Phys · cardiovascular
Cardiovascular Prevention and Rehabilitation
Also known as cardiovascular risk assessment · absolute cardiovascular risk · lipid management · statin therapy · LDL targets · primary prevention · secondary prevention · cardiac rehabilitation · familial hypercholesterolaemia · statin intolerance
Consultant-physician-depth guide to cardiovascular prevention — absolute risk assessment, lipid targets and the statin-to-PCSK9 ladder, statin intolerance and the nocebo problem, triglycerides, Lp(a) and familial hypercholesterolaemia, lifestyle prescription with numbers, the post-ACS secondary prevention bundle, and cardiac rehabilitation — structured for FRACP DWE and DCE preparation.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
FRACP DWEFRACP DCEMRCP Part 2ABIM Internal Medicine
Red flags
- Suspected familial hypercholesterolaemia — LDL persistently very high with tendon xanthomata or premature family history; cascade-screen first-degree relatives
- Post-ACS patient not on a statin, not referred to cardiac rehabilitation — both are mortality-reducing interventions being missed
- Muscle pain with dark urine on a statin — rhabdomyolysis until proven otherwise; check CK, creatinine and potassium urgently
- Primary prevention aspirin in an elderly patient — ASPREE-era evidence shows net harm; stop and reassess
- Very high triglycerides with abdominal pain — pancreatitis risk, not just cardiovascular risk
Cardiovascular Prevention and Rehabilitation
Meet the patient
A 52-year-old non-smoker sits in your clinic with an LDL of 3.4 mmol/L and a calculated five-year cardiovascular risk of 4 percent. He wants a statin "to be safe". His twin brother — diabetic, hypertensive, a smoker with an LDL of 2.4 — has never been near a clinic.[1]
Which one gets the statin? The brother — because prevention is absolute-risk medicine, and the benefit of a statin is proportional to baseline risk while the harms are roughly constant. The LDL number alone never answers "should I treat?"[5]
References26ShowHide
- [1]Nelson MR, Banks E, Brown A, et al. 2023 Australian guideline for assessing and managing cardiovascular disease risk Med J Aust, 2024.PMID 38623719
- [2]Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study BMJ, 2017.PMID 28536104
- [3]Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S) Lancet, 1994.PMID 7968073
- [4]Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial Lancet, 2002.PMID 12114036
- [5]Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins Lancet, 2005.PMID 16214597
- [6]Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials Lancet, 2010.PMID 21067804
- [7]Ridker PM, Danielson E, Fonseca FAH, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein N Engl J Med, 2008.PMID 18997196
- [8]Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes N Engl J Med, 2015.PMID 26039521
- [9]Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease N Engl J Med, 2017.PMID 28304224
- [10]Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome N Engl J Med, 2018.PMID 30403574
- [11]Nissen SE, Lincoff AM, Brennan D, et al. Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients N Engl J Med, 2023.PMID 36876740
- [12]Bhatt DL, Steg PG, Miller M, et al. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia N Engl J Med, 2019.PMID 30415628
- [13]Wood FA, Howard JP, Finegold JA, et al. N-of-1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects N Engl J Med, 2020.PMID 33196154
- [14]Estruch R, Ros E, Salas-Salvadó J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts N Engl J Med, 2018.PMID 29897866
- [15]Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease Cochrane Database Syst Rev, 2016.PMID 26730878
- [16]McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly N Engl J Med, 2018.PMID 30221597
- [17]Bowman L, Mafham M, Wallendszus K, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus N Engl J Med, 2018.PMID 30146931
- [18]Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial Lancet, 2018.PMID 30158069
- [19]Nordestgaard BG, Chapman MJ, Humphries SE, et al. Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: consensus statement of the European Atherosclerosis Society Eur Heart J, 2013.PMID 23956253
- [20]Nordestgaard BG, Chapman MJ, Ray K, et al. Lipoprotein(a) as a cardiovascular risk factor: current status Eur Heart J, 2010.PMID 20965889
- [21]Wright JT Jr, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control N Engl J Med, 2015.PMID 26551272
- [22]ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group Lancet, 1988.PMID 2899772
- [23]Pfeffer MA, Braunwald E, Moyé LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators N Engl J Med, 1992.PMID 1386652
- [24]Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial Ann Intern Med, 2005.PMID 15710956
- [25]Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis JAMA, 2009.PMID 19454641
- [26]Freemantle N, Cleland J, Young P, et al. beta Blockade after myocardial infarction: systematic review and meta regression analysis BMJ, 1999.PMID 10381708