Who / when
- Adults aged 40 to 74 (the age range of the 2019 WHO charts), especially: smokers, people with obesity, hypertension or diabetes, a first-degree relative with early heart disease or stroke, or a first-degree relative with diabetes or kidney disease.
- People with known heart disease, stroke, peripheral arterial disease or kidney disease: do not use the chart. They are already at high risk (treat as 20% or more).
Red flags: refer now
- Chest pain now, or signs of a heart attack.
- Signs of stroke or a recent transient ischaemic attack: new weakness, numbness, speech difficulty or facial droop.
- BP 180/110 or higher with headache, breathlessness, blurred vision or confusion.
- A cold, pale, painful limb.
These are emergencies, not risk-chart questions: refer the same day.
Assess
Information for the chart
- Age, sex, current smoker or not, systolic BP.
- Laboratory chart: diabetes yes or no, and total cholesterol in mmol/L (mg/dL multiplied by 0.02586).
- Non-laboratory chart: body mass index instead (weight in kg divided by height in metres squared). Use it where cholesterol and glucose cannot be measured.
Using the chart
- Choose the chart for your region (21 regions).
- Pick the section (with or without diabetes, laboratory chart), then sex, smoking status and age band.
- Find the cell where systolic BP meets cholesterol (or BMI). Record the percentage.
DiabetesThe non-laboratory chart does not include diabetes, so it underestimates risk in people with diabetes. Use the laboratory chart for them.
Classify
Risk of a fatal or non-fatal heart attack or stroke in 10 years. Countries may set different thresholds.| 10-year risk | Band | Management (adapted from WHO PEN Protocol 1) |
|---|
| 30% or more | Very high | As for 20% to under 30% |
| 20% to under 30% | High | Counsel. Consider BP medicines if BP stays 130/80 or more. Give a statin. Follow up every 3 months; refer if risk has not fallen after 6 months |
| 10% to under 20% | Moderate | Counsel. Consider BP medicines if BP stays 140/90 or more. Follow up every 3 to 6 months |
| 5% to under 10% | Low to moderate | Counsel. Follow up every 3 months until targets are met, then every 6 to 9 months |
| Under 5% | Low | Counsel. Reassess in 12 months |
Treat regardless of the chart: established heart disease, stroke or peripheral arterial disease; kidney disease; diabetes with CVD (all as 20% or more); albuminuria, retinopathy or left ventricular hypertrophy; persistent BP 160/100 or higher; total cholesterol 8 mmol/L (320 mg/dL) or higher.
Treat
Statins
- Give a statin when risk is 20% or more, and after a heart attack or stroke (start it with BP treatment).
- Statins are recommended for everyone with type 2 diabetes aged 40 and over, as long as this does not take money from glucose and BP medicines.
- Do not use statins in pregnancy, or in women who could become pregnant and are not using contraception.
Example doses from the WHO HEARTS evidence-based treatment protocols (2018). Your national protocol and formulary take precedence.| Medicine | Start | Higher dose | Watch for |
|---|
| Simvastatin | 20 mg in the evening | 40 mg in the evening | Muscle pain. With amlodipine or diltiazem, do not exceed 20 mg a day |
| Atorvastatin (alternative) | 40 mg | 80 mg | Muscle pain |
Other treatment
- Blood pressure: see the hypertension protocol. Diabetes: see the type 2 diabetes protocol.
- Low-dose aspirin (75 to 100 mg) only after a heart attack or ischaemic stroke, not for prevention.
Follow-up
- Follow-up interval by band (see Classify). Reassess risk every 12 months in people not on medicines, or sooner if symptoms appear.
- Each visit: new symptoms, tobacco and alcohol, activity, diet, adherence, BP; re-estimate risk; refer if needed.
Counsel
- Everyone: healthy diet (less salt, less fat), regular physical activity, stop all tobacco (smoked and smokeless), avoid harmful alcohol.
- Explain the risk as a number: "about 2 in 10 people like you will have a heart attack or stroke in the next 10 years".
- Risk goes down when BP and cholesterol are both treated; it roughly halves.
- Statins are long-term; keep taking them. Report unexplained muscle pain.
Your chance of a heart attack or stroke in the next 10 years is high. Stopping smoking, eating less salt, and taking these tablets every day will lower it.
When to refer
- Same day: any red flag above.
- Risk 20% or more with no fall in risk after 6 months of follow-up.
- Total cholesterol 8 mmol/L or more.
- Statin side effects you cannot manage.
Sources
World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: risk-based CVD management. 2020. WHO CVD Risk Chart Working Group. World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions (Lancet Global Health 7: e1332-45). 2019. World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018. World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020. World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020.