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Cardiovascular Risk Assessment

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Overview

Cardiovascular disease (CVD) is an umbrella term describing conditions that affect the heart, blood vessels, or both. It is caused by thrombosis or atherosclerosis. Cardiovascular conditions include coronary heart disease (angina and myocardial infarction), stroke, transient ischaemic attack (TIA), and peripheral arterial disease.

QRISK

Overview

QRISK calculates a 10-year estimated risk of developing a cardiovascular disease (CVD, angina, myocardial infarction, stroke, TIA, or peripheral arterial disease). It is expressed as a percentage.

For example, if someone’s QRISK score is 30%, this means they have a 30% chance (3 in 10) that they will develop a cardiovascular disease.

QRISK is not used in:

  • Patients ≥85 years old
  • Patients with type 1 diabetes
  • Patients with a glomerular filtration rate (eGFR) less than 60 ml/min and/or albuminuria
  • Patients with a history of familial hyperlipidaemia

QRISK may underestimate the risk of CVD in:

  • Patients treated for HIV
  • Patients taking drugs that can cause hyperlipidaemia (e.g. immunosuppressants, antipsychotics)
  • Patients with hypertriglyceridaemia (>4.5 mmol/L)
  • Patients already taking antihypertensive or lipid modification therapy, or have recently given up smoking

Primary Prevention

Overview

Primary prevention involves reducing the risk of CVD in people who have never had CVD.

Patients with a QRISK score ≥10% should be offered a statin. Atorvastatin 20 mg is offered first-line. For patients ≥85 years old, consider offering atorvastatin (as these patients are not included in QRISK assessments).

Type 1 diabetes mellitus

NICE recommends that clinicians ‘consider statin treatment’ for the primary prevention of CVD in all adults with type 1 diabetes mellitus. As mentioned above, atorvastatin 20 mg is first-line, particularly if any of the following apply:

  • >40 years old
  • Has had type 1 diabetes mellitus for >10 years
  • Has established nephropathy
  • Has other CVD risk factors

Chronic kidney disease (CKD)

Atorvastatin 20 mg should be offered to patients with CKD. The dose should be increased if a >40% decrease in non-HDL cholesterol is not achieved and the eGFR is >30 mL/min.

If the eGFR is <30 mL/min, consult a renal specialist.

Secondary Prevention

Overview

Secondary prevention involves treatment after a diagnosis of CVD to reduce the risk of further cardiovascular events (such as myocardial infarction or stroke). It depends on the specific condition.

All patients with CVD should be given a statin in the absence of any contraindication. Atorvastatin 80 mg is first-line. More specific regimes include:

  • Angina:
    • Aspirin daily lifelong
    • If aspirin is contraindicated/not tolerated: consider clopidogrel daily
  • Medically managed acute coronary syndrome (ACS):
    • Aspirin daily lifelong with ticagrelor twice daily for 12 months
      • The addition of ticagrelor is known as dual antiplatelet therapy (DAPT)
    • If high bleeding risk: consider DAPT for at least 1 month
    • If high risk of myocardial ischaemia consider DAPT for up to 36 months
  • ACS managed with a primary percutaneous coronary intervention (PCI):
    • Aspirin daily lifelong and one of prasugrel, ticagrelor, or clopidogrel for 12 months as part of a DAPT regime and an angiotensin-converting enzyme (ACE) inhibitor and beta-blocker
    • If high bleeding risk: continue DAPT for 6 months and avoid prasugrel
    • If DAPT tolerated without bleeding: consider continuing DAPT for up to 36 months
  • Stable coronary artery disease treated with a PCI:
    • Aspirin daily lifelong with clopidogrel for 6 months as part of a DAPT regime
    • If high bleeding risk: continue DAPT for 3 months
    • If 3 months of DAPT is unsafe: continue DAPT for 1 month
    • If DAPT tolerated without bleeding: consider continuing DAPT for up to 36 months
  • Coronary artery bypass grafting (CABG):
    • Antiplatelet therapy is managed by specialists
  • Stroke or transient ischaemic attack (TIA):
    • Clopidogrel daily lifelong
    • If clopidogrel contraindicated/not tolerated: modified-release dipyridamole and aspirin
    • If clopidogrel and dipyridamole contraindicated/not tolerated: aspirin alone
    • If clopidogrel and aspirin contraindicated/not tolerated: modified-release dipyridamole alone
  • Peripheral arterial disease (PAD):
    • Clopidogrel daily
    • If clopidogrel contraindicated/not tolerated: give aspirin alone

Monitoring

Overview

Patients taking statins are followed up at 3 months where a lipid profile and liver function tests (LFTs) are measured.

  • If non-HDL cholesterol has not fallen by at least 40%, discuss adherence and lifestyle changes and consider increasing the dose to 80 mg.
  • Statins can cause a transient increase in AST and ALT during the first few weeks of use. They do not need to be stopped if the increase is <3 times the upper limit of normal.

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