Calculating CV risk and antiplatelet therapy in CKM disease

The ‘traditional cardiovascular risk assessment (CVRA)’ no longer applies to people with CKM disease. People with CKM disease should have their 5 year CV risk calculated using the PREDICT CV risk calculator at diagnosis of CKM disease and then as part of their annual CKM assessments
5 year CV risk is now characterised as:
- Low CV risk (5 year CV risk < 5%)
- Moderate CV risk (5 year CV risk 5 – <10%)
- High CV risk (5 year CV risk ≥ 10%) OR any of the following irrespective of calculated CV risk:
  - Previous CV event
  - Established CV disease including known asymptomatic coronary and carotid disease
  - Type 2 diabetes with any microvascular complication e.g. diabetic eye, chronic kidney disease (eGFR < 60 mL/min and/or UACR > 3 mg/mmol)
  - UACR ≥ 30 mg/mmol
  - eGFR < 45 mL/min
  - UACR 3 – 29 mg/mmol and eGFR 45 – 59 mL/min
  - Age > 50 years and UACR > 3 mg/mmol and/or eGFR < 60 mL/min
  - Familial hypercholesterolaemia
Management of CKM disease should always be optimised, which may be independent of CV risk. The main role of calculating CV risk in CKM disease is to determine whether treatment is recommended for:
- Antihypertensives if BP 130 – 139/80 - 89 mmHg in the absence of CV or renal disease, or complications of diabetes
- Antiplatelet therapy for primary prevention if no diabetes or chronic renal disease
- Lipid lowering therapy if not high CV risk
- SGLT2i and/or GLP1Ra in type 2 diabetes if no established renal or CV disease or heart failure
- CV risk calculations should not influence any other treatment decisions
Additional management and timing of next CV risk calculation based on current CV risk:
- High CV risk:
  - Start lipid-lowering therapy with a target LDL cholesterol (LDLc) < 1.4 mmol/L
  - Start blood-pressure lowering therapy if BP ≥ 130/80 mmHg
  - Start SGLT2i and/or GLP1Ra if type 2 diabetes regardless of HbA1c
  - Start aspirin 75–150 mg daily for primary prevention if < 70 years of age and benefits appear to outweigh risks:
    - NB: The risks of aspirin in primary prevention likely now outweigh the benefits in people with diabetes, significant renal or liver disease, or significant bleeding risk
    - Tools to help informed individualised decision making include aspirin benefit harm calculators
    - Aspirin and other antiplatelet agents such as clopidogrel and ticragrelor remain important for secondary prevention of CV events for all
  - Onceified as high-risk there is no need to re-calculate CV risk as treatment should always be optimised as per high-risk unless contraindications
Moderate CV risk:
- Strongly consider lipid lowering therapy aiming for LDL cholesterol < 1.8 mmol/L, particularly if any significant risk factors:
- Start blood pressure lowering therapy if BP ≥ 140/90 mmHg
- Strongly consider blood pressure lowering therapy and treating underlying condition if BP 130 - 139/80 - 89 mmHg AND ANY of:
  - Gout or auto-immune inflammatory disease
  - MASLD
  - OSA
  - Severe mental illness particularly with antipsychotic use
  - Previous gestational diabetes and/or preeclampsia
  - Direct family history of CVD < 40 years of age
  - Cardiac calcium score ≥ 100
- Start SGLT2i and/or GLP1Ra if type 2 diabetes regardless of HbA1c if any renal impairment or heart failure OR if HbA1c above target despite lifestyle management and metformin and weight loss desirable
- Risks of aspirin for primary prevention typically outweigh the benefits at moderate CV risk
- Recalculate CV risk at next annual CKM assessment
  - May be relaxed to 2 yearly if gout or metabolic liver disease alone
Low CV risk:
- Consider lipid lowering therapy if 5 year CV risk ≥ 3% and any significant risk factors are present with a target LDL cholesterol (LDLc) < 1.8 mmol/L, but is largely driven by patient preference.
- Start blood-pressure lowering therapy if BP ≥ 140/90 mmHg
- Start SGLT2i and/or GLP1Ra if type 2 diabetes regardless of HbA1c if any renal impairment or heart failure OR if HbA1c above target despite lifestyle management and metformin and weight loss desirable
- Aspirin is not recommended for primary prevention in low CV risk
- Recalculate CV risk in 5 years

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