Overview

General considerations

Managing CVD risk should always involve encouraging, supporting and advising appropriate healthy lifestyle and behaviours, with or without blood pressure-lowering (BP-lowering) and/or lipid-modifying pharmacotherapy.

Once the recommended management plan is identified according to risk category, this needs to be further refined in collaboration with the person. This process should include a discussion regarding the benefits and risks of treatment options, and their personal values and preferences.

People vary in what they find motivating; for some this is having targets in place. Set targets in consultation with the person according to what is practicable and achievable for them.

Although the pharmacotherapy interventions outlined in this guideline are for BP-lowering and lipid modification, a holistic approach to address clinical factors that contribute to CVD is necessary. This includes good glycaemic control in people with diabetes, good management of renal disease, and addressing other clinical risk factors which may contribute to CVD risk.

Newer glucose-lowering agents (e.g. SGLT2 inhibitors and GLP-1 analogues) have shown significant reductions in CVD death and all-cause mortality.¹⁴⁶-¹⁴⁸ SGLT2 inhibitors have additionally shown reductions in heart failure hospitalisations and progression of CKD, regardless of an individual’s diabetes status.¹⁴⁹

Manage according to risk category

In people without known CVD, the CVD risk category guides optimal management, including monitoring and reassessing risk (Table 1).

Table 1: Overview of CVD risk management according to risk category

1. Estimated probability of a cardiovascular event within the next 5 years, determined using the Aus CVD Risk Calculator.
2. 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.
3. Unless contraindicated or clinically inappropriate, and in discussion with the person on the benefits and harms of treatment. Encourage shared decision-making.

Practice points

• Risk factors that should be managed, regardless of Aus CVD Risk Calculator results include:
  • severe hyperlipidaemia (serum total cholesterol >7.5 mmol/L or LDL cholesterol ≥5 mmol/L)
  • very high blood pressure (systolic BP ≥160 mmHg; diastolic BP ≥100 mmHg).
  Pharmacological treatment of the above risk factors is recommended, even if the person is considered at overall low CVD risk.
• For people at intermediate or high risk, treat according to the general recommendations for those risk categories.

First Nations people

Practice points

• For First Nations people, assess CVD risk as part of an annual health review (or opportunistically).
• This recommendation is based on the higher incidence rates of CVD compared with non-Indigenous peoples, the earlier onset of risk factors such as diabetes and CKD, and the limited literature on population-specific risk transition to, and progression of, CVD.
• Although the decision to prescribe pharmacotherapy should be guided by CVD risk estimates, the presence of additional CVD risk factors and clinical indicators may warrant treatment regardless of CVD risk category.

Resources

1. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people - RACGP and National Aboriginal Community Controlled Health Organisation (NACCHO)

Approaches to addressing lifestyle risk factors

Where this guideline refers to certain modifiable factors as ‘lifestyle’ factors, this term is not intended to imply that these behaviours are necessarily an individual’s choice, but reflect the complex interplay of social, cultural, and environmental factors, which may be further influenced by clinical conditions. The use of the term ‘lifestyle’ does not attribute blame to a person.

Smoking cessation

General considerations

Smoking increases the risk of CVD and is the single leading cause of preventable mortality and morbidity in Australia.^150,151

Smoking is the most important modifiable determinant of CVD risk and therefore should be addressed at any level of CVD risk.

Successful smoking cessation reduces the risk of CVD. Simple advice from a health professional is a cost-effective intervention to help people quit smoking.

Similarly, the effectiveness of smoking cessation pharmacotherapies is well established. These medicines help people to quit by minimising withdrawal symptoms and reducing cravings.

For people who smoke, interventions can assist with both the emotional and behavioural aspects of dependence.

At the time of writing, e-cigarettes and vaping is an area of intense investigation and key findings are available in the Australian National University’s Summary Brief: Review of Global Evidence on the Health Effects of Electronic Cigarettes (see Resources).

Practice points

• Ask all people if they smoke and record in their clinical record.
• Use the Ask, Advise, Help (AAH) or RACGP 5As (ask, assess, advise, assist, arrange) models to support people who smoke to quit.
• For people who smoke, offer a referral to a multi-session behavioural intervention (e.g. Quitline referral) and TGA-approved pharmacotherapy if clinically appropriate. See resources.
• Quitting can be difficult and long-term cessation may require repeated attempts. Support people who smoke (including after relapse) with advice and help to access the evidence-based strategies described above.
• Encourage people who use e-cigarettes (whether the product contains nicotine or not) to quit.¹⁵⁰
• Reassure people who are anxious about gaining weight after quitting smoking, that the health benefits associated with smoking cessation are likely to far exceed the health risks of being overweight or obese. Consider referral to a relevant allied health professional (e.g. referral to an Accredited Practising Dietitian and/or an exercise physiologist).
• People with a mental health condition may need special support to quit smoking. See the RACGP smoking cessation guidelines¹⁵² for more information on how to support people with a mental health condition.

First Nations people

There have been significant reductions in tobacco use among First Nations people over the last decade.

Recent data shows that 33% of First Nations adults have never smoked, 39% smoke tobacco daily, 3% smoke less than daily and 25% are previous smokers. Whilst there have been significant reductions in tobacco use among First Nations people over the last decade, rates amongst this population remain high.¹⁵³,¹⁵⁴

Practice points

• There are a range of smoking cessation resources and programs tailored for First Nations people.
• Quitline is recommended for multi-session behavioural intervention because of their accessibility and because they use tailored protocols for specific groups, including for First Nations people through the ‘Aboriginal Quitline’ (see Resources).
• The resources and programs are culturally responsive and often developed in partnership with communities to meet the needs of First Nations people. Referral to these resources and programs should be prioritised.

Resources

1. Aboriginal Quitline - offers a smoking cessation service with First Nations counsellors and resources and supports specifically for First Nations people
2. Medicines to help Aboriginal and Torres Strait Islander people stop smoking: A guide for health workers - Department of Health and Aged Care
3. Australian Indigenous Alcohol and Other Drugs Knowledge Centre - Australian Indigenous HealthInfoNet
4. Heart risks resources for First Nations people - National Heart Foundation of Australia

Support for the recommendation

Clinical trial evidence has consistently demonstrated that the most effective way to quit smoking is a combination of behavioural interventions (smoking cessation counselling delivered over multiple sessions), and pharmacotherapies (varenicline,¹⁵⁵ nicotine replacement therapies^156,157 and bupropion).¹⁵⁵-¹⁵⁸

Nutrition

1. Low for CVD and moderate for stroke.

General considerations

Healthy eating patterns

Globally, there is a shift in research and guidelines to recognise that whole foods and healthy eating patterns, rather than individual nutrients, can better support nutritional status and counselling to improve overall eating patterns.^159,160

Based on common features across various diets and healthy eating patterns that are supported by evidence (as summarised below), a heart-healthy pattern of eating is:

• rich in wholegrains, fibre, and antioxidants
• low in salt and added sugars
• naturally low in saturated and trans fats
• rich in unsaturated fats (monounsaturated fatty acids, omega-3 and omega-6 polyunsaturated fatty acids).¹⁶¹

Advice for a heart-healthy eating pattern

1. Eat plenty of vegetables, fruit, and wholegrains.
2. Include a variety of healthy protein-rich foods from animal and/or plant sources (e.g. legumes such as chickpeas and lentils).
3. Choose unflavoured milk, yoghurt, and cheese.^*
4. Include foods that contain healthy fats and oils (e.g. olive oil, nuts and seeds, and animal sources such as fish).
5. Use herbs and spices to flavour foods instead of salt.
6. Avoid highly processed and discretionary (junk) food items.

* Milk, yoghurt and cheese are included in some, but not all, dietary patterns linked to better cardiovascular health outcomes, therefore can be included in, but are not defining features of a heart-healthy diet.¹⁶² Evidence suggests that dairy fat from cheese and yoghurt does not raise LDL-C in the same way that dairy fat from butter does, and that LDL-C response to dairy fat is higher for those with elevated LDL-C.¹⁶² Therefore, individuals with elevated cholesterol should opt for reduced fat varieties.¹⁶³

Dietary salt reduction

The World Health Organization (WHO) recommends an intake of less than 5g salt/day (approximately 2000 mg of sodium).¹⁶⁴ The present Australian average intake is in the order of 10g/day.

Salt intake can be reduced by:

• avoiding adding salt to food while cooking (e.g. using herbs and spices to flavour food instead)
• avoiding highly processed and discretionary (junk) foods as these often have a high salt content
• where available, buy products labelled as 'no added salt' or 'reduced salt' (e.g. canned vegetables or fish).

Reducing salt intake to recommended levels has no known harms.

DASH diet

The Dietary Approaches to Stop Hypertension (DASH) diet emphasises fruit, vegetables, fat-free or low-fat dairy products, wholegrains, nuts and legumes, and limits total and saturated fat, cholesterol, red and processed meats, confectionary, added sugars, and sugar-sweetened drinks.^163,165

Whilst DASH diets have been shown to lower BP, the direct effects of DASH diets on cardiovascular events or mortality are unknown due to a lack of clinical trials measuring these outcomes.

Mediterranean diet

Mediterranean diets are based on a high ratio of monounsaturated to saturated fats (e.g. using olive oil as main cooking ingredient, or high consumption of other foods high in monounsaturated fats).¹⁶⁶

Some Mediterranean diets also include:

• high intake of fruits, vegetables and legumes, wholegrains, cereals and fish
• moderate intake of milk and dairy products
• low intake of meat and meat products.¹⁶⁶

Whilst consuming wine is often associated with the Mediterranean diet, alcohol intake should be avoided or limited to minimise the health risks associated with consuming alcohol (see Alcohol reduction).

This eating pattern is not associated with any known harms.

Fish and fish oil

Current dietary guidelines recommend 2–3 serves per week of oily fish that is high in long-chain omega-3 fatty acids (omega-3), with one serve equal to 100 grams of cooked fish. This provides around 250–500mg of marine-sourced omega-3 (eicosapentaenoic [EPA] and docosahexaenoic acid [DHA]) per day.¹⁶⁷,¹⁶⁸

A variety of fish oil supplements derived from oily fish containing EPA and/or DHA are available without prescription in varying formulations and doses.

Overall, the certainty of the evidence that taking fish oil supplements has any substantial effect on cardiovascular mortality or risk is low. While there is some evidence that increasing intake of omega-3 fatty acids may reduce CHD events and mortality, the effect is small, and number needed to treat for additional beneficial outcome is high.^44,150

While taking fish oil supplements containing EPA and/or DHA may modestly reduce the risk of CVD,^169,170 it is unclear what the optimal formulation or dose is, or whether higher doses are more effective.

While increasing omega‐3 fatty acid intake may benefit people with hypertriglyceridaemia, it does not reduce LDL cholesterol.¹⁷¹

Omega-3 fatty acid supplementation and algae-based omega-3 supplements containing alpha-linolenic acid are alternatives for people who do not eat fish or seafood.

Fish oil supplements are generally well tolerated but some people experience minor adverse effects such as heartburn, gastrointestinal upset, or bad breath, especially at high doses. High-dose fish oil supplementation has also been associated with rash and atrial fibrillation, so may not be suitable for some people.¹⁷²

Practice points

• Apply the RACGP 5As model (ask, assess, advise, assist, arrange).
• Encourage healthy eating patterns based on fresh, wholefood meals, prepared with no added salt.
• Advise people to avoid highly processed discretionary (junk) foods as they are unhealthy and may displace core foods.
• Refer to an Accredited Practising Dietitian for personalised support, if needed.
• Encourage people to choose whole foods over supplements. For example, explain that although fish oil supplements are available, eating fish – in particular oily fish such as sardines, whitefish, salmon, and tuna – is recommended as part of a healthy, balanced eating pattern.¹⁷³
• The Heart Foundation’s position statement Heart Healthy Eating Patterns¹⁶¹ and online advice on healthy eating¹⁶⁰ incorporate principles of the DASH and Mediterranean diets (see Resources). ¹⁷⁴,¹⁷⁵
• The cost and limited availability of some fresh foods may make it harder for people living in regional and remote communities to adopt these eating patterns. Other social equity disadvantages may also impede access to recommended foods. Frozen and canned fruits and vegetables (with no added salt or sugars) are good nutritional alternatives to fresh fruits and vegetables when access to fresh foods is restricted.
• Access to fresh fish is variable across Australia. It is also expensive in some regions. Canned fish is an acceptable alternative.
• The choice of foods eaten as part of a healthy eating pattern should align with sociocultural preferences,¹⁷⁶ and the ingredients must be accessible and affordable.
• To achieve long-term benefits, any recommended eating pattern must be sustainable.¹⁷⁷

First Nations people

Practice points

Nutrition advice should be individualised and take a person-centred approach. It is important to contextualise nutrition advice within:

• the cultural relevance of any recommended healthy eating pattern
• the person’s primary language
• financial resources and capacity within families to purchase, store and follow recommended food preparation techniques
• food security and the availability, accessibility and affordability of healthy food, especially in remote settings.³⁵

When providing individualised advice, consider the appropriateness of supporting the uptake of First Nations traditional foods that have a highly beneficial nutritional composition.

The Menzies Remote Short-item Dietary Assessment Tool (MRSDAT) has been developed for First Nations women and young children (2-4 years).¹⁷⁸ It has also been validated for use with First Nations children aged 6–36 months.¹⁷⁹ Consider using this tool in preference to tools developed in non-Indigenous populations.

A number of comprehensive nutritional programs addressing the needs of First Nations people have shown promising results. Refer to local resources and supports.¹⁸⁰

Resources

Review availability and consider use of appropriate resources to promote good nutrition.

1. Nutrition resources - Australian Indigenous HealthInfoNet
2. Aboriginal and Torres Strait Islander guide to healthy eating - Department of Health and Aged Care
3. Cooking in the Pilbara - National Heart Foundation of Australia recipe book
4. Heart risks resources for First Nations people - National Heart Foundation of Australia

Support for the recommendations

Cohort and observational studies demonstrate that healthy eating patterns are associated with reduced CVD risk¹⁸¹,¹⁸² and cardiovascular mortality.¹⁸¹

RCTs in people with or without hypertension, and a wide range of baseline BP levels, found that the DASH diet results in clinically meaningful reductions in BP, compared with control diets, independent of energy intake restriction, with no evidence of harm.¹⁸³

One RCT in people at high risk of CVD found that Mediterranean diets reduced stroke risk by approximately 40%, compared with a low-fat diet.¹⁶⁶ Other RCTs provide moderate-quality evidence for small reductions in BP, compared with no or minimal dietary interventions, and for small beneficial effects on lipid profiles, compared with other diets.¹⁶⁶

Evidence from RCTs included in a systematic review indicates that reducing dietary salt intake results in decreased systolic and diastolic BP.¹⁸⁴

There is insufficient evidence from RCTs included in a Cochrane review and meta-analysis in adults with and without CVD (18 years or older living in North America, Europe, Australia and Asia) to ascertain the benefits of increased fish consumption on CVD risk.¹⁷¹ No differences were found between trials that compared dietary fish versus supplemental fish oil, however there were too few trials providing or advising consumption of whole fish to provide conclusive evidence.¹⁷³

The Cochrane review meta-analysis suggests there is little or no effect of increased long‐chain omega‐3 fatty acid intake on all-cause mortality, cardiovascular mortality, cardiovascular events, stroke or arrhythmias in either primary or secondary prevention compared with usual, lower or no intake of omega-3 fatty acids. Long‐chain omega‐3 fatty acid doses ranged from 0.5g to more than 5g per day.¹⁷¹

Physical activity

General considerations

Increasing physical activity above sedentary levels improves lipid and metabolic profiles.¹⁸⁵-¹⁸⁷

Even small reductions in blood pressure reduce the risk of CVD. A reduction of 1–5mmHg due to regular physical activity is likely to reduce the risk of CVD by approximately 4–22% in people with high blood pressure.¹⁸⁸-¹⁹¹

The World Health Organization’s evidence-based guideline on physical activity and sedentary behaviour¹⁹² states that, in adults, physical activity confers benefits for CVD mortality and incident hypertension. Measures of adiposity may also improve.

It also found that in adults, higher amounts of sedentary behaviour are associated with detrimental effects on the following CVD-related health outcomes: all-cause mortality, CVD mortality and incidence of CVD.¹⁹²

Although exercise-based cardiac rehabilitation is known to be effective in reducing the risk of cardiovascular mortality and MI in people with CHD,¹⁹³ there is insufficient evidence from RCTs to discern the direct effects of exercise programs specifically on cardiovascular morbidity and mortality in people without pre-existing CVD. Most clinical trials evaluating exercise programs have been short-term. It is therefore unclear how long they must be sustained to achieve long-term benefits.

Physical activity (including exercise programs), and limiting time spent being sedentary, are unlikely to cause significant harm.

Practice points

• Apply the RACGP 5As model (ask, assess, advise, assist, arrange).
• Ask about the person’s typical current daily level of physical activity and sedentary behaviour, and assess according to current guidelines.¹⁹⁴
• Advise people that increasing physical activity, including exercise programs, and limiting sedentary behaviours can achieve meaningful reductions in BP (even for people with hypertension), help maintain mobility, as well as improving lipid and metabolic disorders, mental health and quality of life.
• Encourage people to reduce the amount of time they are sedentary, and to be as physically active as possible throughout the day, every day of the week, if possible.^186,187 Refer to relevant physical activity guidelines (see Resources).
• Physical activity advice should be tailored to meet individual needs, accounting for factors including comorbidity and cultural values. Refer to relevant physical activity guidelines (see Resources).
• If an exercise or physical activity program is not suitable or available, explore how other forms of physical activity can be incorporated into their daily life as a sustainable alternative to formal exercise programs. Refer to relevant physical activity guidelines (see Resources).
• Cost and accessibility of supervised exercise programs might prevent some people from participating but there are many physical activity programs that do not require payment (e.g. Heart Foundation personal walking plans).

First Nations people

Practice points

• Advice on physical activity should be individualised and take a person-centred approach.
• It is important to contextualise advice within the cultural relevance of any recommended physical activity or exercise program, the person’s primary language and their capacity to engage with recommended activities.¹⁹⁵
• A number of programs supporting the physical activity of First Nations people have shown promising results. Practitioners should familiarise themselves with local resources for appropriate supports.

Resources

1. Heart health resources for First Nations people - National Heart Foundation of Australia

Support for the recommendation

A systematic review of RCTs found that participating in low- to moderate-intensity exercise training programs (resistance, aerobic or combined training) reduced BP by 1–5mmHg in adults with or without hypertension, compared with no exercise training intervention.¹⁸⁸

Healthy weight

General considerations

Weight-reducing diets can contribute to achieving a healthy weight and reducing BP,¹⁹⁶ however, reductions in cardiovascular morbidity and mortality related to weight loss have not been established because very few high-quality RCTs evaluating these diets measured these outcomes.

It is unclear whether BP reductions achieved by following a weight-reducing diet within a structured program are sustained long term. However, even small reductions in BP can reduce the risk of CVD.

In adults who are living with obesity or overweight, achieving weight loss is associated with statistically significant changes in serum lipids.¹⁹⁷

Practice points

The following principles apply when encouraging people to achieve a healthy weight:

• Consider referral to appropriate allied health professionals, such as an Accredited Practising Dietitian, for support.
• Apply the RACGP 5As framework (ask, assess, advise, assist, arrange).
• Consider that communication and terminology relating to weight is a highly sensitive topic (see Resources).
• Achieving a healthy weight may be an unachievable target for many, leading to demotivation. Instead, aiming for a healthier weight may be a more achievable approach.
• BMI and waist circumference can both be useful tools to identify people who are living with obesity or overweight and at subsequent risk of developing CVD. Record measurements as part of the person’s clinical history.
• Advise people that achieving a healthy – or healthier – weight could help reduce blood pressure and provide metabolic, musculoskeletal and other health benefits.
• Support people to achieve a healthy weight and optimise their health through a healthy eating pattern. Consider referral to an Accredited Practising Dietitian.
• Support the person to develop sustainable healthy eating pattern in order to achieve and maintain a healthy weight.
• Advise the person that achieving a healthy weight, combined with increased physical activity and reduced sedentary behaviours, can improve overall health and reduce CVD risk. The most effective strategies are comprehensive programs that include reduced energy intake, increased physical activity, and support for behavioural change for a duration of at least 6–12 months, followed by long-term support to maintain a healthy weight.¹⁹⁸
• Consider that sociocultural preferences are likely to influence adherence to a healthy eating pattern
• Acknowledge that access to foods that are affordable, nutritious and socioculturally appropriate may be limited for people experiencing socioeconomic disadvantage and for those living in regional or remote areas.
• Inform the person that many organisations in Australia support people to achieve a healthy weight through healthy eating patterns and exercise. However, some may not be accessible to everyone due to cost or availability.
• Advise against following extreme eating patterns that do not follow healthy eating pattern guidance (see Nutrition section), and programs that focus on short-term weight reduction, as these have poor long-term outcomes.
• Consider referral for bariatric surgery for people living with severe obesity to reduce CVD and diabetes risk.

First Nations people

First Nations people are more likely to demonstrate central adiposity than non-Indigenous people for a given body weight or body mass index (BMI).¹⁹⁹,²⁰⁰ There is also significant variation across First Nations communities and between men and women.²⁰¹

Waist circumference has been suggested as a better predictor of CVD than BMI in the First Nations population, however, it is measured to a lower accuracy in clinical practice when compared to research studies.²⁰²,²⁰³

There is evidence that the appropriate BMI range for First Nations people is lower than for non-Indigenous Australians.¹⁹⁹,²⁰⁴

Practice points

In addition to the practice points above, consider the following:

• BMI and waist circumference can both be useful tools to identify people who are overweight and those with central adiposity who are at subsequent risk of developing CVD.²⁰³
• Follow clinical practice guidelines when measuring BMI and waist circumference.
• Record measurements as part of the person’s ongoing clinical history.
• Weight change programs addressing the needs of First Nations people have shown promising results. Practitioners should familiarise themselves with local resources for appropriate supports.^205,206

Resources

1. First Nations people - National Heart Foundation of Australia

Support for the recommendation

• A systematic review and meta-analysis of RCTs in people with hypertension (systolic BP >140mmHg, diastolic BP >90mmHg, or both) found that weight‐reducing diets of 6–36 months’ duration resulted in a meaningful reduction in body weight (mean 4kg), and reduced BP (mean 3–5mmHg), compared with no weight-reducing diet.¹⁹⁶
• A systematic review and meta-analysis of 34 RCTs in people with obesity found that weight loss diets (with or without exercise) significantly reduced all-cause mortality, in people with diabetes or known CHD.²⁰⁷

Alcohol reduction

General considerations

Moderate or high alcohol consumption increases the risks of hypertension, CHD, and stroke.²⁰⁸,²⁰⁹

The risk of atrial fibrillation (AF) also increases in proportion to levels of long-term alcohol consumption.^208,209

Reducing alcohol intake lowers blood pressure in a dose-dependent manner among people who drink more than 2 standard drinks per day.²¹⁰ People who succeed in reducing their blood pressure by drinking less alcohol are therefore likely to reduce their CVD risk.

For people who consume alcohol regularly, reducing consumption is also likely to reduce the risk of other health problems, in addition to reducing blood pressure.

Practice points

When supporting people who drink alcohol to reduce their intake:

• Apply the RACGP 5As model (ask, assess, advise, assist, arrange).
• Advise them to reduce their consumption to help reduce the health risks associated with drinking alcohol.²¹¹
• Emphasise that there is no safe level of alcohol consumption for anyone, and that not drinking at all is the safest option, particularly for women who are pregnant, attempting to become pregnant, or breastfeeding.²¹¹ Women who are pregnant or attempting to become pregnant should be advised not to drink any alcohol.
• Advise people that they should not drink more than 10 standard drinks a week and no more than 4 standard drinks on any one day, to reduce the health risks from drinking alcohol.²¹¹
• Inform them that a ‘standard drink’ is a way of measuring the amount of alcohol in the drink. One standard drink contains 10 grams of pure alcohol. A particular drink may contain more or less alcohol than one standard drink. Advise people to read the label on their drink to find out how many standard drinks it contains.²¹²
• Encourage at least 2 alcohol-free days every week.
• Explain that a small reduction in blood pressure is likely to have a meaningful effect on heart health.
• People with alcohol dependence or an alcohol use disorder will require specialist help to stop or control their drinking. For these people, ceasing or restricting alcohol consumption has benefits beyond CVD risk reduction.

First Nations people

A greater proportion of the First Nations population abstain from alcohol consumption compared with the non-Indigenous population.

Among those who do drink alcohol, a greater proportion exceed lifetime risk guidelines.²¹³

Alcohol consumption may be connected to the historical and current socio-political context for First Nations people and the resulting disadvantage, discrimination and intergenerational trauma.^214,215

Practice points

There is a range of culturally responsive resources to support reduced alcohol consumption tailored for First Nations people. Referral to these resources should be prioritised.

Resources

1. Resources, publications and programs - Australian Indigenous Alcohol and Other Drugs Knowledge Centre
2. Heart risks resources for First Nations people- National Heart Foundation of Australia
3. Alcohol - Strong Spirit Strong Mind
4. Talking about alcohol: A brief intervention tool for health professionals - Australian Government
   

Support for the recommendation

A systematic review and meta-analysis found that reducing alcohol intake was associated with short-term blood pressure reductions in people with or without hypertension who drank more than 2 standard drinks per day.²¹⁰

People who drank 6 or more standard drinks per day, who halved their alcohol consumption, reduced their systolic blood pressure by about 5.5mmHg and diastolic blood pressure by about 4mmHg.²¹⁰

Pharmacotherapy

Managing risk according to treatment thresholds

Based on current available evidence, the benefits of blood pressure-lowering (BP-lowering) and lipid-modifying treatment outweigh the risk of harm in people whose estimated risk of a cardiovascular event within the next 5 years is high (10% or greater).

Benefits may also outweigh the risk of harms in people at intermediate CVD risk (5 to <10%).

In people whose 5-year CVD risk is low (less than 5%), preventive pharmacotherapy is not routinely recommended. Instead, CVD risk should be managed according to the clinical context and in collaboration with the person.

1. 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.
2. The literature review found no randomised trials comparing outcomes according to different risk thresholds. Therefore, a linked evidence approach was used.

General considerations

There is strong evidence for the efficacy of BP-lowering and lipid-modifying treatments in preventing cardiovascular events. However, there is limited evidence to determine the optimal CVD risk threshold for initiating treatment.

There is also a lack of Australian data and no evidence on optimal risk treatment thresholds in First Nations people.

This guideline recommends that BP-lowering and/or lipid-modifying treatment should be considered for people with intermediate CVD risk (5% to <10%) as part of shared decision-making with their health professional. This reflects the fact that CVD risk is a continuum, and that treatment should be guided by CVD risk, individual preference and other clinical factors.

Lipid-modifying and BP-lowering medicines are cost-effective, even at lower levels of risk.²¹⁶

A systematic review of the published, peer reviewed literature relating to different risk treatment thresholds for primary prevention of CVD was conducted (see Appendix 4).

The Aus CVD Risk Calculator and treatment initiation thresholds

All recommendations in this guideline relate to CVD risk level assessed using the Aus CVD Risk Calculator, which includes adjustment due to any reclassification factors. The algorithm underpinning the calculator is based on the New Zealand PREDICT-1° equation, calibrated to relevant Australian populations.

Treatment threshold recommendations in the Guidelines for the management of absolute cardiovascular disease risk (2012)⁵ were based on the Framingham risk equation, which was not calibrated for the Australian population. The Framingham equation is now known to overestimate CVD risk in the general population.

The 2012 guidelines recommended initiating BP-lowering and lipid-modifying therapy in people with an estimated CVD risk >15%. For people with estimated CVD risk 10% to 15%, initial behavioural factor modification was recommended, with pharmacotherapy added if CVD risk was not sufficiently reduced.

Although this updated guideline recommends initiating treatment in people at CVD risk ≥10%, this risk level for initiating treatment is likely to be comparable to the previously recommended >15% CVD risk level calculated using the Framingham equation.

Initiating treatment at lower CVD risk thresholds

It is estimated that in people with estimated CVD risk of >10%, one cardiovascular event would be prevented for every 35 people receiving BP-lowering treatment for 5 years. At a risk threshold of >15%, this number of people reduced to 30. The number of people needed to treat in order to prevent one cardiovascular event become less favourable at lower levels of risk e.g. 5-year risk <5%. (See Appendix 4).

A modelling study found that people were more worried about experiencing moderate or severe stroke or MI (the risks of which are reduced by BP-lowering and lipid-modifying medicines) than developing potential adverse effects such as myopathy or diabetes (see Appendix 4). This finding suggests that lower treatment thresholds, which prioritise the benefits of statins in reducing major cardiovascular events, would be acceptable to most people (see Appendix 4).

Potential disadvantages of initiating treatment at lower risk thresholds include:

• people taking unnecessary medicines
• increased costs to people and the health system
• adverse effects of medicines.^216-218

Elevated single CVD risk factors

Although this guideline recommends initiating pharmacotherapy based on estimated 5-year CVD risk levels, some clinical situations may warrant initiation of therapy based on individual risk factors. Very high blood pressure (e.g. blood pressure above 160/100mmHg) or very high cholesterol (e.g. total cholesterol above 7.5mmol/L) warrant initiation of blood pressure-lowering and lipid-modifying pharmacotherapy, respectively. Refer to specific hypertension and lipid guidelines for management guidance.

Blood pressure-lowering treatment

1. 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.

General considerations

Reducing blood pressure reduces CVD risk, in a wide range of age groups, irrespective of baseline blood pressure. However, the higher the initial CVD risk, the greater the benefit.

There is strong evidence for the beneficial effects of BP-lowering and lipid-modifying treatment in people at intermediate or high risk of CVD, and these benefits extend into older age.^219,220 Reductions in major cardiovascular events were larger in older people irrespective of baseline blood pressure.²²⁰

Studies assessing the benefit of commencing BP-lowering and statin medicines at a variety of ages were reviewed to inform this recommendation.

Reducing blood pressure further may achieve greater benefits,^220,221 but optimal reduction targets remain unclear.

Practice points

• For specific recommendations about choosing BP-lowering medicines and blood pressure targets, refer to national clinical practice guidelines for managing hypertension.⁸⁴
• Prescribe a BP-lowering medicine if clinically appropriate, affordable and acceptable to the person.
• Explain that many people will benefit from reducing their blood pressure, and that reducing blood pressure reduces the risk of heart attacks and stroke regardless of starting blood pressure.²²²
• In older people, monitor for medicine-related adverse effects such as orthostatic hypotension or syncope.
• Combine BP-lowering with other risk reduction strategies, including exercise, healthy eating patterns, and achieving a healthy weight, to achieve the target.
• Advise and support people to increase physical activity, reduce sedentary behaviours, quit smoking (if relevant), adopt healthy eating patterns, achieve a healthy weight, and where needed, reduce blood pressure.
• Although treating to a specific blood pressure target may promote adherence to treatment, consider setting a target based on individual CVD risk factors, in collaboration with the person.
• Encourage adherence by giving practical advice such as making medicines part of a daily routine, setting alarms or reminders, or providing repeated education at consultations.
• The greatest blood pressure reductions are achieved with the initial dose of a BP-lowering agent. However, adding one or more other agents from different pharmacological classes separately or as combination preparations is usually required.

First Nations people

First Nations people of any age are eligible for Closing the Gap PBS Co-payment Program to subsidise access to medicines including BP-lowering medicines.

Refer to the PBS factsheet on the Closing the Gap (CTG) - PBS Co-payment Program for information on access to the scheme.

Support for the recommendations

A large meta-analysis of 51 RCTs in 358,707 people aged 21–105 years (median 65 years) compared BP-lowering medicines with placebo or other classes of BP-lowering medicines. It found that BP-lowering medicines significantly reduced major cardiovascular events (stroke, ischaemic heart disease, heart failure and death) in all age groups, regardless of baseline blood pressure level.²²⁰

For every 5mmHg reduction in systolic blood pressure, the risk was reduced by approximately 18% in people younger than 55 years, and by 9% in people aged 55 to 84 years.²²⁰ Similar benefits were seen for diastolic blood pressure reductions of 3mmHg.²²⁰

Lipid-modifying treatment

1. 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.

General considerations

Reducing plasma concentrations of lipids (total cholesterol, low-density lipoprotein [LDL] cholesterol and triglycerides) reduces CVD risk, irrespective of baseline lipid levels.

The higher the initial CVD risk, the greater the expected reductions in risk. For people with intermediate or high risk of cardiovascular events, any reduction in blood lipid levels reduces this risk.

A large body of high-quality clinical trial evidence indicates that lipid-lowering treatment reduces the risk of cardiovascular events and mortality. Statin therapy effectively reduces LDL cholesterol levels equally in men and women.²²³

It is uncertain whether treating to a specific, lower, plasma lipid target in primary prevention, results in lower cardiovascular morbidity or mortality than a modest target or no specific target.

The intensity of lipid-modifying treatment must be balanced with the prospect of long-term adherence.

Practice points

• For people with intermediate or high risk of CVD, explain that:
  • different types of fat (e.g. types of cholesterol) have important functions in the body, and that the right proportion of each type in the blood is essential for good health
  • reducing the amount of some types of fat in the blood will help lower their risk of heart attacks and stroke
  • achieving any degree of reduction in LDL cholesterol level is of benefit, compared with no LDL cholesterol reduction.
• Identify people with familial hypercholesterolaemia for closer monitoring and more intensive risk management. Refer to specific guidelines.²²⁴
• Encourage and support healthy behaviours – including increasing physical activity, reducing sedentary time, quitting smoking (if relevant), following a healthy eating pattern and achieving a healthy weight – and prescribe medicines where clinically indicated, to improve lipid profile.
• Statins are an appropriate first line lipid-modifying therapy.
• Refer to relevant clinical practice guidelines for specific recommendations about choosing lipid-modifying agents and targets.⁸⁸,²²⁴,²²⁵
• Encourage adherence by giving people practical advice (such as making medicines part of their daily routine, setting alarms or reminders) and providing regular education at consultations.
• For people unable to tolerate a prescribed statin, consider a lower dose, alternate day dosing, or switching to an alternative statin or non-statin therapy. Statin intolerance is often overestimated (true prevalence 8–10%).²²⁶

First Nations people

First Nations people are more likely to have a normal total cholesterol level but with high triglycerides, low high-density lipoprotein (HDL) cholesterol, and small dense LDL particles compared with non-Indigenous Australians.²²⁷

This lipid profile has been associated with increased CVD risk.

First Nations people of any age are eligible for Closing the Gap PBS Co-payment Program to subsidise access to medicines including lipid-modifying medicines.

Refer to the PBS factsheet on the Closing the Gap (CTG) - PBS Co-payment Program for information on access to the scheme.

Support for the recommendations

A meta-analysis of clinical trials of statins found that, compared with control, for every 1.0mmol/L reduction in LDL cholesterol, the overall risk of major coronary events, coronary revascularisation, and stroke was reduced (women: 16%; men 22% reduction).²²³ Reductions in risk of these outcomes were also similar in men and women with less than 10% predicted 5-year risk.²²³

A large meta-analysis of 11 RCTs in people with or without existing CVD, compared intensive (LDL cholesterol <1.8mmol/L) with less intensive lipid-lowering treatments (statin monotherapy or combinations of statins with ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors). It found that more intensive treatment was associated with a reduction in all outcomes (reductions for cardiovascular mortality: 10%; MI: 20%; cerebrovascular events: 19%; major adverse cardiovascular events: 11%; revascularisation: 17%; ischaemic stroke: 23%).²²⁸ The reduction in risk of ischaemic heart disease was independent of baseline LDL cholesterol or drug regimen.²²⁸ Three of the trials were conducted in people without pre-existing CVD; the quality of evidence for most outcomes in this population was very low.

Combination therapies

Population-wide fixed-dose combination treatments (ie. ‘polypills’) in unscreened adults are not recommended because the potential benefits have not been shown to outweigh the harms in those at lower CVD risk.

A meta-analysis of RCTs in people without diagnosed atherosclerotic CVD found that, compared with placebo or non-pharmacological intervention, fixed-dose combination treatments (statin, angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist, and a thiazide diuretic, with or without a beta1 -blocker or aspirin) reduced composite cardiovascular events by 38% (cardiovascular death, MI, stroke, revascularisation, angina, or heart failure) and cardiovascular death by 35%, irrespective of blood pressure or cholesterol levels.²²⁹

Risk reduction was greater in people taking combinations containing aspirin, compared with non-aspirin combinations, but the rate of gastrointestinal bleeding was higher in people taking aspirin.²²⁹ It is unclear if the additional benefits of aspirin outweigh the potential harms.

Single-pill combinations can aid adherence to preventative treatment. Consider prescribing combination treatment if available, clinically appropriate, affordable and acceptable to the person.²³⁰,²³¹