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Overview

Overview

Cardiovascular disease (CVD) risk assessment and management in people without known CVD involves: identifying the appropriate people to be assessed; using the Australian cardiovascular disease risk calculator (Aus CVD Risk Calculator) to estimate their risk; identifying their risk category (Table 1); communicating their risk to them; and managing their risk.

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

Risk category Estimated 
5‑year CVD riska		 Management Reassessment interval
High 
≥10%

Encourage, support and advise a healthy lifestyle.b

Prescribe blood pressure-lowering and 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.

  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.

Introduction

Cardiovascular disease (CVD) is responsible for significant morbidity and premature mortality in Australia. Ischaemic heart disease was the leading cause of death in 2020 and cerebrovascular disease was the third most common cause of death.3 CVD places a significant burden on the Australian healthcare system.

An individual’s risk of developing CVD depends on the combined effect of multiple risk factors. Risk assessment, therefore, remains fundamental to the primary prevention of CVD. It encourages early CVD risk factor modification, helps target pharmacotherapy to those who will benefit most, and informs clinical decision-making.

This guideline replaces Guidelines for the management of absolute cardiovascular disease risk (2012), incorporating a new risk calculator and updated evidence-based recommendations on assessing and managing CVD risk to reduce cardiovascular events.

Although CVD risk generally increases with age, the underlying pathology of atherosclerosis begins earlier in life and develops over many years.4 This guideline recommends targeted CVD risk assessment in age groups where the greatest gains for risk reduction can be achieved.

Managing CVD risk effectively involves communicating risk to the person in a way that they can clearly understand, and collaborating with them to choose and implement strategies to reduce their risk. Communication and raising awareness about CVD risk should commence well before any formal assessment is conducted. Discussion of modifiable lifestyle* factors, and the importance they play in CVD risk reduction, can be woven into consultations throughout life and form the basis of ongoing education.

Specific recommendations, resources and practice points for First Nations people have been embedded throughout the guideline. These specific considerations recognise differential outcomes in health that have resulted from dispossession, discrimination, disadvantage and disempowerment. First Nations people is used throughout the guideline to refer to Aboriginal and Torres Strait Islander peoples on the advice of consultation.

Purpose

This guideline provides recommendations and advice for assessing and managing CVD risk in Australia. The guideline includes:

  • recommendations for when and how to assess CVD risk
  • guidance and tools for using the new Aus CVD Risk Calculator
  • practical advice on how to apply the recommendations
  • tools to support communicating CVD risk
  • recommendations on how to manage CVD risk
  • a summary of the available evidence supporting the recommended approaches to risk assessment and management, together with the rationale for how available evidence has been interpreted for the Australian setting
  • specific recommendations, resources and practice points for assessing and managing CVD risk in First Nations people.

Scope

This guideline primarily covers atherosclerotic cardiovascular disease. The term ‘cardiovascular disease’ used in this guideline refers to the following conditions, which reflect outcomes predicted by the Aus CVD Risk Calculator:

  • myocardial infarction (MI)
  • angina
  • other coronary heart disease (CHD)
  • stroke
  • transient ischaemic attack
  • peripheral vascular disease
  • congestive heart failure
  • other ischaemic CVD-related conditions.

This guideline makes recommendations for:

  • assessing CVD risk in adults without known CVD
  • communicating CVD risk
  • managing CVD risk with lifestyle modifications and pharmacotherapy.

This guideline does not include detailed guidance for managing related clinical conditions such as hypertension and lipid disorders. Health professionals should refer to existing guidance, where available in these circumstances.

Intended Audience

This guideline is intended for use by general practitioners, First Nations health workers and practitioners, nurses and nurse practitioners, allied health professionals, other primary care health professionals and physicians who support the primary prevention of CVD.

It is also intended to provide health system policy makers with the best available evidence as a basis for developing population health policy.

Summary of recommendations

Recommendation
Strengtha Certainity of evidencea

Approach to assessing CVD risk

Age ranges for assessing CVD risk

For all people without known CVD, assess CVD risk from age 45 to 79 years.

CONDITIONAL
b

For people with diabetes without known CVD, assess CVD risk from age 35 to 79 years.

CONDITIONAL
b

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
Identify people at clinically determined high risk

Assess CVD risk as high for people with moderate-to-severe chronic kidney disease meeting any of these criteria:

  • people with sustained eGFR <45mL/min/1.73m2, or
  • men with persistent uACR >25mg/mmol, or
  • women with persistent uACR >35mg/mmol.
CONSENSUS

Assess CVD risk as high for people with a confirmed diagnosis of familial hypercholesterolaemia.

CONSENSUS
CVD risk assessment frequency and intervals using the Australian cardiovascular disease risk calculator

Intervals between reassessment of CVD risk using the Australian cardiovascular disease risk calculator should be determined from the most recent estimated risk level.

CONDITIONAL
MODERATE

For people receiving pharmacological treatment to manage CVD risk, including those previously assessed as being at high risk (≥10%) of a cardiovascular event within 5 years, formal reassessment of CVD risk is not generally recommended, and management should be guided by the clinical context.

CONDITIONAL
VERY LOW

In people with an intermediate risk (5% to <10%) of a cardiovascular event within 5 years who are not receiving pharmacological treatment to reduce CVD risk, reassess after 2 years.

Reassess earlier if any of the following apply:

  • the most recent risk assessment was close to the threshold for high risk (≥10%)
  • risk factors worsen
  • new CVD risk factors are identified.
CONDITIONAL
VERY LOW

In people with a low risk (<5%) of a cardiovascular event within 5 years who are not receiving pharmacological treatment to reduce CVD risk, reassess after 5 years. 

Reassess earlier if any of the following apply:

  • the last risk assessment was close to the threshold for intermediate risk (5% to <10%)
  • risk factors worsen
  • new CVD risk factors are identified.
CONDITIONAL
LOW

For First Nations people, reassess every year as part of an annual health check (or opportunistically), or at least every 2 years.

CONSENSUS

Consider reclassification factors

Ethnicity

For First Nations people, consider reclassifying estimated CVD risk to a higher risk category after assessing the person’s clinical, psychological and socioeconomic circumstances, and community CVD prevalence.

CONDITIONAL
MODERATE

In people whose estimated CVD risk is close to the threshold for a higher risk category, consider reclassifying estimated CVD risk to a higher risk category for the following groups:

  • Māori people
  • Pacific Islander people
  • people of South Asian ethnicity (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian ethnicities).
CONDITIONAL
MODERATE

For people whose estimated CVD risk is close to the threshold for a lower risk category, consider reclassifying estimated CVD risk to a lower risk category for people of East Asian ethnicity (Chinese, Japanese, Korean, Taiwanese, or Mongolian ethnicities).

CONDITIONAL
MODERATE
Family history of premature CVD

For people with a family history of premature CVD, consider reclassifying estimated CVD risk to a higher risk category, particularly if calculated risk is close to a higher risk threshold.c

CONDITIONAL
MODERATE
Chronic kidney disease

People with moderate-to-severe chronic kidney disease, defined as sustained eGFR <45mL/min/1.73m2 or a persistent uACR >25mg/mmol (men), or >35mg/mmol (women), are at clinically determined high risk and the Australian cardiovascular disease risk calculator should not be used.

Manage as high CVD risk
CONSENSUS

For people who do not have diabetesd with sustained eGFR 45–59mL/min/1.73m2 and/or persistent uACR 2.5–25mg/mmol (men) or 3.5–35mg/mmol (women), strongly consider reclassifying estimated CVD risk to a higher risk category, particularly if calculated risk is close to a threshold.

STRONG
HIGH
Severe mental illness

For people living with severe mental illness, consider reclassifying estimated CVD risk to a higher risk category, particularly if calculated risk is close to a higher risk threshold.e

CONDITIONAL
MODERATE
Coronary artery calcium score

Coronary artery calcium (CAC) score is not recommended for generalised population screening for CVD risk.

STRONG
MODERATE

Do not consider measuring CAC if:

  • the person has a history of myocardial infarction or revascularisation, or known coronary heart disease
  • the person is already known to be at high CVD risk.

Treatment to reduce risk is indicated in these people, regardless of the CAC result.

CONDITIONAL
MODERATE

When assessing CVD risk, reclassifying risk level due to CAC score can be considered when treatment decisions are uncertain, e.g.:

  • when risk of cardiovascular events is assessed as low or intermediate using the Australian cardiovascular disease risk calculator and other risk concerns are present that are not accounted for by the calculator
  • when further information is required to inform discussions between practitioner and the person on whether to modify therapy.
CONDITIONAL
MODERATE
Other risk considerations

The ankle-brachial index should not be measured as part of a CVD risk assessment as it provides very little discrimination value beyond that of traditional CVD risk calculators.
CONDITIONAL
MODERATE

The high-sensitivity C-reactive protein test should not be routinely performed as part of a CVD risk assessment as it provides very little discrimination value beyond that of traditional CVD risk calculators.

CONDITIONAL
MODERATE

Do not reclassify the estimated CVD risk solely due to the presence of rheumatoid arthritis.

CONDITIONAL
MODERATE
Communicate risk

Use a relevant decision aid to support effective risk communication and enable informed decisions about reducing CVD risk.

STRONG
MODERATE

Combine risk communication tools with behavioural strategies (e.g. motivational interviewing, personalised goal setting and health coaching), repeated over time, to reduce overall CVD risk.

CONDITIONAL
LOW

Communicate CVD risk using a variety of formats (e.g. percentages, 100-person charts) to enable people with varying health literacy needs and learning styles to understand their risk.

CONSENSUS

Manage CVD risk - Lifestylef modification

Smoking cessation

Encourage, support and advise people who smoke to quit, and refer them to a behavioural intervention (such as a smoking cessation counselling program) combined with a TGA-approved pharmacotherapy, where clinically indicated.

STRONG
MODERATE
Nutrition

Advise people to follow a healthy eating pattern that is low in saturated and trans fats, and incorporates:

  • plenty of vegetables, fruit, and wholegrains
  • a variety of healthy protein-rich foods from animal and/or plant sources
  • unflavoured milk, yoghurt and cheese
  • foods that contain healthy fats and oils (e.g. olive oil, nuts and seeds, and fish).
CONSENSUS

Consider recommending restriction of salt intake to reduce blood pressure.

CONDITIONAL
MODERATE

Consider recommending the Dietary Approaches to Stop Hypertension (DASH) diet to reduce blood pressure.

CONDITIONAL
MODERATE

Consider recommending a Mediterranean-style diet to reduce risk of CVD or stroke.

CONDITIONAL
LOW/MODERATEg

Recommend regular consumption of oily fish to reduce risk of coronary heart disease (CHD) and death due to CHD.

STRONG
LOW
Physical activity

Encourage, support and advise people to do regular sustainable physical activity, such as exercise programs, to reduce their risk of CVD.

CONDITIONAL
LOW
Healthy weight

Encourage, support and advise people to achieve and maintain a healthy weight.

CONSENSUS
Alcohol reduction

Encourage, support and advise people who consume alcohol to reduce their consumption, where necessary, in line with national guidelines, to reduce health risks from drinking alcohol.

CONDITIONAL
LOW

Manage CVD risk - Pharmacotherapy

Managing risk according to treatment thresholds

For people at high CVD risk (estimated 5-year risk ≥10% determined using the Australian cardiovascular disease risk calculator), encourage, support and advise a healthy lifestyle.f After discussing the benefits and harms of treatment, prescribe blood pressure-lowering and lipid-modifying pharmacotherapy, unless contraindicated or clinically inappropriate.

CONDITIONAL
h

For people at intermediate CVD risk (estimated 5-year risk 5% to <10% determined using the Australian cardiovascular disease risk calculator), encourage, support and advise a healthy lifestyle.f

After discussing the benefits and harms of treatment, consider blood pressure-lowering and lipid-modifying pharmacotherapy, unless contraindicated or clinically inappropriate.

CONDITIONAL
h

For people at low CVD risk (estimated 5-year risk <5% determined using the Australian cardiovascular disease risk calculator), encourage, support and advise a healthy lifestyle.f

Pharmacological treatment is not routinely recommended.

CONDITIONAL
h

Some clinical situations may warrant initiation of pharmacotherapy based on individual risk factors. Very high blood pressure (i.e. blood pressure above 160/100 mmHg) or very high cholesterol (ie. total cholesterol above 7.5 mmol/L) warrant initiation of blood pressure-lowering and lipid-modifying pharmacotherapy respectively. Refer to specific hypertension and lipid guidelines for management guidance.

CONSENSUS
Blood pressure-lowering treatment

For people at high risk of CVD (estimated 5-year risk ≥10% determined using the Australian cardiovascular disease risk calculator), prescribe blood pressure-lowering medicines to reduce CVD risk, unless contraindicated or clinically inappropriate.

Explain the potential benefits and harms of treatment to the person and encourage shared decision-making.

Encourage, support and advise a healthy lifestylef

STRONG
MODERATE

For people at intermediate risk of CVD (estimated 5-year risk 5% to <10% determined using the Australian cardiovascular disease risk calculator), consider prescribing blood pressure-lowering medicines to reduce CVD risk, unless contraindicated or clinically inappropriate.

Explain the potential benefits and harms of treatment to the person and encourage shared decision-making.

Encourage, support and advise a healthy lifestylef

STRONG
MODERATE
Lipid-modifying treatment

For people at high risk of CVD (estimated 5-year risk ≥10% determined using the Australian cardiovascular disease risk calculator), prescribe lipid-modifying medicines to reduce CVD risk, unless contraindicated or clinically inappropriate.

Explain the potential benefits and harms of treatment to the person and encourage shared decision-making.

Encourage, support and advise a healthy lifestylef

STRONG
MODERATE

For people at intermediate risk of CVD (estimated 5-year risk 5% to <10% determined using the Australian cardiovascular disease risk calculator), consider prescribing lipid-modifying medicines to reduce CVD risk, unless contraindicated or clinically inappropriate.

Explain the potential benefits and harms of treatment to the person and encourage shared decision-making.

Encourage, support and advise a healthy lifestylef

STRONG
MODERATE
  1. See Table 2: GRADE definitions for strength and certainty of evidence.
  2. Due to a lack of studies specifically addressing starting age, a linked evidence approach was used.
  3. Family history of premature CVD: coronary heart disease or stroke in a first-degree female relative aged <65 years or a first-degree male relative aged <55 years.
  4. For people with diabetes, eGFR and uACR are included in the Australian cardiovascular disease risk calculator.1,2 Suitable data were not available to include eGFR and uACR in the calculation for people without diabetes.
  5. Severe mental illness: 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
  6. 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.
  7. Low for cardiovascular disease and moderate for stroke.
  8. The literature review found no randomised trials comparing outcomes according to different risk thresholds. Therefore, a linked evidence approach was used to answer proxy PICO questions (see Evidence Synthesis to Support the Development of the Guidelines for Absolute Cardiovascular Disease Risk).

Figure 1: Overview of cardiovascular disease (CVD) risk assessment and management

AF: atrial fibrillation; BMI: body mass index; BP: blood pressure; CAC: coronary artery calcium; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; FH: familial hypercholesterolaemia; HbA1c: haemoglobin A1c; HDL-C: high-density lipoprotein cholesterol; TC: total cholesterol; uACR: urine albumin-to-creatinine ratio.  Family history: 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: 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

*  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.