10 min Review-de Lusignan prf4 10/12/09 17:45 Page 1

CONCISE CONSULTATION

Assessing cardiovascular risk

Safia Debar1,
Simon de Lusignan2*
Juan Carlos Kaski3
1 Academic GP registrar (ST4)
2 Reader in General Practice
3 Professor of Cardiovascular
Science; Director, Cardiovascular
Biology Research Centre; Deputy
Head, Cardiac and Vascular
Sciences
St George’s University of London
Cranmer Terrace
London, SW17 0RE
*Corresponding author
in the 10-minute consultation
BACKGROUND
Cardiovascular disease is a major cause of mortality and
morbidity which can be managed successfully in
primary care. However, despite the quality of the
evidence base and the universal use of practice-based
information systems that can flag suboptimally
managed patients and calculate risk for individuals
opportunistically, there remains a gap in the primary
care management of cardiovascular disease.1,2
CASE
A 45-year-old Indian minicab driver attends the surgery
to discuss his recent test results. He saw the practice
nurse for a cholesterol test after his younger brother

© Ian Hooton/Science Photo Library

died suddenly from an acute myocardial infarction (MI).
Prim Care Cardiovasc J 2009; 2: The nurse recorded the following information:
181-3
currently unemployed, smokes occasionally (three
doi:10.3132/pccj.2009.058
cigarettes/day), body mass index (BMI) 28 kg/m2 and BP
138/88 mmHg. His blood results report a total
cholesterol (TC) of 5.3 mmol/L, high-density lipoproteins
(HDL) 1.1 mmol/L, low-density lipoproteins (LDL) 3.3
mmol/L and a fasting glucose 5.5 mmol/L.
WHAT YOU SHOULD COVER
It is not practical or feasible to manage all
cardiovascular risk factors in this consultation. Instead,
you should include the elements that are essential to
most accurately calculate his cardiovascular risk.
You should record the patient’s ethnicity. The South
Asian population has a higher mortality from
cardiovascular disease than any other ethnic group.3
Acute events occur about 8-10 years earlier than in the
white population and people of South Asian origin have
more advanced disease on angiogram. The cause is likely
to be a combination of genetic predisposition and
environmental factors resulting in central obesity, insulin
resistance, slightly raised triglycerides and a low HDL.4,5
This patient’s risk is compounded by social deprivation.
Explore if there is any family history. Any first-degree
relatives under 60 years with a history of a heart attack
or stroke automatically place the patient at high risk and
he should have any risk factors – in this case, his TC,
LDL, obesity and smoking – actively managed.
Check the patient’s blood pressure. If he is hypertensive,
consider checking his creatinine and urinary albumin-
creatinine ratio for evidence of chronic kidney disease
(CKD). Fasting blood sugar should be measured for
evidence of metabolic syndrome and thyroid function
tests performed, as thyroid problems can occasionally be
the cause of hyperlipidaemia. An ECG should be checked
for evidence of left ventricular hypertrophy.
CALCULATING RISK
Calculate the patient’s cardiovascular risk using the risk
calculator in your computerised medical record system or
using an online tool. Whichever tool you decide to use,
you must be aware of its limitations – it may not take into
account important risk factors relevant to this patient.
In this case the risk may appear lower because the
risk calculators do not usually take into account
ethnicity or family history (see Table 1).
WHAT YOU SHOULD DO
The first step is to explain the risk to the patient. A risk
score of 20% could be explained by saying: “In a group of

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CONCISE CONSULTATION

“
Table 1: The different variables included in risk factor calculators and the difference in apparent
vascular risk
Calculate the Risk calculator: ASSIGN BNF ETHRISK Framingham7 QRISK8
patient’s Factors included:
cardiovascular Age, sex, BP, smoking, cholesterol (TC, HDL or TC:HDL) ✔ ✔ ✔ ✔ ✔
risk using the
Ethnicity and social deprivation ✔
risk calculator
Diabetes ✔ ✔ ✔
in your
computerised Family history ✔ ✔ ✔

medical record LVH on ECG ✔

system or using CKD, BP Rx, AF, BMI, personal history of CHD ✔

an online tool Risk of developing CVD over 10 years 9.7% 13.6% 14% 17.1% 19%

” Table 2: Resources for calculating risk

1 Online risk calculators

Framingham/ASSIGN/BNF: http://cvris1-Online Risk Calculators
Framingham/ASSIGN/BNF: http://cvrisk.mvm.ed.ac.uk/calculator/calc.asp
QRISK: http://qr2.dyndns.org/index.php
ETHRISK: http://www.epi.bris.ac.uk/CVDethrisk/CHD_CVD_form.html

2 Resources about calculating risk

MeReC Bulletin: Assessing cardiovascular risk (Part 1). Volume 11, Number 7, 2000.
http://www.npc.co.uk/MeReC_Bulletins/2000Volumes/pdfs/vol%2011n07.pdf
MeReC Bulletin: Assessing cardiovascular risk (Part 2). Volume 11, Number 8, 2000.
http://www.npc.co.uk/MeReC_Bulletins/2000Volumes/pdfs/Vol11n08.pdf
The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management. A report prepared for the
UK National Screening Committee by the University of Leicester. 2008.

3 National guidelines
Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and
children: 43 (2006) http://www.nice.org.uk/nicemedia/pdf/CG43quickrefguide2.pdf
Diabetes – type 2 (update): 66 (2008) http://www.nice.org.uk/nicemedia/pdf/CG66T2DQRG.pdf
Lipid modification, cardiovascular risk assessment and the modification of blood lipids for primary and
secondary prevention of cardiovascular disease: 67 (2008)
http://www.nice.org.uk/nicemedia/pdf/CG67quickrefguide.pdf

4 Information about communicating risk

Alaszewski A, Horlick-Jones T. How can doctors communicate information about risk more effectively? BMJ
2003; 327:728-31.
Dr Chris Cates’ EBM website: http://www.nntonline.net/visualrx/cates_plot/

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“
100 people like you, 20 will develop heart disease or have a
stroke in the next 10 years. In other words, you have a one
in five chance of getting cardiovascular disease over the
Present the next 10 years”. The patient’s absolute risk can also be
benefits of graphically represented using online risk calculators, or
by using a Cates plot.9
lifestyle and An explanation of the patient’s relative risk is useful,
treatment especially when comparing the risk in different groups of
options in the people (for example, smokers versus non-smokers) and
when discussing the benefit of treatment.10
context of the Present the benefits of lifestyle and treatment options
patient’s high in the context of the patient’s high risk of cardiovascular
disease.
risk of Agree which risk factors might be addressed first.
cardiovascular These may include: giving prompt smoking advice,
”
disease lifestyle advice, and starting a statin (simvastatin 40
mg).11 Brief smoking advice is one of the most cost-
effective interventions to reduce cardiovascular risk.12
Suggested advice may be: “Stopping smoking will reduce
your risk of developing heart disease. Your chances of
stopping increase significantly with support from a trained
advisor. If you are interested, here is the number for our
local smoking cessation service."
Diet and exercise advice may well be heeded by
someone realising his or her risk and contemplating
change. Currently, no target lipid levels are routinely
recommended for primary prevention.
Finally, arrange further follow-up to check on the
patient’s progress and to ensure that his/her risk is
effectively reduced.
SUMMING UP
This patient is at high risk for cardiovascular events
because he has traditional risk factors in addition to
South Asian ethnicity, strong family history, social
PCCJ VOLUME 2, ISSUE 4, OCTOBER/NOVEMBER/DECEMBER 2009
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CONCISE CONSULTATION
deprivation, and central obesity, which all add to
cardiovascular risk. If tests detect diabetes, metabolic
syndrome, chronic kidney disease and left ventricular
hypertrophy, these further add to his risk. Risk
calculators are a useful guide, but they do not replace
using clinical judgement to personalise patient care.
References
1. de Lusignan S, Belsey J, Hague N et al. Audit-based education to reduce
suboptimal management of cholesterol in primary care: a before and after
study. J Public Health (Oxf) 2006; 28(4):361-9.
2. Belsey J, de Lusignan S, Chan T et al. Abnormal lipids in high-risk patients
achieving cholesterol targets: a cross-sectional study of routinely collected
UK general practice data. Curr Med Res Opin 2008; 24(9):2551-60.
3. British Heart Foundation: http://www.heartstats.org/datapage.asp?id=737
4. Forouhi NG, Sattar N, Tillin T, McKeigue PM, Chaturvedi N. Do known risk
factors explain the higher coronary heart disease mortality in South Asian
compared with European men? Prospective follow-up of the Southall and
Brent studies, UK. Diabetologia 2006; 49(11): 2580-8.
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Predicted and observed cardiovascular disease in South Asians: application
of FINRISK, Framingham and SCORE models to Newcastle Heart Project
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family history to cardiovascular risk assessment: the ASSIGN score from the
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URL: http://www.assign-score.com/
7. Kannel WB, McGee D, Gordon T. A general cardiovascular risk profile: the
Framingham Study. Am J Cardiol 1976; 38:46-51.
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Brindle P. Predicting cardiovascular risk in England and Wales: prospective
derivation and validation of QRISK2. BMJ 2008; 336(7659):1475-82.
9. Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into
meaningful pictures. BMJ 2002; 6;324(7341):827-30.
10. Gigerenzer G, Edwards A. Simple tools for understanding risks: from
innumeracy to insight. BMJ 2003; 327:741-4.
11. National Institute for Health and Clinical Excellence. Lipid modification,
cardiovascular risk assessment and the modification of blood lipids for
primary and secondary prevention of cardiovascular disease 2008. (Clinical
Guideline 67).
12. Critchley JA, Capewell S. Mortality risk reduction associated with smoking
cessation in patients with coronary heart disease: a systematic review.
JAMA 2003; 290:86-7.
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