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1. Identify people for CVD risk assessment

Age ranges for assessing CVD risk

Targeting CVD risk assessment to recommended age groups enables people at high risk of CVD to be identified early before they develop overt disease.

This approach helps direct pharmacological strategies for intensive CVD risk factor management to people at high risk and diverts unnecessary interventions away from people at lower risk.

Recommendations
Strength Certainty of evidence
For all people without known CVD, assess CVD risk
from age 45 to 79 years.		 Conditional a
For people with diabetes without known CVD, assess
CVD risk from age 35 to 79 years.		 Conditional a
For First Nations people without known CVD:
  • assess individual CVD risk factors from age 18 to 29 years
  • assess CVD risk using the Australian cardiovascular disease risk calculator from age  30 to 79 years.
Consensus
  1. Due to a lack of studies specifically addressing starting age, a linked evidence approach was used.

General considerations

There is very limited evidence available from Australian populations to guide starting age for CVD risk assessment. There is also no direct evidence from clinical trials comparing cardiovascular outcomes of risk assessment conducted at different ages in the same population.

The current recommendations are therefore based on population-level observational data and expert consensus in consultation with consumers. However, this does not reduce the importance of considering, assessing and managing CVD risk in people from younger or older age groups, as clinically necessary.

Studies relating to the benefit of commencing blood pressure-lowering and statin medicines at a variety of ages were also reviewed to inform this recommendation.

Sex difference in age-related CVD risk

Although there are differences between men and women in the experience of heart disease, and cardiovascular events are more common in men than women, CVD is a major issue for both sexes. Women have similar CVD risk incidence to men, manifesting approximately 10 years later.10 Recognition of menopause or perimenopause represents an opportune time to assess CVD disease risk in women.

People 80 years or older

The evidence underpinning the Aust CVD Risk Calculator supports its use up to age 79 years.1 Risk equations derived from younger cohort equations (30–79 years), such as the Aus CVD Risk Calculator, do not accurately predict risk in older age groups. Individual clinical decision-making should support the assessment and management of CVD risk in people 80 years or older.11

Practice points

  • People with risk factors such as smoking, diabetes, family history of premature CVD,* kidney impairment, gestational diabetes, pre-diabetes, familial hypercholesterolaemia (FH), severe mental illness,† and severe obesity generally develop CVD at a younger age than the general population. Therefore, earlier monitoring of CVD risk factors may be warranted.12
  • For people younger than 30 who meet the clinically determined high risk criteria, manage as high CVD risk.

*Family history of premature CVD is defined as coronary heart disease (CHD) or stroke in a first-degree female relative aged <65 years or a first-degree male relative aged <55 years.

†Severe mental illness is defined in this guideline as a current or recent mental health condition requiring specialist treatment, whether received or not, in the 5 years prior to the CVD risk assessment. Derived from PREDICT cohort.50

First Nations people

Where possible, cardiovascular risk assessment should be completed as part of a holistic health assessment for First Nations people, with appropriate follow up and management. In alignment with the National Agreement on Closing the Gap, all care should be taken to ensure cultural safety, shared decision-making, informed consent and ownership of information.

Recommendations were developed in partnership with First Nations clinicians and researchers, and clinicians and researchers with experience working with First Nations people and communities. 

CVD is the single largest contributor to mortality and accounts for a quarter of all deaths among First Nations people.13

An estimated 75% of First Nations adults younger than 35 years have one or more risk factors for CVD, and more than 44% of people aged 65–74 years are at high risk of a primary CVD event.13,14

MI, stroke and cardiovascular-related death generally occur 10–20 years earlier in First Nations people compared with the non-Indigenous Australian population.13

First Nations women experience higher rates of CVD, compared with non-Indigenous women.15 First Nations women experience a high burden of CVD from a young age, although the drivers of this premature burden are not well understood.16

Practice Points

  • Assess CVD risk as part of an annual health check (or opportunistically) or at least every 2 years.13
  • The following CVD risk factors should be screened for in people ages 18–29 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

Resources

  1. Resources to support health checks for Aboriginal and Torres Strait Islander people - RACGP

Support for the recommendations

Data from the Australian National Health Measures Survey (applying the National Vascular Disease Prevention Alliance algorithm) and the large New Zealand PREDICT study cohort suggest a small proportion of people aged 18-44 years are at high risk of developing CVD within 5 years (see Appendix 4). 1, 12, 17

The recommendation to start routinely assessing CVD risk at age 45 in both males and females is based on sex-specific studies and is intended to balance gender bias and support implementation by minimising complexity or health professionals and consumers.4, 12, 18

The 2020 joint consensus statement by the Australian Chronic Disease Prevention Alliance, National Heart Foundation of Australia, Editorial Committee for Remote Primary Health Care Manuals, National Aboriginal Community Controlled Health Organisation, and the Royal Australian College of General Practitioners, recommends risk factor screening in First Nations people starting at age 18 years at the latest and assessing CVD risk using a calculator from age 30 at the latest.13