Key Facts

Cardiovascular risk assessment (CVRA) is the systematic evaluation of risk factors to estimate an individual's likelihood of developing atherosclerotic cardiovascular disease (MI, stroke, PAD) over a defined time period, typically 10 years.

Epidemiology

• CVD is the second leading cause of death in the UK (~25% of all deaths)
• ~7.6 million people in the UK live with CVD
• CVD is largely preventable through risk factor modification
• NHS Health Check programme aims to identify and manage high-risk individuals

Risk Factors

Non-modifiable:

• Age (risk increases with age)
• Sex (men at higher risk; women catch up post-menopause)
• Ethnicity (South Asian and Black African/Caribbean at higher risk)
• Family history of premature CVD (first-degree relative: male <55, female <65)
• Genetic factors

Modifiable:

• Smoking
• Hypertension
• Dyslipidaemia (high LDL, low HDL)
• Diabetes mellitus
• Obesity (especially central)
• Physical inactivity
• Excess alcohol
• Chronic stress, depression
• Chronic kidney disease
• Inflammatory conditions (RA, SLE)
• Atrial fibrillation

Indications for Risk Assessment

• All adults aged 40-74 without pre-existing CVD (NHS Health Check)
• Younger adults with significant risk factors
• Patients with conditions that increase CVD risk (CKD, diabetes, RA, etc.)

Assessment Components

• Age, sex, ethnicity
• Smoking status
• Blood pressure (clinic BP)
• Total cholesterol and HDL cholesterol (non-fasting acceptable)
• Body mass index
• Medical history: diabetes, CKD, AF, RA, migraine, SLE, erectile dysfunction, severe mental illness, atypical antipsychotic use
• Family history of premature CVD
• Townsend deprivation score (postcode-based in QRISK3)

When NOT to Use QRISK3

• Established CVD (already secondary prevention → treat directly)
• Type 1 diabetes >40 years or with >10 years duration or nephropathy/other risk factors (treat as high risk)
• Familial hypercholesterolaemia (treat directly)
• CKD stage 3-5 (already at increased risk)
• Age <25 or >84 years

Required Measurements

• Blood pressure: clinic BP (ideally average of 2 readings)
• Lipid profile: total cholesterol, HDL-C (non-fasting acceptable per NICE)
• HbA1c / fasting glucose: diabetes screening
• U&Es + eGFR: CKD screening
• Urine ACR: microalbuminuria (CKD, diabetic nephropathy)
• BMI: weight and height
• ECG: if AF or other cardiac symptoms suspected

QRISK3 Variables

Risk Communication

• Discuss QRISK3 score with patient
• Explain absolute vs relative risk
• Shared decision-making regarding treatment
• Address health literacy and patient preferences

Lifestyle Interventions (All Patients)

• Smoking cessation: single most effective intervention (refer to NHS Stop Smoking service)
• Diet: Mediterranean diet; reduce saturated fat; increase fruit, vegetables, fibre, oily fish
• Exercise: ≥150 minutes moderate aerobic activity per week
• Weight management: target BMI <25 kg/m²; waist <94 cm (men), <80 cm (women)
• Alcohol: ≤14 units per week
• Mental health: address stress, depression

Pharmacological (Based on QRISK3)

QRISK3 <10%:

• Lifestyle advice only
• Reassess in 5 years (NHS Health Check interval)

QRISK3 ≥10%:

• Offer atorvastatin 20mg OD (primary prevention)
• Recheck lipids at 3 months: aim >40% reduction in non-HDL-C
• If target not met: optimise adherence, consider dose increase, add ezetimibe

Blood pressure management:

• Per NICE NG136: treat if clinic BP ≥140/90 mmHg (or lower thresholds if high risk)

Diabetes management:

• Optimise glycaemic control (HbA1c target varies)
• Consider SGLT2 inhibitors or GLP-1 agonists for cardiorenal benefit

Antiplatelet therapy:

• NOT recommended for primary prevention (bleeding risk outweighs benefit)
• Only for secondary prevention (established CVD)

Referral Criteria

• Suspected FH: specialist lipid service
• Very high-risk patients with multiple uncontrolled risk factors: specialist cardiovascular prevention clinic
• Young patients with premature CVD: genetics/specialist assessment

• Addressing modifiable risk factors can reduce CVD risk by 50-80%
• Smoking cessation: ~50% reduction in CVD risk within 2 years
• Statin therapy: ~25% reduction in major vascular events per mmol/L LDL reduction
• BP control: each 10 mmHg reduction in SBP reduces stroke by ~40% and MI by ~20%
• Exercise: reduces CVD mortality by ~30%
• NHS Health Check programme estimated to prevent ~1,600 heart attacks and strokes per year

NICE CG181 Primary Prevention Pathway

NHS Health Check Components