menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Guidelines for the assessment of absolute cardiovascular disease risk.
Bibliographic Source(s)
National Vascular Disease Prevention Alliance. Guidelines for the assessment of absolute cardiovascular disease risk. Canberra (Australia): National Heart Foundation of Australia; 2009. 49 p. [118 references]
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse is working to update this summary.

Scope

Disease/Condition(s)

Cardiovascular disease (CVD)

Note: The term 'cardiovascular disease' is used in these guidelines to refer collectively to coronary heart disease (CHD), stroke, and other vascular disease, including peripheral arterial disease and renovascular disease.

Guideline Category
Prevention
Risk Assessment
Screening
Clinical Specialty
Cardiology
Family Practice
Internal Medicine
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Health Plans
Managed Care Organizations
Physician Assistants
Physicians
Public Health Departments
Utilization Management
Guideline Objective(s)
  • To assist Australian primary care health professionals and others to assess cardiovascular disease (CVD) risk as accurately as possible, so that they and their patients can make reasonable and well-informed decisions about clinical care to manage CVD risk
  • To provide recommendations on how to identify adults at increased absolute risk for CVD and those in whom numerical calculation of absolute CVD risk is indicated
  • To provide recommendations on special considerations in the assessment of absolute CVD risk in the following groups: Aboriginal and Torres Strait Islander adults, adults with diabetes, adults who are overweight or obese, and adults with chronic kidney disease (CKD)
Target Population

Among adults (over the age of 18 years) without known cardiovascular disease (CVD), the following target populations were identified:

  • Adults without diabetes
  • Aboriginal and Torres Strait Islander adults
  • Adults with diabetes
  • Adults who are obese or overweight
  • Adults with chronic kidney disease (CKD)
Interventions and Practices Considered

Absolute cardiovascular risk assessment using the Framingham Risk Equation

Major Outcomes Considered
  • Five year risk level of cardiovascular disease (CVD)
  • Incidence rate of coronary heart disease, stroke, cardiac procedures
  • Mortality
  • Prediction of CVD compared to observed data

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): The National Vascular Disease Prevention Alliance (NVDPA) commissioned the Monash Institute of Health Services Research (MIHSR) to perform a systematic literature review and prepare a technical report (see the "Availability of Companion Documents" field).

Search Methods

Databases Searched

The following electronic databases were used to identify relevant literature:

  • Australasian Medical Index
  • CINAHL
  • The Cochrane Library
    • Cochrane Database of Systematic Reviews (Cochrane Reviews)
    • Database of Abstracts of Reviews of Effects (Other Reviews)
    • Cochrane Central Register of Controlled Trials (Clinical Trials)
    • Cochrane Database of Methodology Reviews (Methods Reviews)
    • The Cochrane Methodology Register (Methods Studies)
    • Health Technology Assessment Database (Technology Assessments)
    • NHS Economic Evaluation Database (Economic Evaluations)
  • EMBASE
  • EBM Reviews (OVID)
  • Medline
  • Medline in-process and other non-indexed citations

The guideline developer also searched bibliographies of relevant studies identified by the search strategy and relevant reviews/meta-analysis for identification of additional studies. Relevant guideline and peak body Web sites were also searched.

Search Strategy

A broad-ranging systematic search was developed through consultation between the Monash Institute of Health Services Research (MIHSR) and a specialist search strategist. The search strategy was limited to English language articles and there were no limits on year of publication. A total of 20,991 records were retrieved on 13 April 2006. A listing of specific search terms used is available in Section 9.7.2 of the Technical Report (see the "Availability of Companion Documents" field).

Review of Evidence

Inclusion of Studies

To determine the literature to be assessed further and on which to base these guidelines, a reviewer scanned the titles, abstracts and keywords of every record retrieved by the search strategy. Full articles were retrieved for further assessment if the information given suggested that the study met the inclusion criteria as described in Section 9.6 of the Technical Report (see the "Availability of Companion Documents" field). Two independent reviewers decided on inclusion/exclusion of retrieved articles.

Where there was doubt regarding these criteria from the information given in the title and abstract, the full article was retrieved for clarification.

Studies which compared the predictive ability of different methods of absolute risk assessment were included and recommendations were made on the basis of the results of these studies. The results of studies which investigated the predictive ability of individual absolute risk assessment methods were also reported to provide further information for the reader.

A table of excluded studies can be found in appendix VI of the Technical Report (see the "Availability of Companion Documents" field).

Review of the Economic Literature

Search Strategy

The main search strategy was considered broad enough to include articles related to economic evaluation and/or cost effectiveness.

Inclusion Criteria for Economic Analysis

  1. A comparison of two different methods for absolute cardiovascular disease (CVD) risk assessment
  2. Effectiveness data described as an intermediate clinical measure or longer-term health outcome
  3. Inclusion of resource or cost impacts of each intervention, including the direct costs of each intervention and subsequent health system resource impacts.

Exclusion Criteria for Economic Analysis

There was no additional exclusion criteria for the economic analysis to those described in section 9.6 of the Technical Report (see the "Availability of Companion Documents" field).

Number of Source Documents

30 articles

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Level Intervention Diagnosis Prognosis Screening
I A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies
II A randomised controlled trial A study of test accuracy with an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation. This study has a very low risk of bias. A prospective cohort study A randomised controlled trial
III-1 A pseudo-randomised controlled trial (i.e., alternate allocation or some other method) A study of test accuracy with an independent, blinded comparison with a valid reference standard, among non-consecutive patients with a defined clinical presentation. This study has a low risk of bias All or none A pseudo-randomised controlled trial (i.e., alternate allocation or some other method)
III-2 A comparative study with concurrent controls:
  • Non-randomised, experimental trial
  • Cohort study
  • Case-control study
  • Interrupted time series with a control group
A comparison with reference standard that does not meet the criteria required for level II and III–1 evidence. This study has a high risk of bias. Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial A comparative study with concurrent controls:
  • Non-randomised, experimental trial
  • Cohort study
  • Case-control study
III-3 A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm studies
  • Interrupted time series without a parallel control group
Diagnostic case-control study.
This study has a high risk of bias
A retrospective cohort study A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm studies
IV Case series with either post-test or pre-test/post-test outcomes Study of diagnostic yield (no reference standard). This study has a high risk of bias. Case series, or cohort study of patients at different stages of disease Case series
Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): The National Vascular Disease Prevention Alliance (NVDPA) commissioned the Monash Institute of Health Services Research (MIHSR) to perform a systematic literature review and prepare a technical report (see the "Availability of Companion Documents" field).

Assessment of Methodological Quality

Methodological quality of the included studies was assessed.

Ability of the Predictive Method

The most rigorous study design for assessing predictive ability is considered to be a prospectively designed longitudinal cohort study that independently compares the absolute risk assessment method with an appropriate reference standard in consecutively selected patients from a relevant clinical population. Based on these criteria, the validity of the methodology of included articles was assessed against the following checklist:

  1. Specified inclusion/exclusion criteria
  2. Explicit description of participants
  3. Appropriate spectrum of consecutively selected participants
  4. Prospective selection of participants
  5. Absolute risk assessment method is compared with an appropriate reference (gold) standard - observed cardiovascular disease (CVD) event
  6. Absolute risk assessment method is compared with the reference standard in all participants
  7. Blinded assessment of absolute risk assessment method and reference standard results
  8. Absolute risk assessment method and reference standard undertaken prior to any interventions

Each criterion was graded as met, unmet or unclear, and a brief description provided in the Evidence Table of study performance against each criteria. Any disagreement was resolved by discussion to reach a consensus.

Studies were required to meet criteria 1) and 6) to be included. Studies which met all or the great majority of the quality criteria were considered to be at lower risk of bias/high quality (more likely to reflect the truth) than those that met few or none of the criteria, which were considered to have higher risk of bias/low quality. While no formal weighting was applied, the impact of each quality criterion on the potential for introduction of bias into the study was used to assess the overall quality.

Data Extraction

Data, according to the inclusion criteria, were extracted from included studies using an evidence table. Information was collected on general details (title, authors, reference/source, country, year of publication, setting), participants (age, sex, inclusion/exclusion criteria, withdrawals/losses to follow-up, sub-groups), results (point estimates and measures of variability, frequency counts for dichotomous variables, number of participants) and validity results. The second reviewer performed double-data extraction on a subset of studies to ensure accuracy of results. Missing data were obtained from the authors wherever possible. Any disagreement was resolved by discussion and mediation with a third party to reach a consensus.

Where reported, data (including confidence intervals where available) on area under the receiver operating characteristic curve (AUC), sensitivity and specificity, and under- or overestimation of risk were extracted.

Evidence tables can be found in Appendix I and are summarised in Sections 2-7 of the Technical Report (see the "Availability of Companion Documents" field). Also, refer to Section 9.8.4.1 of the Technical Report for further information on the data extraction process.

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): The National Vascular Disease Prevention Alliance (NVDPA) commissioned the Monash Institute of Health Services Research (MIHSR) to perform a systematic literature review and prepare a technical report (see the "Availability of Companion Documents" field).

Question Development

The clinical questions on which these guidelines are based were originally set by the NVDPA based upon input from clinicians and consumers and further developed through consultation between the guideline developers in the MIHSR team and the NVDPA team.

The clinical questions for these guidelines are:

  1. Which absolute risk assessment method is most predictive of future CVD events in a mixed adult (aged >18) population not known to have CVD or diabetes?
  2. Which absolute risk assessment method is most predictive of future CVD events in a mixed adult (aged >18) population not known to have CVD and who have diabetes?
  3. Which absolute risk assessment method is most predictive of future CVD events in a mixed adult (aged >18) population not known to have CVD and who are overweight (defined as BMI within the range 25.0-29.9 kg/m2 [2]) or obese (BMI 30 kg/m2)?
  4. Which absolute risk assessment method is most predictive of future CVD events in adult (aged >18) Aboriginal and Torres Strait Islander peoples not known to have CVD?
  5. Which absolute risk assessment method is most predictive of future CVD events in adult (aged >18) people with chronic kidney disease (GFR <60 mL/min) not known to have CVD?

Formulation of Recommendations in Systematic Review

Where evidence exists to answer the clinical questions, evidence-based recommendations were made, with the level of the recommendation reflecting the volume, quality, clinical impact, applicability and generalisability of the evidence available to answer the question. The recommendations were graded and summarised in table form.

Studies which compared the predictive ability of different methods of absolute risk assessment were included and recommendations were made on the basis of the results of these studies. The guideline developer also reported the results of studies which investigated the predictive ability of individual absolute risk assessment methods to provide further information for the reader.

Where there was no, or very low quality, evidence to answer a clinical question, a statement has been included that highlights the lack of evidence and no recommendations were made.

Recommendations were not separated based on gender.

Evidence-Based Recommendations

The systematic review included only data from studies that compared the predictive abilities of different methods of absolute risk assessment, subject to the inclusion criteria for each separate clinical question (see "Availability of Companion Documents" field for the "Technical report: review of the evidence and evidence-based recommendations for practice"). Evidence was assessed for quality according to NHMRC criteria.

Recommendations were formulated based on the findings of the systematic literature review whenever the body of evidence yielded support for recommendations of at least NHMRC grade C (defined as 'Body of evidence provides some support for recommendation(s) but care should be taken in its application'; see "Rating Scheme for the Strength of the Recommendations" field).

Clinical questions were referred to the Consensus Statement Development Group (see below) if the systematic review yielded insufficient evidence to make a recommendation of grade C or better.

Consensus Statements Development Process

The working group considered that guidance should be provided on each of the clinical questions to facilitate clinical uptake of these guidelines by General Practitioners (GPs) and other target users. Therefore, where the systematic review identified insufficient evidence to answer a clinical question, a consensus statement was formulated based on available evidence and on expert clinical judgement. The consensus statements development process involved the following steps:

  1. The National Vascular Disease Prevention Alliance selected experts and key opinion leaders (including GPs, cardiologists, endocrinologists, neurologists, nephrologists and health economists) to form a Consensus Statement Development Group.
  2. The Consensus Statement Development Group identified key clinical issues to be addressed:
    • Clinical issues relevant to absolute cardiovascular disease (CVD) risk assessment in the population groups unanswered by the systematic review:
      • Aboriginal and Torres Strait Islander adults
      • Adults who are overweight or obese
      • Adults with chronic kidney disease (CKD)
    • Further clinical issues on which GPs would require guidance when applying the evidence-based recommendations in practice:
      • The age range for application of absolute CVD risk assessment
      • Clinical markers and other indicators of high absolute risk, which would make calculation of numerical absolute risk unnecessary.
  1. Each clinical issue was assigned to a Consensus Statement Development Group member with the appropriate expertise, who reviewed literature published up to August 2007, including any relevant evidence outside the systematic review inclusion criteria.
  2. A consensus development conference of all Consensus Statement Development Group members was convened, during which the following tasks were undertaken:
    • Clinical experts presented the findings of the literature searches and proposed a draft statement on each clinical issue
    • The group discussed the merits of the evidence and considered changes to the proposed statements in consideration of current health system policy and practice contexts
    • Consensus was reached on each statement
  1. The draft consensus statements were circulated to the Consensus Statement Development Group to ensure that all experts concurred.
Rating Scheme for the Strength of the Recommendations
Grade of Recommendation Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Cost Analysis

Effectiveness, Cost-Effectiveness and Economic Implications of Absolute Cardiovascular Disease (CVD) Risk Assessment

Findings of the Systematic Review

No studies directly assessed the cost-effectiveness of absolute CVD risk assessment versus usual assessment, or assessed the cost-effectiveness of absolute CVD risk assessment by one method versus another method.

No studies directly comparing different absolute CVD risk assessment methods in clinical care reported costs of assessment, cost of interventions or individual health outcomes.

Conclusions of the Systematic Review

No conclusion can be made as to the cost-effectiveness of one absolute CVD risk assessment tool over another in any of the identified populations, based on the evidence identified by the systematic review.

Other Considerations

Cost Implications

Factors that must be considered when assessing cost-effectiveness include:

  • Risk threshold for intervention
  • Direct and indirect resource costs for risk assessment and interventions, including costs associated with clinical events
  • Effectiveness (proportion of events prevented by the intervention)
  • Uptake of guidelines by primary care doctors

In the absence of evidence from studies directly measuring the cost-effectiveness of CVD prevention strategies based on different methods of absolute risk assessment, the best currently available information on cost-effectiveness is obtained from modelling studies and inferred from effectiveness data. (See the original guideline document for more information on the most cost-effective risk management approach.)

A recent modelling study found that the direct costs of implementing national guidelines were 4–6 times lower for New Zealand guidelines than for Australian, US, UK or Canadian guidelines. Assessment costs were partly minimised by screening only age groups in which case-finding was most likely.

The New Zealand guidelines were also more cost-effective than Australian, US, UK or Canadian guidelines. However, all the guidelines showed similar cost-efficiency when applied to individuals aged over 65 years, because cost per cardiovascular event prevented was markedly lower in those aged 65–74 years than in younger age groups.

Modelling studies suggest that the most cost effective population strategies for preventing CVD are those which apply all the following principles:

  • Intervention thresholds are based on absolute CVD risk assessment rather than targeting a particular risk factor (e.g., high blood pressure or high cholesterol) in isolation
  • Medical interventions are targeted to the highest-risk segment of the population based on absolute risk assessment
  • Effective low-cost pharmaceutical treatments (e.g., aspirin) are used.

Some non-medical CVD prevention strategies that target the entire population are also likely to be highly cost-effective. These include mass education on risk reduction, or reducing dietary salt intake through the food industry.

Therefore, it is reasonable to expect that improved cost-effectiveness will result from implementation of these guidelines' recommendations for routine absolute risk assessment using the most accurate tools currently available – provided that optimal intervention trigger cutpoints are set and effective interventions recommended. An evaluation of the cost-effectiveness of applying these recommendations for absolute CVD risk assessment in Australian primary care is beyond the scope of these guidelines and further evidence would be required before a modelling study could be undertaken.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Finalising the Guidelines

Comments received from the public consultation process were considered individually and passed on to relevant experts to further inform their inclusion in the guidelines. The Executive Working Group met on 23 July 2008 to finalise outstanding issues from the public consultation submissions. Based on all the feedback, the guidelines were revised accordingly. The final draft of the guidelines was sent to the National Health and Medical Research Council (NHMRC) for review on Monday 28 July 2008.

Prior to endorsement by the NHMRC, the guidelines underwent an independent review process conducted by the NHMRC. The guidelines were further refined in response to the reviewer's recommendations.

The final guidelines were submitted to the NHMRC for endorsement on 20 November 2008.

Endorsement from the NHMRC was received in January 2009.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

These recommendations are from the guideline's "Summary of Recommendations" with more detailed information in the original guideline document. The grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Summary of Recommendations*

Recommendation I

Absolute cardiovascular risk assessment, using the Framingham Risk Equation to predict risk of a cardiovascular event over the next 5 years, should be performed for all adults aged 45–74 years who are not known to have cardiovascular disease (CVD) or to be at increased risk of CVD (see Recommendation V below).

(Grade B)

Recommendation II

In Aboriginal and Torres Strait Islander adults aged 35 years and older who are not known to have CVD or to be at high** risk, absolute cardiovascular risk over the next 5 years should be calculated using the Framingham Risk Equation.

Although the Framingham Risk Equation might underestimate risk in this population, available evidence suggests that this approach will provide an estimate of minimum cardiovascular risk***.

(Grade D)

Recommendation III

In adults with diabetes aged 60 years or less who are not known to have CVD or to be at high** risk, absolute cardiovascular risk over the next 5 years should be calculated using the Framingham Risk Equation.

Although the Framingham Risk Equation might underestimate risk in this population, available evidence suggests that this approach will provide an estimate of minimum cardiovascular risk***.

(Grade C)

Recommendation IV

In adults who are overweight or obese and who are not known to have CVD or to be at high** risk, absolute cardiovascular risk over the next 5 years should be calculated using the Framingham Risk Equation.

The results should be interpreted with the awareness that its predictive value has not been specifically assessed in this population.

(Grade D)

Recommendation V

Adults with any of the following conditions do not require absolute cardiovascular risk assessment using the Framingham Risk Equation because they are already known to be at increased absolute risk of CVD:

  1. Diabetes and age >60 years
  2. Diabetes with microalbuminuria (>20 mcg/min or urinary albumin:creatinine ratio >2.5 mg/mmol for males, >3.5 mg/mmol for females)
  3. Moderate or severe chronic kidney disease (CKD) (persistent proteinuria or estimated glomerular filtration rate [eGFR] <45 mL/min/1.73 m2)
  4. A previous diagnosis of familial hypercholesterolaemia****
  5. Systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg
  6. Serum total cholesterol >7.5 mmol/L

(Grade D)

*Recommendations I and III are derived from findings of the systematic literature review whenever the body of evidence yielded support for recommendations of at least National Health and Medical Research Council (NHMRC) Grade C. Recommendations II, IV and V are clinical consensus statements developed where the systematic literature review process was undertaken, but no evidence was found for or against these recommendations.

**Greater than 15% probability of CVD within 5 years.

***While CVD risk is known to be elevated for the population identified, it is not possible to quantify the degree of additional CVD risk in an individual. Clinical judgement is necessary when assessing an individual's overall CVD risk.

****Refer to the National Heart Foundation of Australia's information sheet Familial hypercholesterolaemia: information for doctors.

Summary of Practice Points*

  1. In adults without known CVD, a comprehensive assessment of cardiovascular risk includes consideration of the below.
Modifiable Risk Factors Non-Modifiable Risk Factors Related Conditions
  • Smoking status
  • Blood pressure
  • Serum lipids
  • Waist circumference and body mass index
  • Nutrition
  • Physical activity level
  • Alcohol intake**
  • Age and sex
  • Family history of premature CVD
  • Social history including cultural identity, ethnicity, socioeconomic status and mental health
  • Diabetes
  • Kidney function (microalbumin ± urine protein, eGFR)
  • Familial hypercholesterolaemia
  • Evidence of atrial fibrillation (history, examination, electrocardiogram)
  1. For adults at high risk of CVD, identifying all cardiovascular risk factors present enables investigation and intensive management by lifestyle interventions (all patients) and pharmacological interventions (where indicated).
  2. A comprehensive assessment of cardiovascular risk involves consideration of socioeconomic deprivation, because it is an independent risk factor for CVD. Absolute risk of CVD calculated using the Framingham Risk Equation is likely to underestimate cardiovascular risk in socioeconomically deprived groups.***
  3. In adults with atrial fibrillation (particularly those aged over 65 years), the increased risk*** of cardiovascular events and all-cause mortality, in addition to thromboembolic disease and stroke, should be taken into account when assessing absolute cardiovascular risk.
  4. The following qualitative risk categories can be used to describe calculated absolute cardiovascular risk:
    • 'Low' risk corresponds to <10% probability of CVD within the next 5 years
    • 'Moderate' risk corresponds to 10–15% risk of CVD within the next 5 years
    • 'High' risk corresponds to >15% risk of CVD within the next 5 years
  1. Regular review of absolute cardiovascular risk is recommended at intervals according to the initial assessed risk level:
    • Low – review every 2 years
    • Moderate – review every 6–12 months
    • High – review according to clinical context

* These practice points were developed to facilitate clinical uptake of these guidelines by general practitioners (GPs) and other target users. These were formulated based on expert clinical judgement.

**Alcohol is a risk factor for elevated blood pressure (which is itself a major independent determinant of risk of atherosclerotic disease), stroke and cardiomyopathy. For a full discussion of this, please see the NHMRC's Australian guidelines to reduce health risks from drinking alcohol.

***While CVD risk is known to be elevated for this population, it is not possible to quantify the degree of additional CVD risk in an individual. Clinical judgement is necessary when assessing an individual's overall CVD risk.

Definitions:

Grade of Recommendation Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations" field).

Recommendations based on clinical consensus opinion are included where evidence-based recommendations are not available.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Potential Benefits of Routine Absolute Cardiovascular Disease (CVD) Risk Assessment

  • There is emerging evidence that clinical decisions based on absolute CVD risk may lead to improved management of CVD risk. Access to absolute CVD risk assessments has been shown to increase prescribing of lipid-modifying drugs for high-risk patients with diabetes and lead to both improvement in lipid profiles and significant reductions in the risk of chronic heart disease (CHD). Given that absolute CVD risk assessment provides a more accurate assessment of risk than individual risk factors, it is reasonable to expect that basing management decisions on this assessment will improve outcomes.
  • Modelling studies provide the most compelling current evidence that absolute CVD risk assessment in general practice is likely to improve CVD outcomes, compared with assessment of single risk factors. When applied to a reference population with known risk factors, a strategy based on targeting those at highest absolute CVD risk is potentially more than twice as effective in reducing death from CHD than treating people with single risk factors (e.g., high total cholesterol level) or attempting to reduce the severity of a single risk factor across the entire population. The strategy of targeting those at high absolute CVD risk also achieves the best balance between preventing deaths and avoiding unnecessary treatment in those at lower risk.
  • Absolute CVD risk assessment helps doctors and patients to make decisions about the priority and intensity that an intervention warrants. The process of assessing absolute CVD risk may stimulate discussion of CVD prevention between patient and doctor, and knowledge of their assessed absolute CVD risk may help to motivate patients to adhere to lifestyle changes or medicine regimens to reduce risk.
Potential Harms

Limitations of the Framingham Risk Equation

The Framingham Risk Equation has been validated in various populations, but has been reported to overestimate risk in populations with low coronary heart disease (CHD)-related mortality and underestimate risk in populations with high mortality, including sub-populations such as socioeconomically deprived groups, some ethnocultural groups including Aboriginal and Torres Strait Islander peoples, and people with comorbid medical conditions. Limitations of the Framingham Risk Equation include failure to incorporate some significant risk factors (e.g., obesity, physical inactivity, family history of cardiovascular disease [CVD], socioeconomic status, psychosocial factors) and insufficient consideration of the effects of advanced age.

Qualifying Statements

Qualifying Statements

This document has been produced by the National Vascular Disease Prevention Alliance for the information of health professionals. The statements and recommendations it contains are, unless labelled as 'expert opinion', based on independent review of the available evidence. Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in consultation with, a relevant health professional.

Implementation of the Guideline

Description of Implementation Strategy

Implementation

Development of an implementation strategy for these guidelines (see Figure 1 in the original guideline document) must consider:

  • Which implementation strategies are likely to be most effective, based on local and international evidence
  • Policy and program opportunities to support uptake of these guidelines
  • The provision of adequate resources and sufficient capacity to translate the recommendations into practice

An implementation plan will be developed in the 12 months following publication of these guidelines. The scope of implementation strategies will be dependent on the availability of adequate resources to support its uptake.

Recommendations for Implementation

  1. Any future review of general practice and/or the development of any new national primary health care strategy will benefit from considering the implementation of these absolute cardiovascular disease (CVD) risk assessment guidelines.
  2. The National Vascular Disease Prevention Alliance (NVDPA) will seek the support of key stakeholders in formulating the full implementation plan for these absolute CVD risk guidelines, including supportive health policy, the political will to achieve better preventive care and adequate resources for the development of an effective implementation plan. This process should be informed by the report The Absolute Risk Project: towards a risk identification tool for coronary heart disease and stroke and should involve key stakeholders, including relevant Department of Health and Ageing (DoHA) divisions (Primary and Ambulatory Care, Population Health, Medical Benefits Scheme and Pharmaceutical Benefits Scheme) and representatives of professional, educational and practice support bodies including the Australian General Practice Network (AGPN), Australian College of Rural and Remote Medicine, Australian Practice Nurses Association, National Aboriginal Controlled Community Health Organisation, National Prescribing Service, NVDPA and the Royal Australian College of General Practitioners (RACGP).
  3. Implementation of these absolute CVD risk guidelines should be based on best-practice chronic disease management principles, including a systematic approach and appropriate incentives and supports for health professionals, and should be adapted to local contexts.
  4. The absolute CVD risk assessment approach can be integrated into all chronic disease management and funding initiatives that encourage general practitioners (GPs) to practise quality preventive health care through an evidence-based approach to the detection and management of chronic disease. This applies to both new and existing initiatives, including:
    • The Australian Primary Care Collaboratives Program
    • The Well Person's Health Check
    • Utilisation of appropriate Medicare (Chronic Disease Management) items
    • An expanded role for practice nurses
Implementation Tools
Chart Documentation/Checklists/Forms
Patient Resources
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Vascular Disease Prevention Alliance. Guidelines for the assessment of absolute cardiovascular disease risk. Canberra (Australia): National Heart Foundation of Australia; 2009. 49 p. [118 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009
Guideline Developer(s)
National Heart Foundation of Australia - Disease Specific Society
Source(s) of Funding

National Heart Foundation of Australia

Guideline Committee

National Vascular Disease Prevention Alliance Working Group

Composition of Group That Authored the Guideline

National Vascular Disease Prevention Association (NVDPA) Executive Working Group

Co-Chairs: Professor Stephen Colagiuri (NVDPA representative), Diabetologist (Diabetes Australia) and Professor of Metabolic Health, University of Sydney; Professor Andrew Tonkin, Cardiologist (Austin Health) and Head of the Cardiovascular Research Unit, Department of Epidemiology and Preventive Medicine, Monash University (formerly National Heart Foundation of Australia)

Other Members: Professor Mark Harris, General Practitioner, Centre for Primary Health Care and Equity, University of NSW and RACGP; Dr Tom Briffa, Research Fellow, Allied Health, University of Western Australia and past Executive Officer, National Heart Foundation of Australia; Dr Nancy Huang, National Manager Clinical Programs, National Heart Foundation of Australia; Ms Karen Carey-Hazell, Consumer Representative; Ms Leva Azadi, Executive Officer, National Heart Foundation of Australia (May 2008–); Ms Jill Waddell, Executive Officer, National Heart Foundation of Australia (Dec 2006–June 2008)

Steering Committee: Dr Erin Lalor (NVDPA Chair), Chief Executive Officer, National Stroke Foundation; Associate Professor Tim Mathew (past NVDPA Chair), Nephrologist (National Medical Director, Kidney Health Australia); Professor Chris Bladin, Neurologist (National Stroke Foundation); Dr Andrew Boyden (NVDPA representative)*, National Director of Clinical Issues, National Heart Foundation of Australia; Dr Dominique Cadilhac (NVDPA representative)*, Head of Public Health Division, National Stroke Research Institute; Associate Professor Nikky Isbel (NVDPA representative), Nephrologist (Kidney Health Australia); Professor Rod Jackson, Epidemiologist, University of Auckland; Professor Garry Jennings, Cardiologist and Director, Baker IDI Heart and Diabetes Institute; Mr Richard McCluskey, Consumer Representative; Dr Sarah Norris, NHMRC Guideline Assessment Register Appointee; Ms Ann Owen, Consumer Representative

MIHSR Systematic Review Team: Professor Sally Green, Director, MIHSR; Dr Marie Misso, Research Fellow, MIHSR; Ms Tari Turner, Senior Project Officer (Evidence), Centre for Clinical Effectiveness; Associate Professor Damien Jolley, Biostatistician, MIHSR; Ms Jenny Watts, Health Economist, Monash University Centre for Health Economics; Ms Hayley Barnes, Research Assistant, MIHSR; Mr Stephen Maloney, Research Assistant, MIHSR; Dr Claire Harris Director, Centre for Clinical Effectiveness

Consensus Statement Development Group: Professor Chris Bladin, Neurologist (National Stroke Foundation); Dr Alex Brown, Head of the Centre for Indigenous Vascular and Diabetes Research, Baker IDI Heart and Diabetes Institute; Professor Alan Cass, Nephrologist and Indigenous Health Researcher; Associate Professor Steve Chadban, Nephrologist; Professor Tim Davis; Diabetologist; Associate Professor Karen Duggan, Nephrologist; Associate Professor Maarten Kamp, Endocrinologist; Dr Chris Levi, Neurologist; Ms Judith Mackson, Education and Quality Assurance Program Manager, National Prescribing Service; Professor Mark Nelson, Professor of General Practice, University of Tasmania; Ms Suzanne Prosser, DoHA

Medical Writer: Ms Jenni Harman, Meducation Pty Ltd

* Participated by correspondence

Financial Disclosures/Conflicts of Interest

Each steering committee member completed a form declaring any potential conflict of interest relevant to participation in this project.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the National Heart Foundation of Australia Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

Patient Resources

The following are available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on April 29, 2010. The information was verified by the guideline developer on May 30, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...