The following CVD risk factors should be screened, as part of an annual health check (or opportunistically) or at least every 2 years :

• smoking status
• blood pressure (BP)
• blood glucose level or glycated haemoglobin (HbA1c)
• estimated glomerular filtration rate (eGFR)
• serum lipids
• urine albumin-to-creatinine ratio (uACR)
• history of familial hypercholesterolaemia (FH).13

Clinically determined high risk:

• Adults with any of the following conditions do not require absolute cardiovascular risk assessment using Equation because they are already known to be at clinically determined high risk of CVD:
  • Moderate or severe CKD
    • persistent proteinuria
    • eGFR <45 mL/min/1.73 m2
  • Familial hypercholesterolaemia
    • most common inherited cause of premature CHD, with a prevalence of 1 in 250
    • People with diagnosed FH are at clinically determined high risk and should be automatically managed as high CVD risk.
    • FH-specific calculators may be useful

Based on variables:

Mandatory
Variable	Application
Age	validated for adults aged 30 to 79 years.
Sex	sex at birth – (there is currently insufficient data to stratify risk for people who are intersex or non-binary sex)
Smoking status	Choose from three categories: never smoked previously smoked currently smokes
Blood pressure (BP)	Systolic blood pressure (SBP) in mmHg. –        Use the average of the last two seated, in-clinic BP measurements. –        Convert home and ambulatory BP readings to in-clinic equivalents before entering into the calculator.
Cholesterol	Enter ratio of total cholesterol (TC) to high-density lipoprotein cholesterol (HDL-C). Use most recent measurements (fasting or non-fasting).
Diabetesa (type 2 only)	status: YES or NO
CVD medicines	CVD medicines used during the 6 months prior to risk assessment (lipid-modifying, BP-lowering, and/or antithrombotic medicines) Lipid-modifying medicines – atorvastatin, fluvastatin, pravastatin, simvastatin, acipimox, bezafibrate, cholestyramine, clofibrate, colestipol, ezetimibe, ezetimibe with simvastatin, gemfibrozil and nicotinic acid. BP-lowering medicines – angiotensin converting enzyme inhibitors, betablockers, thiazide, angiotensin II receptor blockers and calcium channel blockers. Antithrombotic medicines – aspirin, clopidogrel, dipyridamole, prasugrel, ticagrelor, ticlopidine, warfarin, dabigatran, phenindione and rivaroxaban.

Additional diabetes type 2-specific variables (not compulsory, but gives more accurate assessment of risk)
Time since diagnosis of diabetes	Enter time in years.
Glycated haemoglobin (HbA1c)	Enter HbA1c in mmol/mol or % (single non-fasting).
uACRb	Enter urine albumin-creatinine ratio (uACR) (measured in mg/mmol).
eGFRb	Enter eGFR in mL/min/1.73m2
Body mass index(BMI)	Measure weight in kilograms and height in metres.  Calculate BMI: kg/m2.
Insulin	Record use of insulin in the 6 months before risk assessment.

(a) The equation on which the Aus CVD Risk Calculator is based has not been validated for people with type 1 diabetes.

(b) Whilst uACR and eGFR have been shown to independently improve prediction of cardiovascular events, they are only included as variables in the diabetes-specific equation due to lack of availability of data in the general population PREDICT cohort. Instead, they have been incorporated into the overall risk calculation as a reclassification factor. In future, when data is available from the PREDICT population, these measures may be incorporated directly into the risk equation.

Non- Mandatory
Postcode	Postcode is used to calculate Socio-Economic Indexes for Areas (SEIFA) quintile, and under the discretion of the clinician, may be manually adjusted to better reflect the socioeconomic status of individual patients.
Medical history of atrial fibrillation	Known history of electrocardiogram (ECG) confirmed atrial fibrillation: YES or NO. Both paroxysmal and persistent AF are included in the definition of AF.

 

Consider reclassification factors

Factor	Potential to reclassify upward or downward
Ethnicity	↑ or ↓
Family history of premature CVD	↑
Chronic kidney disease	↑
Severe mental illness	↑
Coronary artery calcium score	↑ or ↓

reclassify downward

• Coronary artery calcium score of 0
• East Asian ethnicity (Chinese, Japanese, Korean, Taiwanese, or Mongolian ethnicities)

reclassify upward

• Coronary artery calcium score > 99 units, or ≥ 75th percentile for age and sex
• Ethinicity
  • First Nations people
  • Māori
  • Pacific Islander
  • South Asian ethnicity (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian ethnicities)
• Family history of premature coronary heart disease (CHD) or stroke in a first-degree
  • female relative aged <65 years or
  • male relative aged <55 years
• Chronic kidney disease
  • eGFR 45–59mL/min/1.73m2 and/or
  • persistent uACR
    • 2.5–25mg/mmol (men) or
  • 3.5–35mg/mmol (women)
• Severe mental illness (current or recent mental health condition requiring specialist treatment, whether received or not, in the 5 years prior to the CVD risk assessment.)

Coronary artery calcium (CAC) score

• Function: Measures burden/amount and density of calcium deposits/plaques in coronary vessels.
• Limitation:
  • Cannot determine the degree of stenosis.
  • Therefore, it should not be used as a standalone test for symptomatic patients (e.g., those with potential cardiac angina).
• Reporting:
  • Agatston units (Au): Absolute measure of coronary calcium.
  • Percentile measure: Relative to age- and sex-matched general population.
• Clinical Utility:
  • Aids in individualized cardiovascular event risk prediction.
  • Informs pharmacological treatment decisions.
  • Strong negative predictive value.
• Young Individuals:
• Age Factor:
  • CAC increases with age.
  • Less discriminative in individuals over 75 years due to generally high scores.
• Normal CAC Score (Zero):
  • Consider retesting in 2–5 years to detect score increase and reclassify risk.
  • 25% of patients develop CAC over 5 years.
• When Not to Measure CAC:
  • History of myocardial infarction, revascularization, or known coronary heart disease.
  • Already known high CVD risk.

Clinical applications of CAC testing

Clinical situation	CAC testing	Clinical implications
Population screening for CVD	Not recommended	Low yield of CAC scoring in mass population screening
People with high risk of a cardiovascular event in the next 5 years	Not recommended (neither initial nor repeat test)	CAC score would not alter management: preventive treatment indicated.
People with known CVD	Not recommended (neither initial nor repeat test)	CAC score would not alter management: preventive treatment indicated.
CVD risk assessed as low or intermediate in a person with one or more additional risk factors	Can be considered if available and affordable	Detection of CAC may reclassify risk to a higher level. Score of zero may reclassify risk level to low. Score >99 Au (or ≥75 th percentile for age and sex) may reclassify risk level to a higher level.
Change in intensity of preventive treatment is under consideration	Can be considered if available and affordable to inform discussions with patient	CAC score may alter management.
Previous score of zero	Consider re-testing in 2–5 years	CAC score provides additional monitoring of risk.

Others:

Elderly (>79)

• the decision to initiate therapy should be based on clinical judgement which takes into
• account:
  • Likely benefits and risks of treatment
  • Life expectancy, co-morbidities and quality of life
  • Personal values.
• Indications to continue treatment with Statin agent in age over 79 years:
  • Coronary Artery Disease
  • High Coronary Calcium Score
  • Ankle brachial index <0.9
  • hs-CRP >2 mg/L
  • Consider continuing agent even without other indications (NNT 83 to avoid 1 MI in 3-4 years – Savarese (2013) J Am Coll Cardiol 62(22):2090-9

Ankle Brachial Pressure Index (ABPI):

1. Measure of Lower vs. Upper Limb Pressures: ABPI compares blood pressures in the lower and upper limbs.
2. Diagnostic Thresholds:
   • <0.9: Indicates peripheral artery disease (PAD).
   • >1.4: Suggests calcified, non-compressible arteries, often associated with PAD.
3. Correlation with Other Diseases: Linked significantly with coronary and cerebrovascular diseases.
4. Screening Recommendation: Insufficient evidence for routine population screening.
5. Clinical Implication: Abnormal ABPI should prompt management of reversible cardiovascular disease (CVD) risk factors, similar to high CVD risk individuals.

High-sensitivity C-reactive Protein (hsCRP):

1. Inflammatory Marker: Produced by the liver in response to inflammation.
2. Normal Levels: Below 3 mg/L in healthy individuals without acute inflammation.
3. hsCRP Test Sensitivity: Detects levels around 0.3 mg/L, used for CVD risk stratification.
4. Epidemiological Correlation: CRP levels correlate with cardiovascular event risk.
5. Screening Efficiency: Modest impact on preventing CVD events over 10 years, making routine screening questionable.

24-hour Ambulatory Blood Pressure (BP) Monitoring:

1. Measurement Method: BP measured regularly over 24 hours during normal activities and sleep.
2. Diagnostic Utility:
   • Identifies ‘white coat’ hypertension.
   • Detects ‘masked’ hypertension not apparent in clinic measurements.
   • Useful for treatment monitoring.
3. Role in CVD Risk Assessment: Limited; primarily used for BP diagnosis and management.
4. Comparison with Office Readings: Tends to be around 5 mmHg lower than clinic measures, but minor impact on overall CVD risk assessment.