Table 2

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