Prioritising CVD risk assessment and management for at-risk patient groups

By Rhiannon Bennett, Healthcare Programs Officer, Heart Foundation, Kerryn Brims, Senior Healthcare Programs Officer, Heart Foundation, Jasmine Just, Senior Medical Writer, Heart Foundation,  Natalie Raffoul, Healthcare Programs Manager, Heart Foundation

Source: APNA Primary Times Winter 2022 (Volume 22, Issue 1)

With one Australian having a heart attack or stroke every 4 minutes, primary health care nurses have the power to change this statistic by focussing on simple, yet life-saving, preventative care. Take the opportunity to deliver routine cardiovascular disease (CVD) risk assessment and management for more of your at-risk patients.  

Two years on from the start of the pandemic, there is growing evidence that COVID-19 is associated with worse cardiovascular outcomes 12 months post-infection.1 The impact of COVID-19 on routine screening activities, together with the potential heart health consequences of long COVID, means that CVD screening is more important than ever.  

But despite the challenges of living with COVID-19, vaccination programs and other uncertainties, primary health care has delivered more than 275,000 Heart Health Checks since the 699 and 177 Medical Benefits Schedule (MBS) items were introduced in 2019. 

Take the opportunity to utilise the Heart Foundation’s Heart Health Check Toolkit to embed regular CVD risk assessment and management into your routine care, particularly for the following four patient groups with known elevated CVD risk.  

  1. Patients with diabetes 

It is estimated that the rate of death from CVD is over 4 times higher for people with diabetes compared to those without diabetes.2,3 Coronary heart disease, stroke and peripheral vascular disease typically appear earlier in patients with type 2 diabetes (by approximately 14 years).  

Australian guidelines recommend that adults who have diabetes and are aged over 60 years and those who have diabetes with microalbuminuria (>20 mcg/min or urinary albumin:creatinine ratio >2.5mg/mmol for males, >3.5mg/mmol for females) are ‘clinically determined high risk’. These individuals should be managed as per high-risk recommendations: initiate lipid and blood-pressure lowering therapy in addition to encouraging lifestyle changes.4  

General Practice Management Plans and Team Care Arrangements can improve clinical outcomes for people living with diabetes.5 You can use the Heart Health Check Toolkit’s data recipes to identify patients eligible for a Heart Health Check and Chronic Disease Management Plan. 

  1. Women with history of gestational diabetes 

In 2016–2017, approximately 15% of all women who gave birth in hospital were diagnosed with gestational diabetes.6 It is estimated that women with a previous diagnosis of gestational diabetes have a twofold increased risk of developing coronary artery calcification, increasing their CVD risk, even if they maintain healthy blood glucose levels postpartum.7 Current recommendations place emphasis on lifestyle interventions and recommend an oral glucose tolerance test 6–12 weeks postpartum and regular screening of blood glucose, HbA1c and cardiovascular risk factors.8  

You can use the Heart Health Check Toolkit’s CAT4 data recipes to identify female patients who are eligible for the Heart Health Check and who have had a previous diagnosis of gestational diabetes.  

  1. Aboriginal and/or Torres Strait Islander Peoples 

On average, cardiovascular events, such as heart attacks and strokes, and CVD-related mortality occur 10–20 years earlier in the Aboriginal and/or Torres Strait Islander population than in the non-Indigenous population.9 Approximately 16% of Aboriginal and/or Torres Strait Islander Peoples aged 35–74 years are at high absolute risk of a future CVD event.10  


The most recent Australian consensus statement recommends that absolute risk assessment should begin from 30 years for Aboriginal and/or Torres Strait Islander Peoples. Individual risk factor screening should begin from 18 years at the latest.11  

Cardiovascular risk assessment and management should occur as part of an annual health check for these patients. You can find out more about the 715 Health Check in the ‘Conducting Heart Health Checks’ section of the Heart Health Check Toolkit. 

  1. People living with mental illness 

One in 5 Australians live with a mental or behavioural condition.12  

It is well-established that serious mental illness increases the risk of developing coronary heart disease, independent of conventional risk factors.13 Anxiety, depression, social isolation and loneliness can increase the risk of having a heart attack or coronary heart disease.13, 14, 15, 16, 17  

Depression has been shown to increase the risk of unhealthy behaviours, including smoking, having an unhealthy diet, physical inactivity and medicine non-adherence.18 

Guidelines recommend assessing for depression and other psychosocial factors when conducting CVD risk assessment, including during a Heart Health Check.4 A comprehensive Heart Health Check assessment template, which includes mental health considerations, can be found in the ‘Conducting Heart Health Checks’ section of the Heart Health Check Toolkit or can be built into Best Practice software. 

The essential role of practice nurses in implementing the Heart Health Check 

A collaborative approach is recommended when implementing the Heart Health Check. The essential role of a practice nurse includes: 

  • Work with the practice manager to develop processes to identify eligible patients. 

  • Work with administration staff to ensure invitations and reminders are sent to patients. 

  • Collect patient information and enter CVD risk factor data. 

  • Educate the patient about modifiable risk factors and provide advice on lifestyle programs. 

  • Use Heart Foundation resources to help educate and engage patients. 

  • Identify quality-improvement activities in line with Practice Incentive Program Quality Improvement (PIP QI) incentive requirements. 

  • Understand the MBS compliance requirements for item numbers 699 and 177. 

  • Identify opportunities for completion of a GP Management Plan (GPMP)/Team Care Arrangement (TCA). 

Resources to streamline your Heart Health Checks 

New resources were added to the Heart Foundation’s Heart Health Check Toolkit in May 2022 to help optimise your management of clinical and lifestyle risk factors, so be sure to browse and bookmark the Toolkit:


Join us across the country at the APNA Roadshow  

Join our session ‘Heart Health Checks – The Road to Preventing Heart Disease in Your Practice’. 

This workshop will explore the latest tools and evidence to improve CVD screening and management, simplified by the Heart Health Check Toolkit. You will learn about tools to support absolute CVD risk assessment, recall of eligible patients, quality improvement and patient-engagement activities. 

Register Now at



1. Y Xie, E Xu, B Bowe and Z Al-Aly, 'Long-term cardiovascular outcomes of COVID-19', Nat Med, 2022, 28:583–590, doi:10.1038/s41591-022-01689-3

2. Baker Heart & Diabetes Institute, 'The dark heart of type 2 diabetes', Baker Heart & Diabetes Institute website, 2018, accessed 2 May 2022. 

3. D Glovaci, W Fan and ND Wong, 'Epidemiology of diabetes mellitus and cardiovascular disease', Curr Cardiol Rep, 2019, 21(4):21, doi:10.1007/s11886-019-1107-y

4. National Vascular Disease Prevention Alliance, 'Guidelines for the management of absolute cardiovascular disease risk', Heart Foundation website, 2012, accessed 2 May 2022. 

5. LK Wickramasinghe, P Schattner, ME Hibbert, JC Enticott, MP Georgeff and GM Russell, 'Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews', Med J Aust, 2013, 199(4):261–265, doi:10.5694/mja13.10161

6. Australian Institute of Health and Welfare (AIHW), 'Incidence of gestational diabetes in Australia – Cat no. CVD 85', AIHW website, 2019, accessed 2 May 2022. 

7. EP Gunderson, B Sun, JM Catov et al., 'Gestational diabetes history and glucose tolerance after pregnancy associated with coronary artery calcium in women during midlife', Circulation, 2021, 143(10):974–987, doi:10.1161/CIRCULATIONAHA.120.047320

8. Royal Australian College of General Practitioners (RACGP), 'Management of type 2 diabetes: a handbook for general practice', RACGP website, 2020, accessed 2 May 2022. 

9. Australian Institute of Health and Welfare (AIHW), 'Cardiovascular disease, diabetes and chronic kidney disease – Australian facts: Aboriginal and Torres Strait Islander People – Series no. 5, Cat no. CDK 5', AIHW website, 2015, accessed 2 May 2022. 

10. B Calabria, RJ Korda, RW Lovett et al., 'Absolute cardiovascular disease risk and lipid-lowering therapy among Aboriginal and Torres Strait Islander Australians', Med J Aust, 2018, 209(1):35–41, doi:10.5694/mja17.00897

11. JW Agostino, D Wong, E Paige et al., 'Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement,' Med J Aust, 2020, 212(9):422–427, doi:10.5694/mja2.50529

12. Australian Bureau of Statistics (ABS), 'National Health Survey: first results, 2017-2018 – ABS cat no 4364055001', ABS website, 2018, accessed 2 May 2022. 

13. MD Hert, J Detraux and D Vancampfort, 'The intriguing relationship between coronary heart disease and mental disorders', Dialogues Clin Neuroscience, 2018, 20(1):31–40, doi:10.31887/DCNS.2018.20.1/mdehert

14. CR Gale, GD Batty, DPJ Osborn, P Tynelius and F Rasmussen, 'Mental disorders across the adult life course and future coronary heart disease: evidence for general susceptibility', Circulation, 2014, 129(2):186–193, doi:10.1161/CIRCULATIONAHA.113.002065

15. N Glozier, GH Tofler, DM Colquhoun et al., 'Psychological risk factors for coronary heart disease', Med J Aust, 2013, 199(3):179–180, doi:10.5694/mja13.10440

16. J Holt-Lunstad, TB Smith, M Baker, T Harris and D Stephenson, 'Loneliness and social isolation as risk factors for mortality: a meta-analytic review', Perspect Psychol Sci, 2015, 10(2):227–237, doi:10.1177/1745691614568352

17. DL Hare, SR Toukhsati, P Johansson and T Jaarsma, 'Depression and cardiovascular disease: a clinical review', Eur Heart J, 2014, 35(21):1365–1372, doi:10.1093/eurheartj/eht462

18. MB Riba, LR Wulsin and M Rubenfire, Psychiatry and heart disease: the mind, brain, and heart, Wiley–Blackwell, Chichester, 2012. 

The Australian Primary Health Care Nurses Association acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respects to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

© Copyright 2024 Australian Primary Health Care Nurses Association (APNA). All rights reserved. MRM by Bond Software.


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