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.

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.⁸

Ambulatory BP monitoring

If possible, use ambulatory BP monitoring or self-measurement or out-of-clinic measurements for patients with:⁸

• 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:^8,9

• 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.⁸ 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 16: 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.¹⁰ 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