Primary & Secondary Prevention of Cardiovascular Disease 2017

Objectives

Provide evidence-based, locally relevant guidance for primary and secondary prevention of cardiovascular disease, including heart disease and stroke, for people with and without established disease. The framework aims to reduce cardiovascular morbidity and mortality by assessing global risk, addressing modifiable risk factors and preventing recurrent events.[1][2][3]

• Apply primary prevention to the general population, people with multiple risk factors and those at high predicted risk, and apply secondary prevention to people with established cardiovascular disease or an index event.[4][5]
• Assess and stratify 10-year cardiovascular risk, principally through the Framingham General Cardiovascular Disease Risk Score, to tailor the intensity of lifestyle and pharmacological intervention.[6][7]
• Prioritise prevention and management of smoking, unhealthy diet, physical inactivity, overweight and obesity, hypertension, dyslipidaemia, diabetes and poor adherence to treatment.[2][8][9]
• Promote healthy dietary patterns rich in fruit, vegetables, wholegrains, legumes, fish and fibre, while reducing salt, added sugar, saturated fat and trans fat.[10][11][12]
• Encourage regular physical activity, including at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous activity weekly, alongside resistance and flexibility activity where appropriate.[13]
• Support smoking cessation, protection from second-hand smoke, and caution regarding electronic cigarettes and shisha because their long-term safety remains uncertain.[14][15]
• Manage clinical risk factors to risk-specific targets through lifestyle measures and indicated therapies, including blood-pressure treatment, lipid lowering, diabetes care, antiplatelet or anticoagulant therapy, and weight management.[16][17][18][19][20]
• Address cardiovascular risks associated with chronic kidney disease, HIV, cancer treatment, connective-tissue disease, sleep disorders, psychosocial stress, depression and gender-specific conditions.[21][22][23][24]
• Use traditional and complementary medicine cautiously, recognising insufficient evidence for cardiovascular benefit and potential risks from adverse effects or interactions; do not allow such practitioners to replace conventional medical professionals for preventive cardiovascular advice.[25][26]
• Advance population-level prevention through tobacco control, salt reduction, healthier food and activity environments, and community empowerment, alongside high-risk clinical prevention.[27][28][29]

Implementation

Implement the guideline through integrated clinical governance, multidisciplinary care, public and professional education, community action and whole-of-government policy measures. It is intended for medical practitioners, allied health personnel and traditional and complementary medicine practitioners, while management should be individualised to clinical presentation, co-morbidities, patient acceptance and locally available options.[1][2]

• Develop recommendations through literature review, appraisal of local clinical practice guidelines, expert consultation, expert-panel agreement, Ministry of Health Technical Advisory Committee review and review by public- and private-sector health personnel.[2]
• Base recommendations on evidence grading adapted from the American College of Cardiology Foundation, American Heart Association and European Society of Cardiology, using levels of evidence and recommendation grades to communicate certainty and benefit.[30]
• Use opportunistic rather than mass screening for adults over 30 years during clinical encounters, assessing smoking or vaping, blood pressure, body mass index, waist circumference, lipids and blood glucose or glycated haemoglobin.[6][31]
• Deliver risk-appropriate care by emphasising lifestyle change for low- and intermediate-risk people, while using intensive lifestyle and drug-based treatment for high- and very-high-risk groups and treating all risk factors to target in established cardiovascular disease.[7][31]
• Provide continuous medical education and training on cardiovascular risk assessment and prevention through roadshows, electronic media and in-house training, and increase public awareness of cardiovascular risk.[2]
• Use multidisciplinary support for diet, exercise, smoking cessation, obesity and adherence, including referrals to MQuit cessation services, physiotherapists or exercise specialists, obesity clinics, medication-adherence clinics and cardiac rehabilitation where appropriate.[13][14][32][9]
• Deliver smoking cessation through counselling and pharmacotherapy, with intensive counselling before hospital discharge and sustained follow-up for cardiac inpatients.[14][15]
• Strengthen adherence at every clinical visit through non-judgemental assessment, simplified regimens, clear information, reminders, feedback, medicine reconciliation, pharmacist and nurse involvement, and patient participation in decisions.[9][33][34]
• Coordinate population measures through a whole-of-government model involving ministries, communities, non-governmental organisations and private providers. Tobacco control uses legislation, enforcement, community empowerment and the MPOWER framework, while salt reduction combines monitoring, awareness, institutional food guidance and food-product reformulation.[27][35][28]
• Implement Komuniti Sihat Perkasa Negara, or KOSPEN, through trained community volunteers who promote healthy behaviour, conduct basic blood-pressure, blood-glucose and body-mass-index screening, and refer high-risk residents to health clinics.[29][36]
• Monitor progress using national non-communicable disease targets, hospital admissions and discharges, periodic national health surveys, mortality statistics and burden-of-disease studies every 10 years.[2][37]
• Track tobacco prevalence and population salt intake, the latter using 24-hour urine analysis, against 2025 targets for smoking and a 30% reduction in average adult salt intake.[35]
• Review and revise the guideline at least every five years, or earlier when important new evidence becomes available.[1][2]

Monitoring & Evaluation

The guideline combines clinical risk assessment with national non-communicable disease performance measures, but does not set out a single comprehensive reporting, audit or accountability framework for all recommendations. It frames implementation as part of good clinical governance and calls for revision at least every five years as knowledge on cardiovascular prevention develops.[2]

• Use opportunistic screening for adults aged over 30 years rather than mass screening, assessing smoking or vaping history, blood pressure, body mass index, waist circumference, lipid profile, and blood glucose or glycated haemoglobin.[6]
• Apply the Framingham General Cardiovascular Disease Risk Score, validated in Malaysians, to estimate 10-year risk and guide the intensity of primary-prevention intervention.[6]Classify risk as very high above 30%, high above 20%, intermediate or moderate at 10–20%, and low below 10%.[7]
• Measure average total and high-density lipoprotein cholesterol using at least two measurements, and establish baseline blood pressure from several readings.[6]Counsel and reassess individuals regularly to support adherence and determine whether treatment goals have been achieved.[7]
• Recognise that the Framingham score is intended for risk stratification rather than tracking changes in risk after modifying risk factors.[6]Interpret alternative tools cautiously because a Malaysian-specific score was unavailable, the World Health Organization and International Society of Hypertension model was not recommended locally, and vascular-age lifetime-risk modelling had not been validated in Malaysia.[6][7]
• Monitor condition-specific clinical targets, including blood pressure, low-density lipoprotein cholesterol, glycated haemoglobin, body weight, body mass index, waist circumference, glycaemic control, lipid profile and quality of life where relevant.[32][38]Use treatment targets and reassessment to identify inadequate response, such as resistant hypertension despite three near-maximal-dose medicines including a diuretic.[16]
• Assess medication adherence at every clinical visit through non-judgemental questioning, questionnaires, review of barriers and refill frequency.[9]Support self-monitoring, feedback, reminders and reinforcement, including team-based input from pharmacists and nurses.[9][34]
• Use evidence grading to support accountability for clinical recommendations: Level A evidence derives from multiple randomised clinical trials or meta-analyses, Level B from a single randomised trial or large non-randomised studies, and Level C from expert consensus, case studies or standard care.[30]Recommendation grades distinguish interventions with established benefit from those with weaker support or those that are not useful or may be harmful.[30]
• Track national targets for premature non-communicable disease mortality, tobacco use, sodium intake, insufficient physical activity, harmful alcohol use, raised blood pressure, and diabetes and obesity.[37]The stated 2025 targets include reducing premature non-communicable disease mortality from 20% to 15%, tobacco use from 23% to 15%, sodium intake from 8.7 grams to 6.0 grams, insufficient physical activity from 35.2% to 30.0%, and raised blood pressure from 32.2% to 26.0%.[37]
• Use hospital admissions and discharges, periodic national health surveys, mortality statistics and burden-of-disease studies every 10 years as additional performance measures.[37]Monitor salt intake through 24-hour urine analysis and assess progress towards the 30% adult salt-intake reduction target by 2025.[35]
• Monitor tobacco-control progress against smoking-prevalence targets of below 15% by 2025 and ultimately below 5%.[35]The Tobacco Control and Framework Convention on Tobacco Control Sector in the Ministry of Health Disease Control Division is the focal point for tobacco control, supported by a national driving committee involving ministries and non-governmental organisations.[27]
• Record KOSPEN implementation and results: by December 2016, 5,900 sites had been established and more than 36,000 volunteers trained.[36]Almost 400,000 adults had been screened for non-communicable disease risk factors, and initial analysis found that 90% of 200 KOSPEN weight-management localities achieved their targets.[36]

Many clinical and thematic sections specify assessment tools, epidemiological findings or treatment targets but do not define formal indicators, reporting schedules, surveillance governance, evaluation methods or named accountability bodies.[31][39]The national target framework is based on the global non-communicable disease monitoring framework, with baseline estimates from the World Health Organization, National Health and Morbidity Survey and population-based studies.[40][37]

Costing & Financing

Financial information is limited. The guideline identifies selected economic considerations and funding disclosures, but does not provide an overall implementation budget, government allocation, financing plan, funding gap or systematic resource-mobilisation strategy.[41][42]

• Recognise prevention at population level as more cost-effective than strategies focused solely on people at high risk, although the supplied material provides no Malaysia-specific economic estimates for this comparison.[5]
• Prioritise affordability in selecting diabetes treatment, after cardiometabolic risk reduction, safety, glycaemic efficacy and patient convenience.[41]Conservative price-list estimates place the expenditure to avoid one composite cardiovascular endpoint at Malaysian Ringgit 922,560 over 3.1 years for empagliflozin and Malaysian Ringgit 1,305,702 over 3.8 years for liraglutide.[41]
• Use lifestyle intervention for prediabetes as the source characterises it as practical and cost effective, with greater efficacy than pharmacological intervention and effects that may persist after active intervention.[43]
• Recognise that low adherence is associated with higher hospitalisation rates and increased costs, while medicine and transport costs may themselves impede adherence.[9][33]
• Consider salt reduction a high-impact, highly feasible and low-implementation-cost measure for cardiovascular disease reduction.[35]Routine echocardiography in asymptomatic populations may increase costs and generate potential harm through downstream testing, whereas the ankle-brachial index is described as inexpensive and reproducible.[24][44]
• Note that policy selection for obesity and non-communicable disease prevention considered cost-effectiveness, affordability, implementation capacity, feasibility and public acceptability.[28][29]Potential fiscal measures include excise duty or goods and services tax on foods and beverages high in fat, salt or sugar, and reductions in cooking-oil subsidies, but their financial implications and revenue assumptions are not specified.[29]
• Record that guideline development was funded through education grants from AstraZeneca, Boehringer Ingelheim, Novartis, Pfizer and Servier to the National Heart Association of Malaysia.[42]The disclosure indicates that funders did not influence the guideline content, but gives no grant amounts or expenditure breakdown.[42]

Resource implications include health-worker education, public and school-based communication, smoking-cessation support, exercise guidance, weight-management referrals and use of medicines already available in Ministry of Health hospitals.[30]However, the source does not quantify the workforce, infrastructure or service-delivery costs associated with these activities.[30]