1) The lecture discussed cardiovascular disease (CVD) risk assessment for nursing students. CVD is a major cause of death worldwide and in Ethiopia. 2) It reviewed various CVD risk factors and scoring systems to assess individual risk, such as the WHO/ISH charts. Risk factors include age, smoking status, blood pressure, cholesterol levels, and diabetes. 3) Prevention strategies were outlined for both primary prevention of high-risk individuals and secondary prevention for those with existing CVD. Lifestyle changes and medications aim to reduce modifiable risk factors and prevent further events.

1. LECTURE ON CVD RISK
ASSESSMENT FOR
MSc. IN CV/CT NURSING
SPHHMMC, CARDIOLOGY UNIT- May 2023
By Seifu Bacha; MD, Internist and Cardiologist

2. 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

5. Introduction
• 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 in Ethiopia.
• 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

6. 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.

8. 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

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

10. Introduction
Non-modifiable risk factors:
• Age
• Sex
• Race
• Genetic predisposition/Family history of CV disease

11. 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.

12. 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)

13. 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

14. 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.

15. 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
✓ACC -SCORE
✓Framingham risk score

16. •

17. 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)

18. 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

19. 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)

20. 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.

21. 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

24. 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.

25. • 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.

26. 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.

27. 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.

28. 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)

29. 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.

30. ❑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.

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

32. 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.

33. ❑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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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

40. Secondary prevention of CV Diseases
❑Lipid lowering therapy
• Statins 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

41. 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.

42. 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

43. THE END