CVD Risk Assessment
Definition:
Cardiovascular disease (CVD) encompasses various conditions affecting the heart and blood vessels, including coronary artery disease, heart failure, and stroke. Risk assessment for CVD is essential to identify individuals at high risk and enable early intervention to reduce morbidity and mortality associated with these conditions.
Aetiology/Causes:
Key risk factors for CVD include:
Hypertension: Chronic high blood pressure is a major contributor to heart disease.
Dyslipidaemia: High cholesterol (especially LDL) and low HDL cholesterol levels increase the risk of atherosclerosis.
Smoking: A leading risk factor for atherosclerosis and CVD.
Diabetes: Increases the risk of both heart disease and stroke.
Family history: First-degree relatives with premature CVD (before age 55 in men, 65 in women) significantly increase an individual's risk.
Obesity: Excess weight contributes to diabetes, hypertension, and high cholesterol.
Physical inactivity: Lack of exercise is linked to a higher risk of heart disease.
Pathophysiology:
CVD develops from a combination of environmental, lifestyle, and genetic factors that contribute to the formation of plaques in the arteries (atherosclerosis). These plaques can restrict blood flow, leading to conditions such as heart attack, stroke, and peripheral artery disease. Chronic conditions like diabetes, hypertension, and dyslipidaemia contribute to endothelial dysfunction, which accelerates the process of atherosclerosis.
Symptoms:
Chest pain or discomfort: Often associated with angina or heart attack.
Shortness of breath: Can occur with heart failure.
Fatigue: A common symptom of heart disease.
Palpitations: Irregular heartbeats may signal an underlying CVD condition.
Dizziness or fainting: Can indicate poor circulation or arrhythmias.
Swelling: Often in the ankles or legs, associated with heart failure.
Differential Diagnosis:
Anxiety: May present with chest pain and palpitations but is typically not associated with exertion or physical activity.
Gastroesophageal reflux disease (GERD): Can mimic chest pain, but it is typically relieved by antacids.
Musculoskeletal pain: Can present as chest discomfort but is usually related to posture or physical activity.
Panic attacks: Can cause palpitations and shortness of breath, but it is not typically associated with exertion.
Investigations:
Blood Pressure Measurement: Key to assessing hypertension, a major CVD risk factor.
Lipid Profile: Total cholesterol, LDL, HDL, and triglycerides are measured to assess dyslipidaemia.
ECG: Used to detect arrhythmias, past heart attacks, and ischemic changes.
Blood Glucose and HbA1c: Important for diabetes screening.
Kidney Function Tests (eGFR, ACR): Chronic kidney disease is a significant risk factor for CVD.
Cardiac Imaging: Tests like echocardiograms and coronary artery CT scans help assess heart function and the presence of coronary artery disease.
CVD Risk Assessment Guidelines:
All individuals aged 45-79 years: Screening for CVD risk is recommended for all adults in this age group.
People with diabetes aged 35-79 years: Diabetes increases the risk of CVD, requiring earlier and more frequent assessment.
First Nations people aged 30-79 years: First Nations people are at higher risk for CVD, and individual risk factors should be assessed starting from age 18-29 years.
Automatic High CVD Risk:
Familial Hypercholesterolaemia: Individuals with a family history of high cholesterol are at an increased risk.
Chronic Kidney Disease (CKD): Patients with moderate to severe CKD (eGFR <45 or urine ACR >25 for men, >35 for women) are automatically considered at high risk for CVD.
Risk Calculation Variables:
To calculate the CVD risk using the Australian CVD risk calculator, the following factors are considered:
Age: Older individuals have a higher risk of CVD.
Sex: Men typically have a higher risk of CVD at younger ages.
Smoking status: Current smokers have a significantly higher CVD risk.
Systolic blood pressure (BP): High BP is a major risk factor for CVD.
Total cholesterol/HDL ratio: A higher ratio indicates a greater risk of heart disease.
Use of CVD medications in the last 6 months: Patients on medications like antihypertensives or statins are considered to have a higher baseline risk.
History of atrial fibrillation (AF): AF increases the risk of stroke and other CVD events.
Postcode: Area of residence can indicate socio-economic and environmental factors impacting health.
Diabetes: If the individual has diabetes, additional details such as HbA1c levels, uACR, eGFR, BMI, and use of insulin in the last 6 months are needed.
CVD Risk Categories:
Low Risk (<5%): Lifestyle changes alone are recommended. Reassess every 5 years.
Medium Risk (5-10%): Consider medication. Reassess every 2 years.
High Risk (>10%): Immediate action is necessary. BP control and statins should be considered. No further reassessment is needed in the short term.
Reclassification of CVD Risk:
Reclassify Downward:
If the coronary artery calcium (CAC) score is 0 or below the 25th percentile, the individual’s risk can be reclassified down.
For individuals of East Asian ethnicity (e.g., Chinese, Japanese, Korean), their risk may be lower, requiring reassessment.
Reclassify Upward:
If the CAC score is above 99 or in the >75th percentile, the risk should be increased.
First-degree family history of premature CVD (men <55, women <65 with CAD or stroke) elevates risk.
Chronic kidney disease (CKD) with an eGFR of 45-59 or microalbuminuria (>2.5 for men, >3.5 for women) is associated with increased CVD risk.
Severe mental illness that requires specialist treatment over the last 5 years is a risk factor.
Management:
Lifestyle Modifications:
Encourage weight loss, healthy eating (low-fat, high-fibre diet), and increased physical activity.
Promote smoking cessation and limit alcohol consumption.
Medications:
Statins for cholesterol management.
Antihypertensive medications to control blood pressure.
Diabetes medications (insulin, metformin) as needed to manage blood glucose.
Aspirin for patients with high CVD risk and history of cardiovascular events.
Complications:
Heart Attack and Stroke: CVD leads to these serious conditions, which may result in disability or death.
Heart Failure: Progressive damage to the heart muscle due to long-standing CVD can lead to heart failure.
Prognosis:
Early identification and management of risk factors can significantly reduce the incidence of heart attacks, strokes, and other cardiovascular complications. Long-term outcomes depend on the severity of underlying risk factors and adherence to treatment and lifestyle changes.
Notes:
ATSI (Aboriginal and Torres Strait Islander) individuals should have their CVD risk assessed annually, even if they are classified as low or intermediate risk.
High Blood Pressure: Blood pressure >160/100 mmHg should be treated regardless of the CVD risk level.
Reclassification: Reclassifying risk is especially important for individuals whose risk is near the threshold of another category (e.g., transitioning from low to medium risk).
