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Australia’s new cardiovascular guideline and calculator in practice
Natalie Raffoul, Senior Manager, Healthcare Programs and Clinical Strategy, National Heart Foundation of Australia, Kerryn Brims, Senior Healthcare Programs Officer, Risk Reduction Lead, National Heart Foundation of Australia, Lisa Kalman, Senior Program Officer, Healthcare Systems Integration Lead, National Heart Foundation of Australia, Tina Garcia, Senior Medical Writer, National Heart Foundation of Australia
Launched in July 2023, the Australian Guideline for Assessing and Managing Cardiovascular Disease (CVD) Risk1 provides recommendations, practice advice and resources to support primary health care professionals in the identification, assessment, communication, and management of a person’s risk of developing CVD. Here we will step you through the new recommendations and practical application to delivery in the primary care setting.
CVD remains Australia’s biggest killer, taking one Australian life every 12 minutes.2 It costs the economy $5 billion each year, more than any other disease.3
CVD is responsible for significant morbidity and premature mortality in Australia.4 In 2023, the Australian Institute of Health and Welfare reported an increase in age-adjusted coronary heart disease mortality rates, representing the first increase in decades.5
The 2023 guideline provides updated evidence-based recommendations for identifying, assessing, communicating and managing CVD risk in a primary prevention setting.
It incorporates the Australian CVD Risk Calculator (Aus CVD Risk calculator), which is based on an equation developed from a large New Zealand cohort study and has been modified and recalibrated for the Australian population.
Specific recommendations, resources and practice advice for First Nations peoples are also included throughout.
The guideline is intended for use by GPs, nurses, Aboriginal Health Practitioners, allied health professionals and other professionals who support the primary prevention of CVD.
Figure 1. Overview of cardiovascular disease risk assessment and management
Reproduced with permission from the National Heart Foundation of Australia, citing the 2023 Cardiovascular Disease Risk Calculator and Guidelines.
© 2023 Commonwealth of Australia as represented by the Department of Health and Aged Care
Note. AF: atrial fibrillation; BMI: body mass index; BP: blood pressure; CAC: coronary artery calcium; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; FH: familial hypercholesterolaemia; HbA1c: haemoglobin A1c; HDL-C: high-density lipoprotein cholesterol; TC: total cholesterol; uACR: urine albumin-to-creatinine ratio. Family history: coronary heart disease (CHD) or stroke in a first-degree female relative aged <65 years or a first-degree male relative aged <55 years. Severe mental illness: a current or recent mental health condition requiring specialist treatment, whether received or not, in the 5 years prior to the CVD risk assessment. Derived from the PREDICT cohort.7 This guideline refers to certain modifiable risk factors as ‘lifestyle’ factors. However, it is recognised that these behaviours are not necessarily an individual’s choice, but reflect the complex interplay of social, cultural, and environmental factors, which may be further influenced by clinical conditions. Use of the term ‘lifestyle’ does not attribute blame to a person.
What’s new in the guideline?
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Different age groups for risk assessment
CVD risk assessment is recommended for a broad range of people without known CVD aged 45 to 79 years.
Target age ranges for risk assessment have also been tailored according to diabetes and First Nations status (for people without known CVD):
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people with diabetes aged 35–79 years
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First Nations people aged 30–79 years
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First Nations people aged 18–29 years should have their individual risk factors assessed.
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Australian CVD Risk Calculator
The Aus CVD Risk Calculator is based on the PREDICT-1 equation,6 which was developed from a large New Zealand population cohort study, then recalibrated to the Australian population and modified for the Australian healthcare setting.
It includes optional risk factors not included in the previous Framingham-based equation, such as geographical area (using postcodes to measure area-level deprivation) and diagnosis of atrial fibrillation.
The calculator allows for improved CVD risk estimation in people with type 2 diabetes, with a specific sub-equation, including time since diagnosis, glycated haemoglobin (HbA1c), urinary albumin-to-creatinine ratio (uACR), estimated glomerular filtration rate (eGFR), body mass index (BMI) and the use of insulin in the previous six months.
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Redefined risk categories
New risk categories have been redefined, representing the chance of having a cardiovascular event in the next 5 years. The Aus CVD Risk calculator produces estimated 5-year CVD risk scores, expressed as a percentage, and places people into one of three risk categories:
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high (≥10% risk over 5 years)
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intermediate (5% to <10% risk over 5 years)
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low (<5% risk over 5 years).
The redefined categories help direct management, including encouraging and supporting healthy lifestyles and behaviours, and target pharmacotherapy to those who will benefit most.
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Reclassification factors
New guidance has been provided on factors that may help clinicians refine risk estimates when using the Aus CVD Risk calculator.
Reclassification factors – including ethnicity, chronic kidney disease, severe mental illness, coronary artery calcium score and family history of premature CVD – have been added to improve risk estimation beyond traditional CVD risk prediction equations and help refine CVD risk categorisation. This is particularly relevant for people close to the threshold of another risk category.
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Communicating risk
The guideline emphasises communicating CVD risk effectively using appropriate communication and decision aids embedded in the calculator, to support shared decision-making between primary care clinicians and patients.
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Considerations for First Nations peoples
Specific recommendations, resources and practice advice for First Nations peoples have been embedded throughout the guideline.
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Pregnancy complications
New information is provided about the association between CVD risk and pregnancy complications, such as hypertensive disorders of pregnancy (including pre-eclampsia) and gestational diabetes.
Approach to assessing CVD risk
The guideline provides updated evidence-based recommendations for assessing CVD risk in adults without known CVD. These recommendations include identifying eligible age groups, using the Aus CVD Risk calculator to estimate their risk, identifying their risk category, communicating CVD risk, and managing CVD risk with lifestyle modifications and pharmacotherapy where indicated. Figure 1 provides an overview of the step-by-step approach.
Overview of the step-by-step approach
Step 1: Identify people for CVD risk assessment
The guideline-recommended age ranges for assessing CVD risk in people without known CVD include:
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all people aged 45–79 years
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people with diabetes aged 35–79 years
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First Nations people aged 30–79 years (and it is recommended to assess individual CVD risk factors in First Nations people aged 18–29 years).
Targeting CVD risk assessment to recommended age groups assists in identifying people at high risk early before they develop CVD.
Available practice software can assist the primary care team to identify and recall eligible people at a practice population level, or opportunistically when people present to the practice.
Step 2: Use the Aus CVD Risk calculator to calculate risk
The Aus CVD Risk calculator is recommended for use in people who meet the age criteria who are not already seen as high risk. The following clinical conditions are determined as high risk, and should be automatically managed as high CVD risk:
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people with moderate-to-severe chronic kidney disease
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people with confirmed diagnosis of familial hypercholesterolaemia.
The Aus CVD Risk calculator estimates the overall risk of a person by considering multiple risk factors, rather than individual risk factors in isolation. Risk factors added to the calculator include, but are not limited to, age, sex at birth, smoking status, diabetes, blood pressure (BP) and lipid profile. History of taking CVD medicines, medical history of atrial fibrillation, with additional diabetes-specific variables, assist to calculate more accurate assessment in individuals.
Variables are added to the Aus CVD Risk calculator and are presented as a percentage, representing an individual’s probability of dying or being hospitalised for CVD in the next 5 years.
Step 3: Identify CVD risk category
Based on the risk percentage, people can be categorised as:
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high risk (≥10% risk over 5 years)
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intermediate risk (5% to <10% risk over 5 years)
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low risk (<5% risk over 5 years).
Reclassification factors may help refine an individual’s risk category and are of most value when the person’s risk lies close to a risk threshold, as a small shift in estimate may result in their risk being categorised in a different risk category.
Risk categories inform communication of risk and appropriate management to reduce a person’s risk.
Step 4: Communicate CVD risk
The guideline recommends using relevant decision aids to support effective communication and enable informed decision-making about reducing CVD risk. It recommends communicating risk in a variety of formats depending on the health literacy needs and learning styles of the patient. These may include communicating risk as a percentage or using interactive visual tools, as shown in Figure 2.
Step 5: Manage CVD risk
Managing CVD risk should always involve a collaborative approach to encouraging, supporting, and advising appropriate healthy lifestyle and behaviours, with or without BP-lowering and/or lipid-modifying pharmacotherapy.
Approaches to addressing lifestyle factors include smoking cessation, adopting healthy eating patterns, regular physical activity, achieving and maintaining a healthy weight and limiting intake of alcohol.
Follow up includes setting recalls for patients based on risk assessment intervals, and ongoing management of risk factors through available Medicare items.
Figure 2. Risk communication tool (Source: Aus CVD Risk calculator)
Reproduced with permission from the National Heart Foundation of Australia, citing the 2023 Cardiovascular Disease Risk Calculator and Guidelines.
© 2023 Commonwealth of Australia as represented by the Department of Health and Aged Care
Access our resources
To access the new guideline and use the Aus CVD Risk calculator, go to www.cvdcheck.org.au/calculator.
To support practices with the implementation of CVD risk assessment in primary care, the Heart Foundation has developed comprehensive resources for healthcare professionals and the Australian public, including:
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‘What is a Heart Health Check?’ brochure
Visit the Heart Foundation's Heart Health Check Toolkit to access these resources and for more tips and tools to support CVD risk assessment and management in your practice: www.heartfoundation.org.au/heart-health-check-toolkit.
Funding: The Australian Government, the Department of Health and Aged Care funded the development of the 2023 Australian Guideline for Assessing and Managing Cardiovascular Disease Risk through the Heart Foundation of Australia.
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