National Guide

Chapter 16 | Cardiovascular disease







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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    17. Chapter 16 | Cardiovascular disease

Cardiovascular disease

Dr Rosemary Wyber, Ms Vicky Wade   

Key messages

  • Cardiovascular healthcare encompasses a broad range of strategies aimed at holistic care and strengthening and building community capacity.
  • There are effective ways to reduce cardiovascular disease (CVD) risk. Supporting people who are at high risk is an important way to improve the cardiovascular health of Aboriginal and Torres Strait Islander people.
  • Assessing and reducing CVD risk is a lifelong process. New guidance about assessing and managing risk for young people (aged 18–29 years) helps provide a foundation for these discussions and decisions in early adulthood.1
  • New Australian guidelines for assessing and managing CVD risk were launched in 2023. These include a new CVD risk calculator with more variables to help better assess CVD risk and new categories of CVD risk (ie high risk [≥10% risk over five years], intermediate risk [5% to <10% risk over five years] ad low risk [<5% risk over five years]).2
  • Services using the CARPA Standard treatment manual should continue to use the CVD risk calculator in that guideline.3
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 12–17 years Assess CVD risk factors by:
  • asking about:
    • smoking
    • family history of hypercholesterolaemia
  • measuring:
    • body mass index (BMI)
    • waist circumference
  • testing, only if clinically indicated:
Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific consensus statement1 Consideration of CVD risk should begin during adolescence and be supported by strengths-based health education (eg celebration of smoking abstinence) but not routinely involve annual blood testing unless there are specific clinical indications
People aged 18–29 years Assess for high-risk conditions:
  • previous CVD diagnosis
  • moderate–severe chronic kidney diseaseA
  • familial hypercholesterolaemia
If not already high risk, assess individual risk factors by:
  • asking about:
    • smoking
    • family history of hypercholesterolaemia
    • history of hypertensive disorders in pregnancy and gestational diabetes
  • measuring:
    • BMI
    • waist circumference
    • BP
  • testing:
    • BSL or HbA1c
    • estimated glomerular filtration rate (eGFR)
    • lipids
    • urinary albumin:creatine ratio (uACR)
 Opportunistically and as per level of risk Good practice point Aboriginal and Torres Strait Islander-specific consensus statement1 Consideration of CVD risk should begin during early adulthood to identify the development of early risk factors and provide a window for early intervention
People aged 30–79 years Assess for high-risk conditions (moderate–severe chronic kidney diseaseA and familial hypercholesterolaemia)

If not high risk, apply the CVD risk algorithm to quantify risk, considering:
  • age
  • sex
  • systolic blood pressure
  • total cholesterol:high-density lipoprotein ratio
  • diabetes status
  • use of CVD medicines
  • post code
  • history of atrial fibrillation (AF)
and, for people with diabetes:
  • HbA1c
  • time since diabetes diagnosis
  • uACR
  • eGFR
  • BMI
  • use of insulin
Then, consider reclassification factors (see Boxes 1 and 2):
  • ethnicity
  • family history
  • eGFR and uACR
  • severe mental illness
  • coronary artery calcium (CAC)
 Opportunistically and as per level of risk Strong National guideline2 CVD risk should be calculated using the CVD risk algorithm from age 30 and the results interpreted in the context of reclassification factors relevant to Aboriginal and Torres Strait Islander people
People aged 18–74 years not already identified at high risk attending health services using the CARPA  Standard treatment manual Assess CVD risk using the risk calculator as per CARPA guidelines Annually, as per CARPA guidelines Strong Jurisdictional guideline3
Single study4		 The CARPA CVD risk calculator has been validated in Aboriginal populations in northern and central Australia
People aged over 50 years Screen for AF by palpation of the pulse followed by full electrocardiogram (ECG) or ECG rhythm strip using a hand-held ECG when further assessment is indicated Opportunistically and annually Good practice point National guideline5
Single study6		 Current Australian guidelines do not recommend early initiation of AF screening for Aboriginal and Torres Strait Islander people, although research evidence is supportive
Starting at age 50 years aligns with an older person’s annual health check and the onset of other preventive health activities, such as cancer screening
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people, regardless of CVD risk Advise on behavioural approaches to risk reduction:
  • smoking cessation
  • physical activity
  • maintain ‘healthy’ BMI and waist circumference
  • avoid harmful levels of alcohol
  • limit salt intake to less than one teaspoon a day
  • cultural, community and family connections
(Refer to Chapter 2: Healthy living and health risks, Healthy eating, Physical activity and sedentary behaviour, Smoking and Alcohol)		 Opportunistically Good practice point National guidelines2,5,7 Primary care teams have the opportunity to regularly and routinely provide factual and contextually relevant information and encouragement about risk-reducing behaviours
People with intermediate or high CVD risk Provide or refer for intensive supports to reduce CVD risks As clinically indicated Good practice point National guideline2 Focused supports and referrals should be offered for people at high CVD risk
Type of preventive activity - Medications
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 18–29 years with isolated risk factors Make a subjective assessment of overall CVD risk, discuss this assessment and make a shared decision about reducing this risk with behaviour change and medication to address specific risk factors, such as blood pressure and lipids Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific consensus statement1 Risk and medication for risk reduction should be clinically determined
People aged over 30 years and with low (less than 5%) CVD risk Medication is not routinely recommended N/A Conditional National guideline2 People at low CVD risk generally do not require medication for risk reduction
People with intermediate CVD risk (between 5% and 10%) Consider blood pressure-lowering and lipid-modifying pharmacotherapy, depending on clinical context, unless contraindicated or clinically inappropriate As clinically indicated Conditional National guideline2 People at intermediate CVD risk should be offered medication for risk reduction
People with high CVD risk (greater than or equal to 10%) Prescribe blood pressure-lowering and lipid-modifying medication, unless contraindicated or clinically inappropriate Ongoing Strong National guideline2 Medication for risk reduction should be encouraged for people at high CVD risk
People diagnosed with AF Explore the cause of AF and manage rate and rhythm control
Assess and manage CVD risk, using the CHA2DS2-VA score to assess the risk of stroke and considering anticoagulation		 As per AF management guidelines Strong National guideline5 AF guidelines provide information about how to assess stroke risk and bleeding risk, and to evaluate the potential benefit of secondary prophylaxis
Type of preventive activity - Environmental
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Consider temperature extremes, air pollution and other extreme weather events as stressors for CVD risks and events (refer to Chapter 21: Health impacts of climate change) Opportunistically Good practice point Single studies8,9 Various environmental exposures are associated with CVD risk and events, including temperature extremes8 and air pollution9
AModerate–severe renal disease is defined as a sustained eGFR of <45 mL/min/1.73 m2 and persistent macroalbuminuria (uACR >25 mg/mmol in men and uACR >35 mg/mmol in women).
 

Box 1. Cardiovascular disease (CVD) reclassification factors and considerations
Reclassification factors should be considered in holistic risk assessment and may change the classification of risk when people lie close to the threshold between different risk levels. Specifically, consider:
  • Reclassification factors should be considered in holistic risk assessment and may change the classification of risk when people lie close to the threshold between different risk levels. Specifically, consider:
  • Ethnicity
    Aboriginal and Torres Strait Islander people may be reclassified into a higher risk factor to account for individual, family or community contexts that increase the risks of CVD (eg exposure to racism, socioeconomic marginalisation and stress/trauma/allostatic load, health beliefs based on culture10).
  • Family history
    For people who have a strong family history (parents and siblings) of stroke and heart attack at a young age (first-degree female relative aged under 65 years or a first-degree male relative aged under 55 years), consider adjusting the person’s estimated CVD risk upwards to the next risk level.
  • Chronic kidney disease
    For people who do not have diabetes but have a sustained eGFR of 45–59 mL/min/1.73 m2 and/or persistent microalbuminuria (uACR 2.5–25 mg/mmol in men and 3.5–35 mg/mmol in women), strongly consider adjusting the estimated CVD risk upwards to a higher risk level.
  • Severe mental illness
    People with severe mental illness, or high levels of psychological distress, may be considered at a higher category of CVD risk. Severe mental illness is defined as ‘illness requiring specialist mental health services in the 5 years, whether received or not, prior to the index CVD risk assessment’.2 Clinicians should consider recommended screening for mental illness (refer to Chapter 20: Mental health) and be aware of gaps in access to culturally safe services that would allow for diagnosis or referral for psychological distress and/or serious mental health illness when considering this factor.
  • Coronary artery calcium (CAC)
    The CAC score is not recommended for population screening for CVD risk and does not attract a Medicare Benefit Schedule rebate.
  • History of hypertensive disorders during pregnancy
    Women who have had high blood pressure or pre-eclampsia during pregnancy are at increased risk of ongoing or subsequent high blood pressure.

Box 2. Other factors influencing cardiovascular disease (CVD) risk
A range of factors that may decrease or increase CVD risk, risk factors and/or events for Aboriginal and Torres Strait Islander people have been explored in research studies.

Potential risk-increasing biomedical factors are broad (high sleep disruption,11 high waist circumference,12,13 low high-density lipoprotein cholesterol14 and low vitamin D15), as are social determinants (high exposure to temperature extremes,8 low socioeconomic status,16 high exposure to air pollution9 and hazardous use of alcohol17).

Protective factors are less well described for CVD risk, but there are broad associations between cultural identity, family/community, Country and place and the health and wellbeing outcomes of Aboriginal and Torres Strait Islander people.10,18 Other biomedical factors that are protective, or likely to be protective, against CVD include regular physical activity, nutritious diet and good sleep.

None of these factors is included in the current risk assessment algorithm. Some do not add value in discriminating beyond ‘traditional’ CVD risk factors and for others the evidence is not sufficiently well developed to include them. However, the development of clinical risk prediction tools necessarily occurs at a population level and may not fully account for specific risks with a disproportionate burden on specific communities, such as Aboriginal and Torres Strait Islander people.

The use of reclassification factors in the Australian CVD risk assessment guidelines provides a new way for clinicians to account for some of these risk/protective factors and combine quantitative risk assessment with real-world context.
  • Systems for annual CVD risk assessment and screening for AF (age >50 years) should be supported through clinical software (including reminders and embedded with health check templates).
  • Aboriginal and Torres Strait Islander health practitioners and health workers can contribute to CVD risk assessment, including through discussing clinical history, calculating risk and contributing to shared decisions about risk reduction.19
  • Clinicians should be aware that the updated guidelines2 recommend annual discussion of CVD risk lifelong from the age of 12 years. Although this provides many opportunities for engagement, education and risk reduction, there is a risk that the discussion becomes repetitive and may not always be appropriate in the context of competing health or life priorities.10 Long-term relationships with trusted primary care services can help ensure that discussion of CVD risk is offered sensitively, at the right times and in conjunction with contextually relevant risk-reduction approaches.
  • Make sure the CVD risk calculator being used is as per Australian guidelines published in 2023,2 noting that some clinical software systems may have an out-of-date calculator. If in doubt, use the risk calculator on the internet (see Useful resources).

Background

CVD, including ischaemic heart disease, stroke, AF and heart failure, is one the leading causes of illness and death for people in Australia. Aboriginal and Torres Strait Islander people experience higher rates of CVD, with earlier onset and premature death, than non-Indigenous Australians. This burden of disease reflects the ongoing effects of colonisation, systematic failings of healthcare, discrimination and racism, psychological distress and socioeconomic marginalisation.1,20 The effects of premature CVD cause ongoing daily trauma for Aboriginal and Torres Strait Islander people.

You’re always hearing about the stats … death happens so often.21

The lived experience of heart disease for Aboriginal and Torres Strait Islander people is pervasive; the high burden of disease means few families have been untouched by cardiovascular events. People and communities live with a background of health-related psychological distress,22 frequent hospitalisations and, too commonly, Sorry business (bereavement) commitments. This context influences every discussion about CVD risk and contributes to experiences of fear, anger, determination, normalisation of disease, hope and hopelessness which may be evoked.20,23 Assessing and reducing CVD risk with Aboriginal and Torres Strait Islander people requires culturally safe shared decision making by biomedical experts (clinicians) and lived experience experts (people, families and communities) across the life course.

This chapter provides guidance on screening and risk assessment for CVD to help guide shared decision-making prevention and risk reduction. The chapter does not cover the management of people who have already had a heart attack, stroke or AF, or the management of specific risk factors, such as moderate–severe kidney disease or familial hypercholesterolaemia. However, primary care teams should be aware that the time following a cardiovascular event is a critical opportunity for secondary prevention, connection to cardiac/stroke rehabilitation and coordination with specialist care services.24 Discharge notifications provide an important opportunity to connect with people following CVD events and tackle risk-reducing strategies. 

 Changes from the third edition

  • Annual assessment of individual CVD risk factors for Aboriginal and Torres Strait Islander people to begin from age 18 years (at the latest)
  • Use of the Australian CVD risk calculator from age 30 years for Aboriginal and Torres Strait Islander people (at the latest) and consideration of adjusting risk assessment upwards if close to a risk threshold
  • Screening for AF opportunistically from age 50 years by palpation of the pulse followed by full ECG or ECG rhythm strip using a hand-held ECG when further assessment is indicated

Numerous rigorous clinical guidelines underpin the screening and management of CVD in Australia, including the cardiovascular risk assessment guidelines (2023),2 AF guidelines (2018)5 and heart failure guidelines (2018).25 In addition, a 2020 consensus statement on CVD risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years provides practical guidance about approaches in younger age groups.1 These resources provide an evidence foundation that is consolidated in this National Guide, noting that the majority of evidence reviews conducted to inform national guidelines focus on whole-of-population approaches, rather than reviews dedicated to the specific needs of Aboriginal and Torres Strait Islander people. Therefore, this chapter of the National Guide seeks to:

  • augment Australian clinical guidelines with evidence that specifically applies to Aboriginal and Torres Strait Islander people
  • adapt recommendations to reflect the cultural, clinical and contextual considerations for Aboriginal and Torres Strait Islander people
  • harmonise recommendations between different guidelines to maximise ease of use and consistency of care for individuals
  • support implementation of evidence-based CVD care into general practice workflow, particularly in Aboriginal Community Controlled Health Organisation and other team settings where many Aboriginal and Torres Strait Islander people access services.

Cardiovascular risk assessment is based on the principle that holistic risk assessment better predicts the probability of cardiovascular events, and can more accurately inform management plans, than assessment of each individual risk factor in isolation. This principle is valid for Aboriginal and Torres Strait Islander people, but there is relatively little population-level CVD data specific to Aboriginal and Torres Strait Islander people that can be used to calibrate risk assessment algorithms or explore specific protective factors or risk. This is particularly relevant at younger ages, when Aboriginal and Torres Strait Islander people are more likely to have a heart attack or stroke than non-Indigenous people. Notably, the term ‘absolute CVD risk’ has been replaced with ‘CVD risk’ to better reflect the context and holistic assessments that cannot be considered ‘absolute’.

Clinicians and patients should be guided by quantitative risk assessment and then make shared decisions about risk reduction based on individual circumstances, beliefs and preferences (see Boxes 1 and 2).

CVD risk assessment

Communicating CVD risk

Discussing CVD risk in a way that is meaningful and empowering for Aboriginal and Torres Strait Islander people is critical for cultural safety and for supporting decisions about risk reduction.19 In particular, clinicians should seek to identify and celebrate strengths (potentially, not smoking, participating in cultural actives, physical activity) alongside a discussion of risk factors. Shared decision making about risk reduction requires a comprehensive discussion about the priorities and context of people and families. Codesigned shared decision-making resources, such as the Finding Your Way tool for discussing COVID-19 vaccine decisions and adapted for CVD risk communication, may help support this kind of conversation.26

Atrial fibrillation

Australian guidelines recommend opportunistic annual screening for AF using pulse palpation followed by an ECG from age 65 years.5 This recommendation is regardless of Aboriginal and Torres Strait Islander status. However, newer data confirm a higher burden of screen-detected AF among Aboriginal people aged >55 years.6 This is consistent with new information about the high rate of stroke among Aboriginal and Torres Strait Islander people mid-adulthood.27 Therefore, this chapter recommends instituting opportunistic annual screening for AF from age 50 years by palpation of the pulse followed by full ECG or ECG rhythm strip using a hand-held ECG when further assessment is indicated, and a low threshold for considering AF at earlier ages, particularly in the setting of risk factors such as rheumatic heart disease (refer to Chapter 12: Acute rheumatic fever and rheumatic heart disease).28

Heart failure

Screening for heart failure (with ECG, echocardiograph or B-type natriuretic peptide [BNP]) is not currently recommended in Australia.25 However, underdiagnosis and delayed diagnosis of heart failure has been identified among Aboriginal and Torres Strait Islander people.29 Clinicians should have a low index of suspicion for considering and investigating heart failure among Aboriginal and Torres Strait Islander people presenting with breathlessness or fatigue.29

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  2. Australian Chronic Disease Prevention Alliance. Australian guideline and calculator for assessing and managing cardiovascular disease risk. Australian Government, 2023 [Accessed 27 May 2024].
  3. Remote Primary Health Care Manuals. CARPA standard treatment manual. 8th edn. Flinders University, 2022 [Accessed 27 May 2024].
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  10. McBride KF, Franks C, Wade V, et al. Good heart: Telling stories of cardiovascular protective and risk factors for Aboriginal women. Heart Lung Circ 2021;30(1):69–77. doi: 10.1016/j.hlc.2020.09.931.
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  12. Tran-Duy A, McDermott R, Knight J, et al. Development and use of prediction models for classification of cardiovascular risk of remote Indigenous Australians. Heart Lung Circ 2020;29(3):374–83. doi: 10.1016/j.hlc.2019.02.005.
  13. Wang Z, Hoy WE. Waist circumference, body mass index, hip circumference and waist-to-hip ratio as predictors of cardiovascular disease in Aboriginal people. Eur J Clin Nutr 2004;58(6):888–93. doi: 10.1038/sj.ejcn.1601891.
  14. Lyons JG, O’Dea K, Walker KZ. Evidence for low high-density lipoprotein cholesterol levels in Australian indigenous peoples: A systematic review. BMC Public Health 2014;14(1):545. doi: 10.1186/1471-2458-14-545.
  15. Maple-Brown LJ, Hughes JT, Lu ZX, et al. Serum vitamin D levels, diabetes and cardio-metabolic risk factors in Aboriginal and Torres Strait Islander Australians. Diabetol Metab Syndr 2014;6(1):78. doi: 10.1186/1758-5996-6-78.
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  18. Verbunt E, Luke J, Paradies Y, et al. Cultural determinants of health for Aboriginal and Torres Strait Islander people – a narrative overview of reviews. Int J Equity Health 2021;20(1):181. doi: 10.1186/s12939-021-01514-2.
  19. Deshmukh T, Abbott P, Reath J. ‘It’s got to be another approach’: An Aboriginal health worker perspective on cardiovascular risk screening and education. Aust Fam Physician 2014;43(7):475–78.
  20. Le Grande M, Jackson AC, Ski CF, Thompson DR, Brown A. Depression, cardiovascular disease and Indigenous Australians. In: Zangeneh M, Al-Krenawi A, editors. Culture, diversity and mental health - enhancing clinical practice. Springer International Publishing, 2019; p. 167–84. doi: 10.1007/978-3-030-26437-6_10.
  21. Taylor KP, Smith JS, Dimer L, et al. ‘You’re always hearing about the stats … death happens so often’: New perspectives on barriers to Aboriginal participation in cardiac rehabilitation. Med J Aust 2010;192(10):602. doi: 10.5694/j.1326-5377.2010.tb03648.x.
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  26. Dimopoulous-Bick T, Follent D. Yarning with mob about COVID-19 vaccines. InSight, 2021
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  28. Balabanski AH, Goldsmith K, Giarola B, et al. Stroke incidence and subtypes in Aboriginal people in remote Australia: A healthcare network population-based study. BMJ Open 2020;10(10):e039533. doi: 10.1136/bmjopen-2020-039533.
  29. McGrady M, Krum H, Carrington MJ, et al. Heart failure, ventricular dysfunction and risk factor prevalence in Australian Aboriginal peoples: The Heart of the Heart Study. Heart 2012;98(21):1562–67. doi: 10.1136/heartjnl-2012-302229.




 

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