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Primary Cardiovascular Risk Calculator

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Cardiovascular Risk Calculator For Primary Prevention
This calculator should not be used if patient has known CVD or Diabetes (already known to be at high risk)
Age (30-74)		Smoking Status	Non Smoker Smoker
Sex	Male Female	Glucose	Normal Impaired fasting glucose Diabetes
Systolic BP		LVH	No LVH LVH on ECG
Diastolic BP		Central Obesity	No Yes
Total Cholesterol		South Asian Origin	No Yes
HDL Cholesterol		Family History of CVD (Men <55 and women <65 years)	No FH Significant FH CVD
Total /HDL Ratio
Serum TG mmol/l		Calculator version 5.8 (2009)
Using Systolic BP prediction, the 10 year risk of CHD Risk MI CHD death Stroke **CVD **CVD death JBS CVD Risk is %
The equivalent risk calculation with diastolic BP is %

Notes

• Impaired fasting glucose (IFG) = fasting glucose ≥6.1 mmol/l and <7.0 mmol/l.
• Risk thresholds for drug treatment will vary according to circumstances. In the UK statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD.¹
• In the original Anderson paper,² based on the Framingham Heart Study, the CVD group (option **CVD in calculator above) was a very mixed bag of conditions, consisting of MI and CHD death (plus angina pectoris and coronary insufficiency), stroke (including transient ischaemia) plus congestive heart failure and peripheral vascular disease. This is not a good match to the CVD end-point in statin and hypertension trials and should not be used.³ The JBS calculator⁴ calculates CVD risk as the sum of CHD risk and stroke risk (JBS Risk option in calculator above) as this is in better agreement with the original New Zealand CVD risk charts;³ so this calculator may be used as an alternative to the new paper CVD Risk charts.⁵ The other (non-JBS) risk calculation results are as per the original Anderson paper,² but all results will be adjusted by risk multipliers as described below (family history, central obesity etc.) if selected.
• The following patients should not have their risk calculated - as they are considered already to be at high enough risk to justify lifestyle and other interventions (antithrombotic, antihypertensive and lipid lowering therapies).⁴
  • Patients with atherosclerotic cardiovascular disease.
  • Hypertension (≥160/100 mmHg) with target organ damage
  • TC to HDL-C ratio ≥6
  • Patients with type 1 or 2 diabetes mellitus
  • Renal dysfunction (including diabetic nephropathy)
  • Familial hypercholesterolaemia, familial combined hyperlipidaemia or other inherited dyslipidaemia
  • People aged 75 or older should also be considered at increased risk of CVD, particularly if hypertensive of smokers. They are likely to benefit from statin treatment. Assessment and treatment should be guided by the benefits and risks of treatment, informed preference and comorbidities that may make treatment inappropriate.¹
• The following patients have higher risks:
  • Significant family history (Men <55 and women <65 years) increases risk by a factor of 1.5; as does impaired fasting glucose and South Asian origin.⁶
  • Obesity (BMI ≥30 kg/m² (especially central obesity men with waists ≥102 in white caucasians (≥90 cm in asians). Corresponding waist values for women are ≥88cm and ≥80 cm). Obesity increases risk by a factor of 1.3.
  • Serum triglyceride of 1.7mmol/l or more increases CVD risk by 1.3 times (this calculator treats it the same as obesity). A low HDL cholesterol (< 1.0 mmol/l in men and <1.2 mmol/l in women) also increases risk.
  • If any combination of impaired fasting glucose, South Asian origin, adverse family history or raised serum triglyceride occurs, risk is only increased by whichever of these factors in the combination gives the highest risk. In this calculator, none of them increases the risk further when left ventricular hypertrophy is present - as left ventricular hypertrophy increases risk so much that further multiplying risk to take into account other factors is likely to be inaccurate.³
    
    Also although, for example it can be shown that raised serum triglyceride increases risk by about 1.3 times, including triglyceride in a multivariate equation will reduce the variation in risk explained by the other risk factors. Successively multiplying risk for factors not included in the original equations of Anderson and colleagues will thus lead to gross overestimations of risk. On the other hand, the clinician should be aware in making clinical decisions that combinations of risk factors such as family history, high triglyceride, South Asian origin, impaired fasting glucose are likely to increase risk above that shown by the programme.
• There are no targets for total cholesterol reduction in the primary prevention of CVD. Aim to start a patient on 40 mg of simvastatin or equivalent.
• Use pre-treatment values where available - using or substituting values on treatment are only a guide to risk trends and probably under-estimate actual risk. If pre treatment values not available JBS 2 suggests using BP of 160/90, and a total cholesterol/HDL ratio of at least 6.⁴
• LVH = definite LVH on ECG.
• Patients should be considered smoker = if they currently smoke or in first few years
  of stopping. Actual increased risk of ex smokers will depend on lifetime exposure to cigarettes, and will lie between the never smoked and still smoking values

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Document references

1. Lipid modification, NICE Clinical Guideline (May 2008); (Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease.)
2. Anderson KM, Odell PM, Wilson PW, et al; Cardiovascular disease risk profiles. Am Heart J. 1991 Jan;121(1 Pt 2):293-8. [abstract]
3. Information kindly provided by Professor Paul Durrington, Department of Medicine, University of Manchester Manchester Royal Infirmary, Oxford Road, Manchester. M13 9WL and Dr Maggie Ireland, SpR in Public Health Medicine Northumberland Care Trust.
4. No authors listed, JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart. 2005 Dec;91 Suppl 5:v1-52.
5. New JBS2 Cardiovascular Disease Risk Charts 2004. British Hypertension Society Website.
6. Tunstall-Pedoe H; The Dundee coronary risk-disk for management of change in risk factors. BMJ. 1991 Sep 28;303(6805):744-7. [abstract]

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Internet and further reading

• New JBS2 Cardiovascular Disease Risk Charts 2004. British Hypertension Society Website.

Acknowledgements EMIS is grateful to Dr Huw Thomas for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
Document ID: 2011
Document Version: 24
Document Reference: bgp133
Last Updated: 30 Jun 2009
Planned Review: 29 Jun 2014

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