Guidelines for preventive activities in general practice

Cardiovascular

Cardiovascular disease (CVD) risk

      1. Cardiovascular disease (CVD) risk

Cardiovascular | Cardiovascular disease (CVD) risk

Screening age bar

09 1014 1519* 2024* 2529* 3034* 3539* 4044* 4549# 5054# 5559# 6064# 6569# 7074# 7579# ≥80
            

*Check blood pressure opportunistically for people aged 1844 years

 

#Screen all people aged 4579 years without known CVD 

Cardiovascular disease (CVD) was the underlying cause of 25% of all deaths in Australia in 2019.1 Behavioural and biomedical risk factors for developing CVD include smoking, diabetes, raised blood pressure (BP), dyslipidaemia, metabolic syndrome, physical inactivity and poor diet.1,2 It is estimated that 57% of Australian adults had three or more key modifiable CVD risk factors in 2014–18.1 Additionally, family history of premature heart disease in a first-degree female relative aged <65 years or a first-degree male relative aged <55 years, severe mental illness, and psychosocial stressors are recognised risk factors for CVD.2,3

Use of the Australian CVD risk calculator is recommended to assess risk and guide further management.

Screening

Recommendation Grade How often References
Screening for high blood pressure (BP) in children and adolescents is generally not recommended. Generally not recommended N/A 4
Screening for hypertension in the general population (from age 18 years) is recommended. Secondary causes and white coat hypertension should be considered (refer to Further information).
For further detail, please see the Heart Foundation’s ‘Guidelines for the diagnosis and management of hypertension in adults – 2016’.
Recommended (Strong) Opportunistically, (Practice point) 2, 5
Routine measuring of cholesterol before age 45 years is generally not recommended, unless familial hypercholesterolaemia is suspected. Generally not recommended N/A 2, 6
Assessing cardiovascular disease (CVD) risk in all people aged 45–79 years using the Australian CVD risk calculator is recommended. Refer to the Australian guideline for assessing and managing cardiovascular disease risk for risk categorisation, management and follow-up. Recommended (Strong) Every 5years unless risk factors worsen. Intervals between reassessments of CVD risk should be determined using the most recent estimated risk level as baseline. 2
Screening for CVD risk using a coronary artery calcium (CAC) score is not recommended in the general population. Not recommended (Strong) N/A 2, 7
If the person has other significant risk considerations (eg family history, severe mental illness, estimated glomerular filtration rate [eGFR] <45), consult the Australian cardiovascular disease risk calculator for further information. Practice point N/A 2

Preventive activities and advice

Recommendation Grade How often Reference
Smoking cessation
Encouraging, supporting and advising all people who smoke to quit is recommended. Refer them to a behavioural intervention (eg smoking cessation counselling program) combined with a Therapeutic Goods Administration–approved pharmacotherapy, where clinically indicated.
Recommended (Strong) N/A 2
Physical activity
Regular, sustainable physical activity, such as an exercise program, is recommended to reduce risk of CVD.
Recommended (Strong) N/A 2
Healthy eating
Following a healthy eating pattern low in saturated and trans fats is recommended. A healthy eating pattern should consist of:
  • plenty of vegetables, fruit and wholegrains
  • a variety of healthy protein-rich foods from animal and/or plant sources
  • unflavoured milk, yoghurt and cheese
  • foods that contain healthy fats and oils (eg olive oil, nuts and seeds, and fish).
 
Recommended (Strong) N/A 2
Consume oily fish
Regular consumption of oily fish is recommended to reduce risk of coronary heart disease and death due to coronary heart disease.
Conditionally recommended N/A 2
Restrict sodium
Restriction of sodium intake to lower BP is recommended.
Conditionally recommended N/A 2
Healthy weight
Achieving and maintaining a healthy weight is recommended.
Conditionally recommended N/A 2
Alcohol consumption
Reducing alcohol consumption where necessary, for people who consume alcohol, is recommended. Refer to the national guidelines to reduce health risks from drinking alcohol.
Conditionally recommended N/A 2
Aspirin
It is currently unclear if the additional benefits of taking aspirin for the primary prevention of CVD outweigh the potential harms of gastrointestinal bleeding. Refer to Further information.
Practice point N/A 2

Blood pressure

Measure BP on at least two separate occasions with a calibrated mercury sphygmomanometer, or automated device that is regularly calibrated against a mercury sphygmomanometer. For the Australian CVD risk calculator, use the average of the last two seated, in-clinic BP measurements, or two measurements at least 10 minutes apart if at the same visit.2 At the patient’s first BP assessment, measure BP on both arms. Thereafter, use the arm with the higher reading.

In patients who may have orthostatic hypotension (eg elderly, diabetic), measure BP in a sitting position and repeat after the patient has been standing for at least two minutes.6

Ambulatory BP monitoring

If possible, use ambulatory BP monitoring or self-measurement or out-of-clinic measurements for patients with:6

  • unusual variation between BP readings in the clinic
  • suspected ‘white coat’ hypertension
  • hypertension that is resistant to drug treatment
  • suspected hypotensive episodes.

Primary aldosteronism

Primary aldosteronism occurs in approximately 5–10% of patients with hypertension, and should be suspected in patients with:6,8

  • moderate to severe hypertension (sustained BP above 150/100 in three separate measurements taken on different days)
  • treatment-resistant hypertension (hypertension is controlled with four or more medications)
  • hypokalaemia.

Referral to a specialist for investigation is recommended when primary aldosteronism is suspected.6 The management of primary aldosteronism: Case detection, diagnosis, and treatment: An Endocrine Society clinical practice guideline provides further information.

Cholesterol

If lipid levels are abnormal, a second confirmatory sample should be taken on a separate occasion (as levels may vary between tests) before making a treatment decision based on a risk assessment. A fasting sample should be used when assessing elevated triglycerides.

Screening tests using capillary blood samples produce total cholesterol results that are slightly lower than on venous blood. These may be used, providing they are confirmed with full laboratory testing of venous blood for patients with elevated lipid levels and there is good follow-up.

In adults with low CVD risk, blood tests results within five years may be used for review of CVD risk, unless there are contrary reasons to review more regularly.

Lipoprotein(a)

There is currently no justification for lipoprotein(a) screening in the general population.2

Prevention

It is important to communicate five-year CVD risk to patients to enable informed decisions about reducing risk and improve compliance.2 

Modifiable risk factors should be managed at all risk levels. 

Managing CVD risk should always involve encouraging, supporting and advising appropriate healthy lifestyle and behaviours, with or without BP-lowering and/or lipid-modifying pharmacotherapy. Once the recommended management plan is identified according to risk category, this needs to be further refined in collaboration with the person, after discussing the risks and benefits of treatment options, and their personal values and preferences.

People vary in what they find motivating; for some this is having targets in place. Set targets in consultation with the person according to what is practicable and achievable for them. 

Pre-existing cardiovascular disease requires preventive pharmacotherapy. Conditions include:2

  • myocardial infarction
  • angina
  • other coronary heart disease
  • stroke
  • transient ischaemic attack
  • peripheral vascular disease
  • congestive heart failure
  • other ischaemic CVD-related conditions. 

Aspirin

As part of patient decision making, GPs may want to also consider the aspirin recommendation in relation to bowel cancer prevention. Please refer to the Bowel cancer chapter.

Please also refer to the Atrial fibrillation, Kidney and Diabetes chapters for further information on screening and preventive activities.

Aboriginal and Torres Strait Islander people experience a higher burden, earlier onset and faster progression of kidney disease, due to ongoing impacts of colonisation (CKD guidelines). CVD risk assessments also need to commence earlier for Aboriginal and Torres Strait Islander people.

Assess CVD risk2

  • Aboriginal and Torres Strait Islander people, without known CVD, aged 30–79 years.

Assess individual CVD risk factors2

  • Aboriginal and Torres Strait Islander people, without known CVD, aged 18–29 years.

Assessment can be considered in younger age groups (aged 12–17 years). Please refer to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, Chapter 11: Cardiovascular disease prevention.

There are some specific populations that are associated with high rates of CVD whose risk assessments need to commence earlier than usual.2

Assess CVD risk2

  • People with diabetes, without known CVD, aged 35–79 years.
  • First Nations people, without known CVD (includes Aboriginal and Torres Strait Islander people and Māori people), aged 30–79 years.

Assess individual CVD risk factors2

  • First Nations people, without known CVD (includes Aboriginal and Torres Strait Islander people and Māori people), aged 18–29 years.

People living with severe mental illness are sixfold more likely to die from CVD than people without severe mental illness.9 For people living with severe mental illness, consider reclassifying estimated CVD risk to a higher risk category, particularly if calculated risk is close to a higher risk threshold.2

People with reduced eGFR, or persistently raised urine albumin-to-creatinine ratio, are at increased CVD risk.2

A guideline for GPs and other health professionals to support people who wish to quit smoking:
Supporting smoking cessation: A guide for health professionals | RACGP
 
A guide for GPs and other health professionals to work with patients on the lifestyle risk factors of smoking, nutrition, alcohol and physical activity (SNAP):
Smoking, nutrition, alcohol, physical activity (SNAP) | RACGP
 
For further information about familial hypercholesterolaemia:
Familial hypercholesterolaemia, Genomics in general practice | RACGP
 
The early identification and optimal management of people with type 2 diabetes:
Management of type 2 diabetes: A handbook for general practice | RACGP
 
Comprehensive guideline about CVD risk assessment and management:
Australian guideline for assessing and managing cardiovascular disease risk | Australian Chronic Disease Prevention Alliance
 
A risk assessment, communication and management tool for health professionals:
Australian CVD risk calculator | Heart Foundation, Australian Chronic Disease Prevention Alliance
 
Evidence-based advice on the health effects of drinking alcohol:
Australian guideline to reduce risks from drinking alcohol | National Health and Medical Research Council
 
Further information and resources to help improve the physical health, including cardiovascular health, of people living with mental illness:
Equally Well

  1. Australian Institute of Health and Welfare. Heart, stroke and vascular disease: Australian facts. AIHW, 2023 [Accessed 15 May 2023].
  2. Heart Foundation, Australian Chronic Disease Prevention Alliance. Australian guideline for assessing and managing cardiovascular disease risk. Department of Health and Aged Care, 2023 [Accessed 13 March 2024].
  3. Gronewold J, Engels M, van de Velde S, et al. Effects of life events and social isolation on stroke and coronary heart disease. Stroke 2021;52(2):735–47. doi: 10.1161/STROKEAHA.120.032070.
  4. Gartlehner G, Vander Schaaf EB, Orr C, et al. Screening for hypertension in children and adolescents: Systematic review for the U.S. Preventive Services Task Force. Evidence Synthesis, no. 193. Rockville, MD: Agency for Healthcare Research and Quality (U.S.), 2020 [Accessed 13 March 2024].
  5. U.S. Preventive Services Task Force; Krist AH, Davidson KW, Mangione CM, et al. Screening for hypertension in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement. JAMA 2021;27;325(16):1650–56. doi: 10.1001/jama.2021.4987. PMID: 33904861.
  6. The Royal Australian College of General Practitioners. Genomics in general practice. RACGP, 2022.
  7. The Royal Australian College of General Practitioners. First do no harm: A guide to choosing wisely in general practice. RACGP, 2023.
  8. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: Case detection, diagnosis, and treatment: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016;101(5):1889–916. doi: 10.1210/jc.2015-4061. PMID: 26934393.
  9. National Mental Health Commission. Equally Well consensus statement: Improving the physical health and wellbeing of people living with mental illness in Australia. NMHC, 2016.
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