Cardiovascular Disease Risk Assessment and Management for Primary Care

Objectives

Provide an evidence-based New Zealand framework for preventing cardiovascular disease (CVD) through five-year risk assessment, risk communication, healthy lifestyles and proportionate treatment of modifiable risk factors.[1][2]The framework combines population-wide prevention with targeted clinical strategies, using estimated individual risk rather than isolated risk factors to guide care.[3]

• Assess eligible people without prior CVD using New Zealand Primary Prevention Equations, including separate equations for people with and without diabetes.[1][2]
• Calculate five-year CVD risk for men and women aged 30 to 74 years, while starting assessment earlier for Māori, Pacific and South Asian peoples, people with diabetes or elevated diabetes risk, and people with severe mental illness.[4][5]
• Prioritise earlier assessment for Māori, Pacific and South Asian peoples by beginning 15 years before the general-population starting age.[6]
• Exclude people with established CVD, congestive heart failure, familial hypercholesterolaemia, specified severe chronic kidney disease, or diabetes with overt nephropathy or renal disease from the primary prevention equations because they require aggressive or individualised management.[4]
• Promote healthy eating, physical activity, healthy weight, smoking cessation, lower salt and alcohol intake, and sustained behaviour change for all risk groups.[7][8]
• Use behavioural counselling, self-monitoring, goal setting, barrier management and referral or support to help people sustain lifestyle change.[7]
• Use shared decision-making to determine preventive treatment, particularly for people with estimated five-year CVD risk of 5 to 15 percent.[2][5]
• Recommend lipid-lowering and blood-pressure-lowering treatment strongly for people with estimated five-year CVD risk of 15 percent or more, treating this group similarly to people with established CVD.[2][7]
• Reduce inequities for people with serious mental illness by recognising their earlier, higher CVD risk and the potential contribution of psychotropic medicines, smoking, diet, co-morbidity and polypharmacy.[9][10][11]
• Individualise decisions for people aged over 75 years by considering estimated risk, expected treatment benefits and harms, life expectancy, co-morbidities and personal values.[9]

Implementation

Deliver prevention principally through primary care, using integrated electronic decision support to calculate risk, communicate results, support shared decisions and record assessments in patient-management systems.[1][12]The approach is underpinned by evidence review, New Zealand cohort data and linked hospitalisation and mortality datasets, with development involving the Ministry of Health, Heart Foundation, University of Auckland VIEW research group, clinical experts and guideline reviewers.[13][3]

• Replace paper risk charts with electronic tools because the equations require expanded demographic, socioeconomic, family-history, clinical, laboratory, medication and risk-factor data.[6][14]
• Integrate computer-generated risk assessments with patient-management systems so that available clinical data populate the assessment automatically and results return to the patient record.[12]
• Present estimated five-year risk, heart age, risk trajectory, intervention effects, benefits, harms and adverse effects through health-literacy-appropriate visual and narrative communication tools.[5][12]
• Enable patients to access assessments electronically and enable clinicians to print risk assessments and management advice where needed.[12]
• Use one open-source web-based updating point for revised algorithms and evidence.[12]
• Record key assessment variables including age, sex, ethnicity, deprivation, smoking, diabetes history and duration, family history, blood pressure, cholesterol ratio, renal function, body mass index, albuminuria where relevant and recently dispensed CVD medicines.[6][14][15]
• Screen for diabetes using a non-fasting glycated haemoglobin test from an accredited laboratory, use fasting plasma glucose where appropriate, and confirm diabetes in asymptomatic people through repeat testing.[15]
• Include CVD risk assessment in annual reviews for people with type 2 diabetes and use diabetes-specific equations that account for duration, albuminuria, renal function, glycaemic control and related factors.[2][4]
• Apply the ABC smoking-cessation approach by asking and documenting smoking status from age 15 years, advising people who smoke to stop, and offering behavioural and pharmacological cessation support or referral.[16]
• Use statins as preferred lipid-lowering medicines and monitor non-fasting lipids every 6 to 12 months until targets are achieved, then annually.[17][18]
• Use ambulatory or home blood-pressure monitoring when white-coat hypertension, variable readings, resistant hypertension or drug-induced hypotension is suspected.[17][19]
• Offer blood-pressure medicines with lifestyle changes for people at risk of at least 15 percent with persistent office blood pressure of at least 130/80 mmHg, using angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers or thiazide diuretics where suitable.[20]
• Consider aspirin for primary prevention only for people under 70 years with risk above 15 percent after discussing bleeding risk and potential benefit; do not recommend it solely for primary prevention for people over 70 years or with risk of 15 percent or less.[21][22]
• Repeat risk assessment every 10 years below 3 percent risk, every five years at 3 to 9 percent, every two years at 10 to 14 percent, and annually at 15 percent or more.[2]
• Monitor people with serious mental illness at least annually after responsibility transfers from secondary care to general practice or another primary healthcare professional.[11]
• Use linked PREDICT cohort, hospitalisation and mortality data to develop, validate and track uptake of risk assessment tools.[3]
• Recognise that the document does not specify a formal national performance framework, reporting schedule, accountability mechanism, implementation budget or resource-mobilisation plan.[13][3]

Monitoring & Evaluation

Monitoring is primarily embedded in individual clinical risk assessment, treatment review and electronic decision support rather than a national performance-management system. Five-year cardiovascular disease risk estimates guide reassessment intervals, follow-up intensity and treatment discussions, while linked health datasets and the PREDICT cohort underpin development and validation of the New Zealand Primary Prevention Equations.[1][3][5]

• Repeat cardiovascular disease risk assessment every 10 years for risk below 3 percent, every five years for risk of 3 to 9 percent, every two years for risk of 10 to 14 percent, and annually for risk of 15 percent or more.[2][7]
• Review people with established cardiovascular disease, people at risk above 15 percent, and people with diabetes annually.[12][7]
• Assess people with severe mental illness from age 25 years and repeat assessment every two years, increasing to annual assessment when estimated risk is 15 percent or more.[2]
• Monitor the physical health of people with psychosis or schizophrenia at least annually after responsibility transfers from secondary care to general practice or another primary healthcare professional.[11]
• Repeat glycated haemoglobin testing annually for people with pre-diabetes; where diabetes is unlikely, repeat testing at the next cardiovascular risk assessment or when clinically indicated.[15]
• Monitor non-fasting lipids every 6 to 12 months until the agreed target is reached, then annually; review lipid levels annually once low-density lipoprotein cholesterol control is satisfactory.[18][19][17]
• Review blood pressure annually once treatment targets are achieved, with home monitoring and electronic communication potentially replacing office monitoring for stable people.[17][20]
• Measure estimated glomerular filtration rate, albumin-to-creatinine ratio and serum potassium 5 to 10 days after commencing blood-pressure treatment for people with diabetes and renal disease, and regularly thereafter.[21]

Clinical indicators and thresholds include low-density lipoprotein cholesterol below 1.8 mmol/L for people with five-year cardiovascular disease risk of 15 percent or more, at least a 40 percent reduction where treatment begins at 5 to 15 percent risk, and office blood pressure below 130/80 mmHg after pharmacotherapy.[17][8]Risk assessment should use the average of two seated blood-pressure measurements, a non-fasting total cholesterol to high-density lipoprotein cholesterol ratio, and estimated glomerular filtration rate calculated with the CKD-EPI equation.[14]

Electronic systems are intended to calculate and communicate risk, quantify intervention effects, record results in patient-management systems and support clinical review.[1][12]Risk communication should include estimated five-year risk, heart age, risk trajectory, intervention benefits and harms, and absolute benefit from each 10 mmHg systolic blood-pressure reduction where relevant.[5][12][20]

Surveillance and evidence development use encrypted National Health Index numbers linked to national hospitalisation and mortality data.[3]The general risk model captures five-year risk of relevant cardiovascular hospitalisation or death, while the type 2 diabetes model includes specified coronary and peripheral vascular events and procedures.[23]PREDICT had assessed 400,728 patients by December 2015, providing evidence of uptake rather than a stated implementation target.[3]

Formal national performance indicators, reporting schedules, audit procedures, evaluation targets, governance arrangements and accountability mechanisms are not specified.[1][13][20][11]Limitations requiring clinical judgement include probable risk underestimation for people with serious mental illness or certain treatment-related risks, and approximate estimates for people aged 75 years and over because the primary prevention equations were developed for ages 30 to 74 years.[4][24][10]

Costing & Financing

There is no implementation budget, programme costing, resource-mobilisation plan, funding allocation, quantified funding gap or economic assumption.[13][12][19][20]The only explicit research financing information is joint support for development of the updated cardiovascular disease risk equations from the Healthier Lives National Science Challenge, the Health Research Council of New Zealand and the Heart Foundation of New Zealand, without stated monetary amounts or dates.[1]

• Consider cost-effectiveness alongside likely benefits, harms, clinical state, comorbidities, frailty, life expectancy and patient preferences when making shared treatment decisions.[5]
• Present comparative benefits and harms graphically through decision-support tools where possible, but no cost-effectiveness threshold, price, or economic model is specified.[5]
• Recognise qualitative cost savings associated with smoking cessation, although no monetary value, time horizon or funding mechanism is provided.[7]
• Note that pioglitazone is identified as the only currently funded alternative pharmacological agent among listed alternatives for particular patient groups in New Zealand; the source does not specify the value or scope of this funding.[21]

Resource implications are described operationally rather than financially. Primary care requires computerised risk-assessment and risk-communication tools integrated with patient-management systems, electronic access for patients, and data linkage for equation development and validation.[1][3][12]The document does not quantify costs for software, laboratory testing, workforce time, medicines, behavioural support, specialist referral, home monitoring devices or service delivery.[15][16][19]