Goals of CVD ask assessment

1. Reduce risk of developing: coronary heart disease (angina or myocardial infarction), stroke/transient ischaemic attack and peripheral arterial disease

2. Improve QoL

3. Improve life expectancy

QRISK 3-2018

QRISK 3 calculates a person’s risk of developing myocardial infarction or stroke over the next 10 years in individuals with no prior diagnosis of coronary heart disease or stroke/transient ischaemic attack.
There is overlap in the risk factors that predispose to MI and stroke.
QRISK is valid for people aged 25y to 84y.

Physiopathology

Underlying cause of CVD is the formation of plaques of atheroma within the walls of arteries (atherosclerosis).
Atheromas contain WBCs, lipids, calcium and fibrous connective tissue.
Over time, progressive growth of atheroma causes arterial narrowing and restriction of blood flow.
Rupture of the plaque of atheroma triggers thrombosis which may completely or partially occlude blood flow in the affected artery.

CVD Risk factors

Non-modifiable risk factors
Older age
Male (at all ages)
Female>75y higher risk of stroke
Family history of CVD
Ethnicity (such as South Asian origin)

Modifiable risk factors
Smoking
Low HDL cholesterol
High non-HDL cholesterol
Elevated BMI (overweight, obesity)
Lack of physical activity
Unhealthy diet
Alcohol misuse

Comorbidities
Hypertension
Atrial fibrillation
Diabetes (and pre-diabetes/metabolic syndrome)
Chronic kidney disease (CKD)
Dyslipidaemia (familial and non-familial)
Rheumatoid arthritis/ SLE
Obesity (and obstructive sleep apnoea)
Influenza
Severe mental illness
Periodontitis
Corticosteroid treatment
Antipsychotic drug treatment
Erectile dysfunction diagnosis/treatment

Prognostic factors under research: blood levels of apolipoprotein B100: apolipoprotein A1, CRP, fibrinogen, lipoprotein(a).

Management

QRISK >10% considered high-risk.
However, clinical judgement is required to adjust for factors that the risk calculator does not take into account.

1. Commence lifestyle interventions: smoking cessation, weight loss, healthy diet, safe alcohol consumption, become physically active.

2. Optimise treatment of comorbidities

3. Commence statin: recommend atorvastatin 20 mg a day (check for contraindications) if QRISK>10% or lifestyle interventions are not effective

Prevention and Control

Primary prevention of CVD without prior diagnosis of diabetes, CVD, CKD, stroke/TIA or dementia:

NHS Health Check Programme screens people aged 40y to 74y every 5 years.
Screening includes:

• CVD risk assessment (checking BMI, BP, smoking, PMHx, FHx and testing for total cholesterol/HDL cholesterol ratio, HbA1c, kidney function)

• Testing for diabetes and chronic kidney disease (if high-risk group)

• Lifestyle assessment (physical activity, alcohol consumption)

• Assessment for dementia (in those aged 65-74y)

Primary prevention of CVD in older adults:
By 61y (if male) or 68y (if female), a person has acquired a QRISK 3 score of least 10%.
QRISK 3 does not estimate risk beyond age 84y.
There is uncertainty in management and the issue is discussed elsewhere.