CVD risk factors

PART 1: COMPREHENSIVE CVD RISK ASSESSMENT

Section 1: Core Organs and Systems Assessed in a Full CVD Assessment

A comprehensive cardiovascular disease (CVD) assessment evaluates the impact of vascular disease on multiple organ systems and identifies modifiable risk factors.

PART 2: OBESITY – CLASSIFICATION, MANAGEMENT, AND PHARMACOTHERAPY

Section 2: National Priorities and Obesity Classification

2.1. Overweight and Obesity Classification (BMI):
The International Classification of adult underweight, overweight, and obesity according to BMI:

2.2. Waist-to-Height Ratio:
An alternative or complementary measure to BMI, reflecting central adiposity, which is a key driver of metabolic risk.

Section 3: Non-Pharmacological Management of Obesity

3.1. Nutrition and Energy Balance (Based on NICE Guidance):

• Sustainable calorie deficit is the core driver of weight loss. How it is achieved should be personalised.

• Use structured approaches: portion control, meal planning, reducing high-energy snacks/drinks.

• Aim for a balanced dietary pattern: vegetables, whole grains, lean proteins; limit alcohol and sugary drinks.

• Plan for weight maintenance early: as weight drops, energy needs fall – relapse prevention is crucial.

3.2. Physical Activity and Function – Practical Messages for Patients:

• Start where the person is: any increase in activity helps (walking, stairs, swimming, cycling).

• For maintaining weight loss, NHS advice highlights the value of higher activity levels (often up to ~60 minutes/day).

• Include strength/resistance activities to protect muscle mass during weight loss.

• Reduce sitting time: short movement breaks can be easier than "gym" goals.

3.3. Behaviour Change Support – Evidence-Based Ingredients:

• Set 1–2 specific, measurable goals (e.g., steps/day, sugary drinks/week).

• Self-monitoring: weight trend, food patterns, triggers, sleep, mood.

• Problem-solving barriers: shift work, stress eating, cost, social situations.

• Motivational interviewing style: explore ambivalence; build confidence.

3.4. NHS Digital Weight Management Programme:

• A 12-week online behavioural & lifestyle programme for adults living with obesity who also have diabetes, hypertension, or both.

• Supports behaviour change alongside routine care.

• Accessible via smartphone/computer; referral routes vary.

• Best used as part of a wider plan (diet + activity + follow‑up).

Section 4: Escalation Pathway for Weight Management (Tiers of Care)

Based on NICE guidance, weight management services are structured in tiers:

• Medicines are an adjunct to lifestyle support – not a substitute.

• Follow‑up is essential for maintaining weight loss and managing adverse effects/comorbidities.

Section 5: Obesity Pharmacotherapy – GLP-1 Receptor Agonists

5.1. Liraglutide (Saxenda®) – At a Glance:

5.2. Semaglutide (Wegovy®) – At a Glance:

5.3. Tirzepatide (Mounjaro®) – At a Glance:

5.4. Other Important Considerations for GLP-1 Agonists:

• Professional and ethical responsibilities (GPhC):

  • Prescribers should independently verify key data (e.g., weight/height/BMI) – not questionnaire-only.

  • Document assessment, counselling, and follow-up plan.

• MHRA licensing and safety considerations:

  • Tirzepatide may reduce effectiveness of oral contraception in some cases → consider non‑oral/barrier methods for a period after starting or dose increases.

  • Discuss fertility changes with weight loss (unplanned pregnancy risk).

PART 3: HYPERTENSION OVERVIEW

Section 6: Hypertension in Context of NHS Health Check and General Practice

• High blood pressure is one of the major contributors to CVD. By raising awareness, improving detection, monitoring, and treatment, pharmacists can make a significant healthcare impact.

• Good blood pressure control is also linked to increasing life expectancy and improved quality of life for people with diabetes.

6.1. Definition of Hypertension:

• Hypertension is persistently raised:

  • Systolic blood pressure ≥140 mmHg, or

  • Diastolic blood pressure ≥90 mmHg, or both (in those without diabetes).

6.2. Hypertension Case-Finding Service – Diagnosis:
Confirm diagnosis of hypertension in people with a:

• Clinic blood pressure of 140/90 mmHg or higher AND

• ABPM (Ambulatory Blood Pressure Monitoring) daytime average or HBPM (Home Blood Pressure Monitoring) average of 135/85 mmHg or higher.

6.3. Diagnostic Requirements:

• Make sure to differentiate stage 1 and stage 2 hypertension to decide treatment.

6.4. Lifestyle Advice for Hypertension:

• Reduce salt consumption or use a salt substitute (dietary sodium intake <100 mmol/day = <2.4 g dietary sodium or <6 g sodium chloride).

• Moderate consumption of coffee and other products with a high content of caffeine.

• Diet, exercise, weight loss, alcohol moderation, smoking cessation, and relaxation techniques.

Section 7: Hypertension as Part of CVD Risk Assessment

For all people with hypertension, offer to:

• Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio (ACR) and test for haematuria using a reagent strip.

• Take a blood sample to measure glycated haemoglobin (HbA1c), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total cholesterol, and HDL cholesterol.

• Examine the fundi for the presence of hypertensive retinopathy.

• Arrange for a 12-lead electrocardiograph (ECG) to be performed.

Section 8: Blood Pressure Targets in Diabetes

• Monitor blood pressure every 1–2 months.

PART 4: CARDIOVASCULAR RISK ASSESSMENT AND PREVENTION

Section 9: Cardiovascular Risk Assessment

• It is essential to calculate the risk to initiate a prevention care pathway.

• A variety of risk calculators are available: charts, tables, computer programs, and web-based tools.

9.1. How Do They Work?
Tools assess cardiovascular risk—coronary heart disease (angina and myocardial infarction), stroke, and transient ischaemic attack—on the basis of:

• Lipid profile

• Systolic blood pressure

• Gender

• Age

• Ethnicity

• Deprivation

• Smoking status

• BMI

• Chronic kidney disease

• Diabetes mellitus

• Atrial fibrillation

• Treated hypertension

• Rheumatoid arthritis

• Family history of premature cardiovascular disease

9.2. QRISK® Tool:

• http://qrisk.org/ – widely used in the UK for CVD risk estimation.

9.3. Cardiovascular Risk Estimation:

• All adults from 40 years onwards, who have no history of CVD or diabetes, and who are not already on treatment for blood pressure or lipids, should be considered for an opportunistic comprehensive CVD risk assessment in primary care.

Section 10: Strategy for Prevention

10.1. Lifestyle Interventions:

• Diet and exercise, alcohol moderation (covered in level 5).

• Cardio-protective diet (Mediterranean diet).

10.2. Mediterranean Diet Adherence and Cardiovascular Risk – Key Evidence (PREDIMED Trial):

• Study: Martínez-González MA et al., 2012. Large randomised controlled trial in Spain. Participants at high cardiovascular risk.

• Compared:

  1. Mediterranean diet + extra-virgin olive oil

  2. Mediterranean diet + nuts

  3. Low-fat control diet

• Impact on CVD Risk:

  • ~30% relative reduction in major cardiovascular events (myocardial infarction, stroke, cardiovascular death).

  • Benefit seen without calorie restriction or weight loss.

  • Greatest reduction observed in stroke risk.

• Key Dietary Components:

  • High: fruit, vegetables, whole grains, legumes, fish, olive oil, nuts.

  • Low: red/processed meat, saturated fat, refined sugars.

• Proposed Mechanisms:

  • Improved lipid profile (↓ LDL, improved HDL function).

  • Reduced inflammation and oxidative stress.

  • Improved endothelial function.

• Clinical Relevance:

  • Strong evidence supporting dietary intervention in CVD prevention.

  • Complements pharmacological lipid-lowering therapy.

  • Reinforces NICE/NHS emphasis on lifestyle modification.

  • A modest improvement in MEDAS adherence (often ~2 points) is clinically meaningful and aligns with the ~30% reduction in major CVD events.

10.3. Physical Activity Recommendation:

• (Refer to previous section on physical activity for obesity management.)

10.4. Smoking Cessation:

• Anyone who is a smoker and wants to quit should be offered the support of a local NHS Stop Smoking Service.

• A combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray, and oral spray) are the most effective treatment options and thus the preferred choices.

• E-cigarettes are better than smoking – (check BNF).

10.5. Alcohol – Useful Resources:

• Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) .

• Alcohol structured advice tool.

Section 11: Primary and Secondary Prevention with Statins

11.1. Lipid Targets and Monitoring Strategy:

• Revise this lecture in conjunction with the lipid modification lecture.

SUMMARY TABLES

Table 1: Comparison of GLP-1 Agonists for Weight Management

Table 2: Hypertension Targets by Patient Group

Table 3: Mediterranean Diet – Key Components