Patients 18 years old and above should receive a risk factor assessment for cardiovascular disease (CVD) at every routine physician visit.
Cardiovascular disease development is closely related to lifestyle characteristics and associated risk factors.
There is an overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a cardiovascular event.
Very high-risk group refers to patients with documented CVD, by invasive or non-invasive testing, and with presence of risk factors.
High-risk patients are those who have already experienced a cardiovascular event or have very high levels of individual risk factors.
Moderate-risk patients require monitoring of risk profile every 6-12 months.
Low-risk patients may be given conservative management, focusing on lifestyle interventions.


  • Patients >18 years of age should receive risk factor assessment for cardiovascular disease (CVD) at every routine physician visit
  • Patients 20-39 years old and those between 40-59 years of age with low 10-year risk should be assessed for long-term/lifetime risk
Coronary Risk Charts for Determination of Cardiovascular Disease Risk 
  • Risk assessment tools that may be used to estimate CVD risk for patients who have not experienced symptomatic CVD or other atherosclerotic diseases include Framingham Risk Assessment Tool, Multi-Ethnic Study of Atherosclerosis (MESA) 10-year ASCVD risk with coronary artery calcification calculator, System for Cardiac Operative Risk Evaluation (SCORE), Reynold’s Risk Score, and United Kingdom Prospective Diabetes Study (UKPDS) risk engine in individuals with type 2 diabetes mellitus (DM)
  • Overall CVD risk is more important than the presence or absence of specific risk factors
  • Gender, smoking status, age, BP, lipid levels, and DM are used to determine the CVD risk

Patients ≥40 years

  • All patients ≥40 years should be evaluated for the absolute risk of CVD at routine physician visit
    • Evaluation should be done every 4-6 years or more frequently if risk factors change

Risk Stratification

Major Risk Factors

  • Cigarette smoking
  • Low HDL cholesterol (<40 mg/dL)
  • Increased total serum cholesterol level
  • Diabetes mellitus (DM)
  • Age (men ≥45 years; women ≥55 years)
  • Chronic kidney disease
  • Increased LDL-cholesterol levels (≥190 mg/dL)
  • Increased non-HDL-cholesterol levels
  • For individuals with high HDL cholesterol (>60 mg/dL), subtract 1 risk factor from the total
  • History of gestational diabetes in women
  • Hypertension (BP ≥140/90 mmHg or on antihypertensive medication)
  • History of preeclampsia or pregnancy-induced hypertension in women
  • Family history of atherosclerotic cardiovascular disease (male 1st-degree relative <55 years; female 1st-degree relative <65 years)
Additional Risk Factors
  • Dyslipidemic triad (hypertriglyceridemia; low HDL-C; and an excess of small, dense LDL-C)
  • Obesity, abdominal obesity
  • Elevated Apo B
  • Elevated LDL particle number
  • Fasting/postprandial hypertriglyceridemia
  • Family history of hyperlipidemia
  • Polycystic ovarian syndrome (PCOS) in women
  • Small dense LDL-C
Nontraditional Risk Factors
  • Elevated lipoprotein
  • Elevated clotting factors
  • Elevated inflammation markers
  • Elevated triglyceride-rich remnants
  • Elevated homocysteine levels
  • Apo E4 isoform
  • Elevated uric acid

Patients with the following conditions are considered coronary heart disease (CHD) risk equivalents:

  • Type 2 DM
    • There was insufficient evidence to support type 1 DM as a CHD risk equivalent, although type 1 DM with proteinuria may increase the risk for ischemic cardiovascular disease
  • Patients with other forms of symptomatic atherosclerotic disease, such as peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA), and symptomatic carotid artery disease
  • Large-vessel atherosclerotic ischemic stroke
  • Framingham Heart Score risk ≥20%

Note that CVD risk may be higher than indicated in the coronary risk chart in the following:

  • Patients approaching the next age, blood pressure (BP) or cholesterol category
  • Sedentary or obese patients
  • Those with family history of premature CHD or stroke in a 1st-degree relative (male <55 years; female <65 years)
  • Patients with low HDL-C or high triglycerides (TG)
  • Patients with DM or impaired glucose tolerance
  • Those already on antihypertensive therapy
  • Patients with evidence of preclinical atherosclerosis
Cardiovascular Risk Categories

Risk Category Risk Factors/10-year Risk
Extreme Risk Progressive atherosclerotic cardiovascular disease including unstable angina after reduction of LDL-C to <70 mg/dL or
Established clinical cardiovascular disease in patients with diabetes mellitus, chronic kidney disease 3/4, or heterozygous familial hypercholesterolemia or
History of premature atherosclerotic cardiovascular disease at <55 years of age in males; <65 years of age in females
Very High Risk History of recent hospitalization for acute coronary syndrome, coronary, carotid, or peripheral vascular disease and 10-year risk >20% or
Diabetes or chronic kidney disease 3/4 plus ≥1 additional risk factor(s) or
Heterozygous familial hypercholesterolemia
High Risk ≥2 risk factors and 10-year risk 10-20% or CHD risk equivalents, including diabetes or chronic kidney disease 3/4 with no other risk factors
Moderate Risk ≤2 risk factors and 10-year risk <10%
Low Risk 0 risk factor


  • Family history of high BP, DM, dyslipidemia, CHD, stroke, renal disease and premature CVD
    • Risk of chronic heart disease increases as number of family members with chronic heart disease increases and the younger the age at which family members develop the disease (before 55 years of age in 1st-degree male relatives or female relatives before 65 years old)
  • Current symptoms of atherosclerosis [eg angina, intermittent claudication, myocardial infarction (MI), transient ischemic attack (TIA), or stroke]
  • Personal history of diabetes, polycystic ovary syndrome, gout, chronic inflammatory conditions, sexual dysfunction, kidney disease, periodontitis
  • Use of drugs known to raise blood pressure (eg oral contraceptives, NSAIDs, licorice, cocaine, amphetamine, erythropoietin, Ciclosporin, and steroids)
  • Personal, psychosocial, occupational and environmental factors that can influence long-term care (eg depression, anxiety, type D personality, lack of social support, social isolation, and stressful conditions at work)
  • Smoking history and status
  • Alcohol consumption
  • Assess intensity and frequency of physical activity
  • Nutritional habits (eg salt and fat intake)

Physical Examination

  • Height, weight, waist circumference
    • Calculate body mass index (BMI) by dividing patient’s weight (kg) by the square of the height (m2)
  • Blood pressure (BP), pulse rate, ankle-brachial index
  • Comprehensive physical examination
    • Cardiovascular (CV): Heart size, apex beat displacement, signs of heart failure, disease in the carotid, renal and peripheral arteries, coarctation of aorta
    • Lungs: Signs of congestion or lung disease
    • Abdomen: Bruits, enlarged kidneys, liver and other masses
    • Eyes: Optic fundi
    • Central Nervous System (CNS): Evidence of CVD and complications of diabetes (ie neuropathy)
  • Examination for features of secondary hypertension (pheochromocytoma, Cushing’s syndrome)

Laboratory Tests

The following should be performed based on patient’s risk for dyslipidemia and diabetes (at least every 5 years or more frequent if risk factors are present)

  • Fasting serum lipoprotein profile [total cholesterol (TC), LDL-C, HDL-C and TG]
    • If patient has not fasted prior to lipid profile: TC and HDL-C can still be measured
  • Fasting blood glucose
  • High-sensitivity C-reactive protein may be considered in intermediate- to high-risk patients with LDL-C levels of <130 mg/dL that needs further stratification
  • The following are not recommended for routine use but may be considered in select patients: Carotid intima-media thickness, coronary artery calcium score on electron-beam computed tomography, homocysteine level, and lipoprotein (a) level, DNA-based tests, any serological or urinary biomarkers


  • Coronary artery calcification (CAC) measurement and carotid intima-media thickness (CIMT) test may help in choosing best treatment strategy for patients
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Cardiology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
3 days ago
Less focus must be given on pretreatment blood pressure (BP) levels, which rarely predict future untreated BP levels or rule out capacity to benefit from BP lowering in high cardiovascular risk patients, according to recent study. Focus must be directed instead on prompt, empirical treatment to maintain lower BP for individuals with high BP or high risk.
16 Nov 2018
Atrial fibrillation appears to be the strongest determinant of stroke over 48 years of follow-up in males, a study has found.
15 Nov 2018
Psychological functioning consistently predicts symptom severity and health-related quality of life (hr-QOL) in atrial fibrillation (AF) patients with preserved left ventricular function, a recent study has found.
Audrey Abella, 16 Nov 2018
Supplementation with either omega-3 fatty acids (ie, fish oil) or vitamin D did not reduce the incidence of major cardiovascular (CV) events (ie, composite of myocardial infarction [MI], stroke, and CV death) or total invasive cancer, according to the VITAL* trial presented at AHA 2018.