CVD risk assessment

Screening & Prevention of
Lynne Powell
Advanced Nurse Practitioner & Clinical Practice Educator
To give you an understanding of
the principles of screening and
identify risk factors for
cardiovascular disease
• Discuss and explore the criteria for screening
• Have an understanding of cardiovascular
• Look at the policies in Wales that drive
screening for cardiovascular disease
• Discuss cardiovascular disease prevention,
risk assessment and the tools used.
• Identify the risk factors for cardiovascular
• How to use a risk assessment tool
What is Screening?
‘Screening is a public health service in which members of a
defined population, who do not already perceive
themselves to be at risk of, or are already affected by a
disease or its complications, are asked a question or
offered a test, to identify those individuals who are more
likely to be helped than harmed by further tests or
treatment to reduce the risk of a disease or its
(UK National Screening Committee 2000)
What is Screening?
Screening is a process of identifying
apparently healthy people who may be at
increased risk of a disease or condition.
They can then be offered information, further
tests and appropriate treatment to reduce
their risk and/or any complications arising
from the disease or condition.
The NSC Criteria for Screening
• The condition should pose an important health problem
• The natural history of the condition should be
• There must be a safe and validated test or examination
• Treatment of the disease at an early stage should be
• The screening programme must reduce mortality and
• The test must be acceptable to the population
• The programme must provide value for money
Extended Screening
Since original criteria were developed the
breadth of screening has extended to
include risk factors (eg. blood pressure or
cholesterol) or susceptibility for disease (eg.
genetic markers for cancer or HIV status).
Limitations of Screening
• Can reduce the risk of developing a condition but
cannot offer a guarantee of protection.
• Screening is therefore increasingly presented as
• Although may benefit populations, not all
participants will benefit and some may even be
Intention of screening
To identify disease in a community who
do not have symptoms, early in the
disease process so that intervention
and management can hopefully reduce
mortality and suffering from the
• Screening has the potential to cause harm
• Benefits must outweigh the harm
• Informed consent is very important
• Inclusion should be voluntary
• People do not have symptoms
• Quality assurance
What is Cardiovascular Disease?
of the heart and blood vessels’
Also known as Coronary Heart Disease
(CHD) and Ischaemic Disease.
(Cardiac Disease NSF for Wales, 2009)
CVD cont.
• Narrowing of the arteries that supply the
heart and is due to a gradual build up of
fatty material called atheroma.
• The narrowing can cause myocardial
infarction, angina and other forms of
chronic heart disease.
• Other forms of CVD include stroke,
transient ischaemic attack and peripheral
vascular disease.
Cardiovascular Disease (CVD)
• CVD is the main cause of death in the UK accounting for
over 216,000 deaths in 2004: around 4 out of every 10
deaths. The main forms of CVD are coronary heart
disease (CHD) and stroke
• CHD accounts for approx 50% of CVD deaths
• Stroke accounts for approx 25% of CVD deaths
• CVD is one of the main causes of premature death: 32%
in men and 24% in women
(BHF, 2006)
Cardiovascular Disease (CVD)
• CHD causes over 105,000 deaths a year in the
• approx 21% deaths in men
• approx15% deaths in women
• This compares to around 33,000 deaths a year
from lung cancer, 16,000 deaths from colorectal
cancer and 12,000 deaths from breast cancer.
(BHF, 2006)
Cardiovascular Disease
• Around 230,000 people in the UK suffer a heart attack
each year
• In around 30% of heart attacks the patient dies
• Death rates from CHD have been falling in the UK since
the late 1970’s; for adults under 65yrs they have fallen by
over 44% in the last 10 years
• Whereas mortality from CHD is falling rapidly, morbidity
from CHD and other circulatory disease appears to be
rising, especially in older age groups.
(BHF, 2006)
Economic Costs
CHD causes health care system in UK
around £3.5 million a year
• Hospital care for CHD patients accounts for 79%
of these costs
• buying and dispensing drugs accounts for a
further 16%.
• Primary Prevention and Primary Care 4%
(BHF, 2006)
Policies in Wales that drive
screening for cardiovascular
Review of Health and Social Care
in Wales (2003)
Builds on the Wanless Report and Identifies
that services need to be realigned to focus
on prevention and early intervention
Designed for Life (2003)
• Sets the direction and requirements for the NHS
describes the kind of health and social care services the
people of Wales can expect by 2015
• Improve health and reduce ill health and where possible
eliminate inequalities in health
• Support the role of people in promoting their health
individually and collectively
• Provide quality assured clinical treatment and care
appropriate to need and based on evidence
The Cardiac Disease National
Service Framework (NSF) for
(WAG 2009)
Everyone at high risk of developing coronary heart
disease and all those who have been diagnosed
as having the disease should have access to a
multi factorial risk assessment and be offered an
appropriate treatment plan.
Health Evidence Bulletin: CHD
• Summarizes the best current evidence to support
the development of guidelines and care pathways
at national and local levels
• Develop, implement and monitor evidence based
programmes to address tobacco use, diet and
physical activity, targeted at the most
disadvantaged communities in Wales.
The NSF for CHD
• Everyone who may be at risk of developing CVD
is to be offered a risk assessment.
• All those found to be at high risk together with
those who have established CHD, occlusive
arterial disease, diabetes or familial
hypercholesterolaemia, are offered lifestyle
advice and appropriate treatment.
Cardiovascular disease
prevention, risk assessment
and the tools used.
Prevention of CVD
Primary prevention aims to prevent
the development of CVD in high risk
Secondary prevention aims to
prevent further events in those
patients with established CVD
How do we assess risks?
• CVD Risk Assessment Tools
• Based on research
• They identify high-risk people for primary
• They are an aid to making a clinical decision
• Usually based on groups of people with untreated
levels of blood pressure and cholesterol levels.
• There are limitations to all the risk tools
• They can under estimate risk in people with a
family history of CVD and certain high risk ethnic
Cardiovascular Risk Prediction
• ASSIGN – Scotland includes deprivation & family
• QRISK13 – GP population, computer based
• Reynold’s Risk Score – risk in females
• ETHRISK – UK ethnic groups
• UKPDS – diabetes
• INDANA – focuses on patients with hypertension
• Joint British Societies Coronary Risk
Prediction Chart (JBS2)
Joint British Societies Coronary
Risk Prediction Chart (JBS2)
• Was considered the most accurate and preferred
method for estimating CVD risk for different
• Not appropriate for people with established CVD,
familial high cholesterol, chronic renal dysfunction
or diabetes.
• Estimates the absolute 10 year risk of developing
• Based on the Framingham Heart Study.
Framingham Heart Study
• Began in 1948.
• More than 10.000 residents of Framingham,
Massachusetts, USA.
• Collected data on blood pressure, diabetic status,
smoking and causes of death.
• People with pre-existing disease were excluded
• This data was used to define the risk factors for
• This study is ongoing
• Framingham score under estimated the risk in certain
QRISK is a computer generated risk assessment tool.
Developed from QRISK1 and the Framingham score.
Includes BMI; family history; age, ethnicity; areas of
deprivation, personal clinical information including
previous heart attack (myocardial infarction)
Still estimates the 10 year risk
What are the Risk Factors for
 Modifiable
 Non-modifiable
Modifiable Risk Factors
• Smoking
• Poor diet
• Lack of physical exercise
• Regular excessive alcohol consumption
• Abdominal obesity
• Hypertension
• Diabetes
• Dyslipidaemia
Non-modifiable Risk Factors
• Gender
• Age
• Ethnic origin
• Family history
• Genetic
Who should have a CVD risk
• All adults aged over 40 years or more
• Adults of any age who have;
• A strong family history of early CVD
• A 1st degree relative with a hereditary cholesterol
People with existing cardiovascular disease
and/or diabetes do not need to be assessed as
they are already known to be high risk
What does screening involve?
Assessing lifestyle factors;
• Smoking
• Diet
• Physical activity
• Alcohol consumption
• Blood pressure
• Weight & Height (BMI); waist
Blood tests for glucose and cholesterol levels
Family history
Measurement of Obesity
• There are various ways in which to measure different aspects
of obesity. They include Body Mass Index (BMI), skin fold
thickness, waist circumference, waist to hip ratio and bioimpedance.
Body Mass Index (BMI)
• The most common method of measuring obesity is the Body
Mass Index (BMI). BMI is calculated by dividing body weight
(kilograms) by height (metres) squared.
• BMI is the most widely used approach in the UK, but it is
important to note that it is not a direct measure of body fat
mass or distribution, and BMI measures may be skewed by
very high muscle mass. The relationship between BMI and
health also varies with ethnicity.
• In children and adolescents BMI varies with age and sex, for
this reason a growth reference must be used.
Skin fold thickness
• Skin fold thickness refers to the measurement of subcutaneous fat
located directly beneath the skin by grasping a fold of skin and
subcutaneous fat and measuring it using calipers. It is used mainly to
determine relative fatness and the percentage of body fat. Measurement
requires callipers and some basic training.
Waist circumference and waist to hip ratio
• The circumference of the waist is sometimes used as a simple measure
of body fatness, though it can be subject to measurement error. Adult
waist circumference cut points are:
• Increased risk of health problems: Men≥ 94cm Women ≥ 80cm
• Greatly increased risk of health problems: Men ≥ 102cm Women ≥ 88cm
• Waist to hip ratio examines fat distribution and in practice is used less
frequently, given the established links between waist circumference alone
and health risk.
• This measures the impedance or opposition to the flow of a very small
electric current as it passes through the body. As lean mass is made up
of 73% water and fat has no water content, this method estimates lean
tissue mass (which acts as a conductor) and fat mass (which acts as an
insulator), through changes in voltage. Home machines are available for
bio-impedance measurement though these can be inaccurate as they
often estimate from the legs only.
Joint British Societies’ cardiovascular disease (CVD) risk prediction chart
Assessment score
• High Risk = 20% or more (2 in 10 chance or more of
developing CVD within the next 10 years
• Moderate Risk = 10% - 20% (between 1in 10 and 2 in 10
• Low Risk = less than 10% chance (less than 1 in 10
• HIGH RISK = medication to lower cholesterol and/or
blood pressure and lifestyle advice including healthy
eating, smoking cessation, physical activity & safe alcohol
Case Studies for week 3
QRisk calculator online
Case Study 1
Mrs Lewis is a 42 year old lady, non –
smoker , with a blood pressure of 120/70
and a cholesterol of 3.9 mmol/l.
• What is this lady’s current risk ?
Case Study 2
A 52 year old male who is currently smoking 20
cigarettes a day, has a systolic blood pressure
of 158mmHg and a non fasting cholesterol of
1. What is his 10 year risk of a CVD event?
2. 3 months later, he has stopped smoking his
systolic blood pressure is 140 and his
cholesterol remains 7.0mmol/l.
Has his risk changed ?
Case study 3
A 50 year old woman who is a non-smoker, does
not have diabetes, and has a blood pressure of
120/80 and a total cholesterol of 8.2mmol/l.
What is this woman’s current level of risk?
How would that risk change if she then told
you that her father died aged 45 years of an
• BNF 62 (Sept 2011)
• British Heart Foundation (2006) Coronary Heart Disease Statistics. London;
British Heart Foundation
may99.htm#.UsGeLhZCgfE (accessed 13/12/13).
JBS2 (2005) Joint British Societies’ guidelines on prevention of
cardiovascular disease in clinical practice. BMJ Journals volume 91
supplement v
Health in Wales NHS Wales (accessed
QRISK Predicting cardiovascular risk in England and Wales: prospective
derivation and validation of QRISK2, BMJ 2008;336:1475-82. (accessed
NSC (National Screening Committee)

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