Cvd

1. CVD RISK
ASSESSMENT
LECTURE FOR
MSc. IN CV NURSING
SPHHMMC, Department of Internal Medicine
Cardiology Unit- June, 2022
Seifu Bacha; MD, Internist and Cardiologist

2. Objectives
• Understand the burden of NCD with emphasis on CVD
• Understand the concept of multiple CV risk factors and their
interplay
• Understand how to assess future risk of cardiovascular
disease in an individual
• Define primary and secondary interventions and the
strategies employed

5. Introduction
• Cardiovascular disease (CVD) is a major cause of disability
and premature death throughout the world
CAD, Heart failure, Atherosclerosis
• Most have identifiable risk factors which can be modified

6. Introduction…..
• Some estimates- NCD account for 46% of all deaths in
Ethiopia
• Risk of premature death (before age 70)- 18.3 (almost 1 in
5), from one of the four NCDs
• No nationwide studies have been carried out on CVDs in
Ethiopia.
• A small number of studies have shown CVDs to be a major
cause of morbidity and mortality.

7. Introduction…..
• Hypertension among adults 31% in Addis Ababa and 8.8% in
Butajira
• Based on a school survey, the prevalence of Rheumatic
Heart Disease (RHD) was 6.4 per 1000 population in Addis
Ababa 4.6 per 1000 in a rural town

8. Introduction…..
• Cardiovascular visits of tertiary hospitals in Addis Ababa
and Gondar:
oRHD accounts for 34.7%.
oHypertension was responsible for 15.2% of CVD visits and
admissions
oAtherosclerotic heart disease accounted for 8.9% of CVD
visits and admissions.

10. Introduction…..
• Large percentage of NCDs are preventable through the
reduction of the four main shared behavioral risk factors
• Tobacco use
• Physical inactivity
• Use of alcohol and
• Unhealthy diets
oUp to 80% of heart disease, stroke, and type 2 diabetes and
oAbout 40% of cancers could be prevented by eliminating
these shared risk factors

11. Introduction…..
The major modifiable CV risk factors include
• Dyslipidemia
• Diabetes
• Hypertension
• Smoking
• Physical inactivity
• Obesity
• Excessive alcohol consumption
• Rheumatic fever*

12. Introduction…..
Non-modifiable risk factors:
• Age
• Gender
• Race
• Genetic predisposition/Family history of CV disease

13. Introduction…..
• CVDs can present gradually or with sudden events like acute
coronary syndrome, hypertensive crisis and cerebro-vascular
events (strokes) that often are fatal
• Risk factor modification can reduce clinical events and
premature death in people
• With established cardiovascular disease
• Who are at high cardiovascular risk due to one or more risk
factors.

14. Prevention Of CVD
Primary prevention
• People with risk factors who have not yet developed
clinically manifest cardiovascular disease
Secondary prevention
• People with established cardiovascular disease (coronary
heart disease, cerebrovascular disease)

15. Prevention Of CVD
• Secondary prevention is usually straight forward
• Decision on primary prevention is complex (selecting high
risk patients who benefit from intervention)
• Risk factors have additive effects
• Considering multiple risk factors together than treating
individual risk factors is a better approach
• Providing optimal prevention without side effect on the
individual and unnecessary strain on resources
• Multiple scoring systems are used to aid decision making

16. Primary prevention of CV Diseases
• Intensive lifestyle interventions and appropriate drug
therapy is required in the following groups, even without
established CVD but have:
• A total cholesterol ≥ 8 mmol/l (320 mg/dl) or;
• Low-density lipoprotein (LDL) cholesterol ≥ 6 mmol/l (240 mg/dl) or
• TC/HDL-C (total cholesterol/high density lipoprotein cholesterol)
ratio >8;
• Persistent raised blood pressure (>160–170/100–105 mmHg);
• Diabetes;
• Overt nephropathy or renal failure or renal impairment.

17. Prevention Of CVD…
Risk Scoring Systems
• Numerous scoring systems are available
• Can easily be accessed from apps on your smart phones with
automatic calculation of risk or
• Manually calculated
• Examples include
WHO/ISH
ESC- SCORE
Framingham risk score

18. The WHO/ISH risk prediction Charts
• Indicate 10-year risk of a fatal or non-fatal major
cardiovascular event (myocardial infarction or stroke)
• Based on age, sex, blood pressure, smoking status, total
blood cholesterol and presence or absence of diabetes
mellitus.
• Used according to the 14 epidemiological sub-regions
categorized by WHO (Ethiopia in sub-region E)

19. The WHO/ISH risk prediction Charts
• There are two sets of charts, with color shades
• One set used in settings where blood cholesterol can be
measured & the other set is for settings in which it cannot
be measured.
• Provides approximate estimates of CVD risk
• Help identify those at high cardiovascular risk and take
preventive measures

20. The WHO/ISH risk prediction Charts
Information necessary to use the chart include:
1- Presence or absence of diabetes
2- Gender
3- Smoker or non-smoker (all current smokers and those who quit
smoking less than 1 year )
4- Age
5- Systolic blood pressure (mean of two readings on each of two
occasions)
6- Total blood cholesterol (if in mg/dl divide by 38 to convert to
mmol/l)

21. The WHO/ISH risk prediction Charts
Steps to estimate the 10-year cardio vascular risk:
• Step 1: Select the appropriate chart depending on the presence
or absence of diabetes.
• Step 2: Select male or female tables.
• Step 3: Select smoker or non-smoker boxes.
• Step 4: Select age group box (if age is 50-59 years select 50, if
60-69 years select 60 etc.).
• Step 5: Within this box and the nearest cell where the
individuals systolic blood pressure (mm Hg) and total blood
cholesterol level (mmol/l) cross.
The color of this cell determines the 10-year cardiovascular risk.

22. The WHO/ISH risk prediction Charts
Patient 1
A 60 years old male who is a known diabetic, smoker with
BP=160/90mmHg, Serum cholesterol of 250mg/dl
Patient 2
A 60 years old male who has no diabetes, non-smoker, with
BP=160/90, Serum cholesterol 195mg/dl

25. 1 When resources are limited, individual counselling
and provision of care may have to be prioritized
according to cardiovascular risk.
• 0 10-year risk of cardiovascular event <10%, 10 to <20%, 20 to <30%,
≥30%
Risk <10%
• Individuals in this category are at low risk. Low risk does not mean “no”
risk”
• Conservative management focusing on lifestyle interventions is
suggested.
Risk 10% to <20%
• Individuals in this category are at moderate risk of fatal or non-fatal
vascular events.
• Monitor risk profile every 6–12 months.

26. • 0 10-year risk of cardiovascular event <10%, 10 to <20%, 20
to≥30%
Risk 20 to <30%
• Individuals are at high risk
• Adults >40 years with persistently high serum cholesterol
(>5.0 mmol/l) and/or LDL cholesterol >3.0 mmol/l, despite a
lipid lowering diet, should be given a statin.
Risk ≥30%
• Individuals in this category are at very high risk of fatal or
non-fatal vascular events.
• Monitor risk profile every 3–6 months.

27. Primary prevention of CV Diseases
Smoking
• All non-smokers should be discouraged from starting
• All smokers should be strongly encouraged to quit smoking
• Those who use other forms of tobacco be advised to stop.

28. Primary prevention of CV Diseases
Dietary Advise
oAll individuals should be strongly encouraged:
• To reduce total fat and saturated fat intake.
• Total fat intake should be reduced to about 30% of calories
• To reduce daily salt intake by at least one- thirds and, if
possible, to <5 g or <90 mmol per day.
• To eat at least 400 g a day of a range of fruits and
vegetables as well as whole grains and pulses.

29. Primary prevention of CV Diseases
Physical activity
• To take at least 30 minutes of moderate physical activity
(e.g. brisk walking) a day.
• To lose weight through a combination of a reduced-energy
diet (dietary advice) and increased physical activity.
• Individuals who take more than 3 units of alcohol per day
should be advised to reduce alcohol consumption
• One unit (drink) = half pint of beer/lager (5 % alcohol), 100
ml of wine (10 % alcohol), spirits 25 ml (40% alcohol)

30. Primary prevention of CV Diseases
Lipid Lowering Treatment (Statins)
• All individuals with total cholesterol at or above 8 mmol/l (320
mg/dl) should be advised to follow a lipid-lowering diet and given
a statin to lower the risk of cardiovascular disease
• Other managed according to their 10 years cardiovascular risk
Risk <10%
• Should be advised to follow a lipid lowering diet.
Risk 10 to <20%
• Should be advised to follow a lipid-lowering diet.

31. Lipid Lowering Treatment
(Statins)…
Risk 20 to <30%
• Adults >40 years with persistently high serum cholesterol (>5.0
mmol/l) and/or LDL cholesterol >3.0 mmol/l, despite a lipid-
lowering diet, should be given a statin.
Risk ≥30%
• Should be advised to follow a lipid-lowering diet and given a
statin.
• Serum cholesterol should be reduced to less than 5.0 mmol/l
(LDL cholesterol to below 3.0 mmol/l) or by 25% (30% for LDL
cholesterol), whichever is greater.

32. Primary prevention of CV Diseases
HYPOGLYCEMIC DRUGS
• Individuals with persistent fasting blood glucose >6 mmol/l
despite diet control should be given metformin.

33. Primary prevention of CV Diseases
Use of Aspirin according to 10 years CV
risk
Risk <10%
• Aspirin should not be given to individuals in this low-risk
category, the harm outweighs the benefits.
Risk 10 to <20%
• The benefits of aspirin treatment are balanced by the harm
caused.
• Aspirin should not be given to individuals in this risk category.

34. Use of Aspirin according to 10 years CV risk…
Risk 20 to <30%
• For individuals in this risk category, the balance of benefits
and harm from aspirin treatment is not clear.
• Aspirin should probably not be given to individuals in this
risk category.
Risk ≥30%
• Individuals in this risk category should be given low-dose
aspirin.

35. Secondary prevention of CV Diseases
People with established cardiovascular disease such as
Angina pectoris
Coronary heart disease/myocardial infarction
Transient ischemic attacks
Cerebrovascular disease (CeVD)
Peripheral vascular disease (PVD)
Or after coronary revascularization or carotid endarterectomy
 are at very high risk of developing recurrent cardiovascular events. Risk charts are
not necessary to make treatment decisions.
• The goal is to prevent recurrent cardiovascular events by reducing their
cardiovascular risk.

36. Secondary prevention of CV Diseases
Smoking
In Patients with established CHD and/or CeVD who smoke
oIntensive life style advice simultaneously with drug
treatment
oStrongly encouraged to stop smoking by a health
professional and supported in their efforts to do so.
oCessation of other forms of tobacco use
• Non-smoking people should be advised to avoid exposure to
second hand tobacco smoke as much as possible.

37. Secondary prevention of CV Diseases
Dietary Advise
• All individuals should be strongly encouraged:
To reduce total fat and saturated fat intake.
Total fat intake should be reduced to about 30% of calories
To reduce daily salt intake by at least one- thirds and, if
possible, to <5 g or <90 mmol per day.
To eat at least 400 g a day of a range of fruits and veg-
etables as well as whole grains and pulses.

38. Secondary prevention of CV Diseases
Exercise/Physical Activity
• Regular light to moderate intensity physical exercise is
recommended for all subjects recovering from major CVD
events (including coronary revascularization).
• Supervised programs offered to all subjects recovering
from major CHD events and CeVD events.

39. Secondary prevention of CV Diseases
Weight loss
• In patients with cardiovascular disease who are overweight
or obese, weight loss should be advised through the
combination of a reduced energy diet and increased physical
activity
• Individuals who take more than 3 units of alcoholic per day
should be advised to reduce alcohol consumption.

40. Secondary prevention of CV Diseases
Hypertension
• Blood pressure reduction should be considered in all patients
with established CHD
• Life style modification, beta-blockers and ACEI. If cannot be
given, or in cases where blood pressure remains high, treat
with a thiazide diuretic
• A target blood pressure of 140/90 mmHg is appropriate.
• Blood pressure reduction should be considered in all patients
with previous TIA or stroke to a target of <140/<90mmHg. For
older patients target of <150/90mmHg

41. Secondary prevention of CV Diseases
Lipid lowering therapy
• Statin is recommended for all patients with established
CHD, continued in the long-term, probably lifelong.
• Treatment with a statin should be considered for all
patients with established CeVD, especially if they also have
evidence of established CHD.
• Monitoring of blood cholesterol levels is not mandatory.
• Secondary prevention of CHD, CeVD and PVD is important in
patients with diabetes, whether type 1 or type 2

42. Secondary prevention of CV Diseases
• Patients with established CHD- Aspirin lifelong.
• Patients with a history of transient ischaemic attack or
stroke presumed due to cerebral ischaemia or infarction
should be treated with long-term (probably lifelong) aspirin.

43. Secondary prevention of CV Diseases
• ACE inhibitors- in all patients following myocardial infarction
(esp LV dysfunction) - long-term, probably lifelong..
• Beta-blockers - in all patients with a history of MI and
those with CHD who have developed major left ventricular
dysfunction leading to heart failure- for a minimum of 1–2
years after MI and probably lifelong, unless serious side
effects occur

44. THE END