Identification of asymptomatic people at high total risk of developing CVD
| CVD, cardiovascular disease; HDL, high density lipoprotein; HDL-C, high density lipoprotein cholesterol; TC, total cholesterol. | |
| Who to assess for CVD risk? | |
| Consider a comprehensive cardiovascular risk assessment in all adults aged 40–80 years who attend their general practitioner, or other member of the primary care team, for whatever reason. Younger adults (<40 years) with a family history of premature atherosclerotic disease should also have their cardiovascular risk factors measured | |
| How to assess for total CVD risk? | |
| A short history, focused clinical examination, and a blood sample provide a simple, quick, practical assessment of an asymptomatic person’s total cardiovascular risk. Using the Joint British Societies, cardiovascular risk prediction charts you can estimate the probability (%) of developing CVD over a 10 year period. | |
| Which risk factors to measure? | |
| Age | □□ years |
| Sex | Male/female |
| Cigarette smoker (current or past) | Yes/No |
| Systolic blood pressure (measured twice—use mean) | □□□ mm Hg |
| Total cholesterol (non-fasting) | □□.□ mmol/l |
| HDL cholesterol (non-fasting) | □.□ mmol/l |
| TC: HDL-C ratio (if an HDL cholesterol measurement is not available assume it is 1.0) | □.□ |
| Non-fasting plasma glucose (This measurement is not required for CVD risk calculation, but is the first step in the diagnosis of impaired glucose regulation and diabetes) | □□.□ mmol/l |
| Calculate total CVD risk from the cardiovascular risk prediction charts | |
| Total CVD risk: □□ % | |
| A CVD risk ⩾20% over 10 years is defined as high risk and justifies professional lifestyle intervention and appropriate use of antithrombotic, antihypertensive, and lipid lowering therapy | |
| What about other CVD risk factors not included in the cardiovascular risk prediction charts? | |
| The following risk factors can all increase the risk of CVD above that calculated from the charts | |
| • Family history of premature CVD (men <55 years and women <65 years) | |
| • Obesity (body mass index ≥30 kg/m2) and especially central obesity (waist circumference in white caucasians ≥102 cm in men and ≥88 cm in women and in Asians ≥90 cm in men and ≥80 cm in women) | |
| • Low HDL cholesterol (<1.0 mmol/l in men and <1.2 mmol/l in women) | |
| Raised triglycerides (>1.7 mmol/l) | |
| • Impaired fasting glucose (⩾6.1 but <7.0 mmol/l) or impaired glucose tolerance (2 hour glucose ⩾7.8 mmol/l and <11.1 mmol/l in an oral glucose tolerance test) | |
| • Women with premature menopause | |
| So a physician should always use clinical judgement by taking account of these other risk factors in reaching a final decision about a person’s cardiovascular risk and their need for professional lifestyle intervention and drug therapy | |
| Which people should NOT have CVD risk calculated? | |
| The following people are at sufficiently high risk to justify professional lifestyle intervention and appropriate treatment with antithrombotic, antihypertensive and lipid lowering therapies without formal risk calculation: | |
| • People with atherosclerotic cardiovascular disease | |
| • Persistently elevated blood pressure (⩾160/100 mm Hg) or when target organ damage due to hypertension is present | |
| • TC to HDL-C ratio ⩾6 | |
| • Type 1 and 2 diabetes mellitus | |
| • Renal dysfunction including diabetic nephropathy | |
| • Familial hypercholesterolaemia, familial combined hyperlipidaemia, or other inherited dyslipidaemias | |
| Many people aged 70 years and older are at high cardiovascular risk and treatment of blood pressure and lipids is a matter for individual clinical management where a physician should also take account of co-morbidity and other factors | |
| What about calculating CVD risk in ethnic groups other than white caucasian? | |
| The cardiovascular risk prediction charts have not been validated in ethnic groups other than white caucasian and therefore they should be used with caution | |