AP examines what the new cardiovascular risk calculator means for patients and whether the wrong people are on preventive medicines.
Why is a new calculator needed?
In short, it wasn’t accurate. It dramatically overestimated the risk of a cardiovascular event.Australia’s previous CVD risk calculator was based on an equation developed using data collected more than 60 years ago from a town in the United States. Although pioneering at the time, the old calculator reportedly overestimated risk for the general Australian population while underestimating risk for Aboriginal and Torres Strait Islander peoples.1
‘The overestimation meant large numbers of people were put on preventive medicine, particularly aspirin,’ says Karl Winckel, Advanced Practice credentialed pharmacist and Lecturer at the School of Pharmacy, University of Queensland, and the Princess Alexandra Hospital in Brisbane.
‘We’re still seeing people on aspirin for primary prevention who started on it decades before, likely because the risk calculator showed a 10% risk of an event over 5 years, which was probably overestimated by two to three times in these patients. The old calculator led to people being put on lifelong medications that were not necessary.’
The new Australian CVD risk calculator (AusCVDRisk) was released in 2023 and assesses the risk of death or hospitalisation from a CVD event within 5 years.
The new calculator is excellent, Mr Winckel says. Described by the National Heart Foundation as a ‘major turning point’ at its launch, AusCVDRisk was developed based on data from a contemporary, diverse primary care population in New Zealand, which was modified and recalibrated for the Australian context.2 It includes optional risk factors not present in the previous equation, such as geographical area, diabetes-specific risk markers, a diagnosis of atrial fibrillation and cardiovascular medicines use.
Reclassification factors including ethnicity, family history of premature CVD, severe mental illness, kidney disease and coronary artery calcium score are also built-in to help individualise risk estimates.
‘The new model is much, much better. The developers did an amazing job, not just in the user interface, but in the data sets they used and the way they picked the risk factors and variables to incorporate. For example, one of the big criticisms of risk calculators in the past was that they didn’t look at socioeconomic factors. The new calculator includes a postcode, which is a very important way to identify patients at low risk versus moderate risk,’ Mr Winckel adds.
Advancing treatment
Cardiovascular disease (CVD) typically develops slowly over decades and research shows that many CVD events are ‘highly preventable’ through early detection.3 Yet CVD kills around 118 Australians every day, or one person every 12 minutes.4
It used to be much worse. CVD now accounts for only 1 in 4 deaths in Australia.4 The proportion of CVD-related deaths has decreased by almost 80% since the 1980s, largely due to improved knowledge of risk factors and advances in medicines and interventions.⁵
The introduction of statins in the late 1980s, and a better understanding of the pathophysiology of coronary heart disease, led to more treatment strategies, says Heart Foundation Chief Medical Advisor Professor Garry Jennings.
Today, the focus has shifted to new drugs for heart failure, such as angiotensin receptor-neprilysin inhibitors (ARNIs), direct acting oral anticoagulants (DOACs) and other antithrombotic medicines, as well as new drug classes developed for the management of diabetes, which have been found to have dramatic effects on CVD.⁶
‘These include SGLT2 inhibitors and GLP-1 agonists. SGLT2 inhibitors reduce hospitalisations and improve outcomes in heart failure and help prevent the progression of kidney disease,’ Prof Jennings says.
‘We now have much more powerful drugs for lowering LDL cholesterol than statins, particularly PCSK9 inhibitors, and there are more exciting lipid lowering and blood pressure drugs on the horizon.’
So where could we be doing better?
Better use of existing medicines, and more effective lifestyle interventions is a start.
Mr Winckel says statin and ezetimibe combinations should also be used more frequently. ‘I think it’s really under-prescribed. There’s good data that supports this right from the first event, whether it was myocardial infarction (MI) or a stroke. It comes from the knowledge that time is blood vessel, so the earlier you get your cholesterol down as low as you can, the longer-term benefits you’ll get. It’s the “legacy effect” of lipid lowering – if you take 10 years’ worth of lipid lowering in your 40s, you’ll continue to see benefits in the coming decades even if you stop the tablets.’
While pharmacists know non-pharmacological options are important, our interventions could be more effective. The language around these has changed, Mr Winckel says. Rather than suggesting patients get ‘more exercise’ – which they might associate with someone younger and fitter – pharmacists should recommend ‘movement’ and being ‘more active’.
Incidental lifestyle changes are key. For example, choosing a parking spot further away from the office. It’s also important to discuss ‘healthy eating’ rather than talking about dieting.
‘Healthy eating incorporates both eating for weight loss but also eating for lower cholesterol and lower blood pressure, like lower salt.’
While individuals can help to reduce their risk of CVD by making positive changes such as following a heart-healthy eating pattern, increasing activity and not smoking or drinking alcohol, some factors require societal change, Prof Jennings adds. ‘We know that, in addition to individuals making better choices for their heart health, there is more that needs to be done at a societal level. Some of our current advocacy work strongly supports healthier food supplies, built environments which are more conducive to healthy, active living and tobacco, e-cigarettes and vaping control.’
Timing your interventions to perfection
One of the biggest challenges in cardiovascular disease is that many people don’t realise they’re at risk until something serious happens.
That’s where pharmacists can come in, says Kate Gunthorpe MPS, Pharmacist Implementation and Change Specialist at TerryWhite. ‘By conducting risk assessments using the AusCVDRisk and associated guidelines, adjusting medicines where appropriate, and having meaningful conversations about lifestyle changes, we can help patients take control of their heart health before it’s too late.’
Ms Gunthorpe is a participant in Queensland’s Scope of Practice Pilot, which enables pharmacists to undertake additional medicines management and prescribing activities, including protocol/structured prescribing as part of a chronic disease management program for CVD.⁷
Pharmacists can initiate, adjust and optimise cardiovascular medicines to improve adherence and safety. They also support lifestyle modifications through smoking cessation services and weight management strategies.
‘I start by consulting with the patient about their general health – family history, diet, exercise, smoking – all those key risk factors. Then I take some clinical measurements, like blood pressure, cholesterol levels and blood glucose,’ Ms Gunthorpe says. ‘Once we calculate their absolute risk score, we have an honest discussion about what it means and what we can do next, whether it’s lifestyle modifications, medication or a referral.’
If you want ‘bang for buck in terms of impact around CVD’, Mr Winckel says, the number one thing is to get community pharmacists involved.
‘Obviously they need to be remunerated, but things like risk assessing patients to figure out who can benefit from intervention is really important.
‘Most community pharmacists are really savvy and know when to talk to patients about these things. Perhaps someone has recently been in hospital for a reason unrelated to their cardiac health, but they’re thinking about their mortality and how they can reduce their risk of something going wrong.
‘It’s about finding those opportunities for patients when they’re a bit more motivated to make changes.’
For Ms Gunthorpe, participating in the trial has been ‘an eye-opener’. ‘It’s really shown me just how much impact pharmacists can have when given the right tools and responsibility.
‘I’ve had moments when a simple assessment has completely changed a patient’s understanding of their health.’
A memorable case was a patient in his early 50s whose brother had recently died from MI. The patient had a CVD risk assessment, and his risk score was higher than expected.
‘The moment completely changed his outlook – he started making small but impactful changes, and when he came back for a follow-up, he told me he was feeling better than he had in years. Those are the moments that make this work so rewarding,’ Ms Gunthorpe says.
‘If we want to reduce preventable heart attacks and strokes, we need more healthcare professionals working to their full potential, and pharmacists are ready for that challenge. There’s still work to be done in making full scope a permanent reality but seeing the impact so far makes me hopeful for the future. Pharmacists are ready, and patients are benefiting – now it’s just about making sure we can keep doing what we do best.’
References
- AusCVDRisk. How the calculator was developed. At: www.cvdcheck.org.au/how-the-calculator-was-developed
- Heart Foundation. Game-changing new approach to stopping cardiovascular disease before it strikes. 2023. At: www.heartfoundation.org.au/media-releases/new-approach-prevention-of-cardiovascular-disease
- Australian Institute of Health and Welfare. Heart, stroke and vascular disease: Australian facts. 2024. At: www.aihw.gov.au/reports/heart-stroke-vascular-diseases/hsvd-facts/contents/disease-types#deaths-trends
- Brown S, Banks E, Woodward M et al. Evidence supporting the choice of a new cardiovascular risk equation for Australia. Med J Aust. 2023 26;219(4):173—186.
- Heart Foundation. Key statistics: cardiovascular disease. 2024. At: www.heartfoundation.org.au/your-heart/evidence-and-statistics/key-stats-cardiovascular-disease
- Lincoff MA, Brown-Fransden K, Calhoun HM et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023 389;24.
- Queensland Health. Queensland community pharmacy pilots. 2024. At: www.health.qld.gov.au/clinical-practice/guidelines-procedures/community-pharmacy-pilots/about
- Deanfield J, Verma S, Scirica BM, et al. Semaglutide and cardiovascular outcomes in patients with obesity and prevalent heart failure: a prespecified analysis of the SELECT trial. Lancet 2024;404(10454):773–86.
- Lincoff MA, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Eng J Med 2023;389(24):2221–32.
- US Food and Drug Administration. FDA approves first treatment to reduce risk of serious heart problems specifically in adults with obesity or overweight. 2024. At: www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-reduce-risk-serious-heart-problems-specifically-adults-obesity-or
- Victor Chang Cardiac Research Institute. Weight loss drugs a vital new tool in preventing heart attacks. 2024. At: www.victorchang.edu.au/news/ozempic
