Cardiovascular Disease

Last updated 1 Jun 2026 · Cardiology

📋 Key Information Summary

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Cardiovascular disease (CVD) remains the leading cause of death in Australia, responsible for approximately 25% of all deaths and disproportionately affecting Aboriginal and Torres Strait Islander peoples.
Modifiable risk factors include hypertension, dyslipidaemia, cigarette smoking, diabetes mellitus, obesity, physical inactivity, unhealthy diet, and harmful alcohol consumption.
Non-modifiable risk factors include age (men ≥45 years, women ≥55 years), male sex, family history of premature CVD, and ethnicity (South Asian, Aboriginal and Torres Strait Islander).
The Australian Cardiovascular Risk Calculator (derived from the Framingham Risk Equation) is recommended by the National Vascular Disease Prevention Alliance (NVDPA) to estimate 5-year absolute CVD risk for asymptomatic adults aged 45–74 years.
All Aboriginal and Torres Strait Islander adults should have cardiovascular risk assessment from age 18 years (RACGP/NVDPA recommendation).
Absolute CVD risk is categorised as low (<5%), moderate (5–<10%), or high (≥10% or clinically determined high risk) over 5 years.
Clinically determined high-risk conditions include established atherosclerotic CVD, diabetes mellitus aged ≥65 years or with microalbuminuria, moderate-to-severe chronic kidney disease (eGFR <45 mL/min/1.73 m²), familial hypercholesterolaemia, and systolic BP ≥180 mmHg or diastolic BP ≥110 mmHg.
Lifestyle modification — including smoking cessation, regular physical activity (≥150 min/week moderate-intensity), heart-healthy diet, weight management, and alcohol reduction — is the foundation of CVD prevention at every risk level.
Pharmacological management includes antihypertensive therapy (target <130/80 mmHg for high-risk patients), lipid-lowering therapy with statins (first-line), antiplatelet therapy (aspirin for secondary prevention only), and glycaemic control for diabetic patients.
Aspirin is not recommended for primary prevention of CVD in the general population due to bleeding risk outweighing benefit; it is reserved for secondary prevention.
Secondary prevention following acute coronary syndrome (ACS) or revascularisation requires lifelong risk-factor modification plus dual antiplatelet therapy (DAPT) for 6–12 months, high-intensity statin, beta-blocker, and ACE inhibitor/ARB.
GPs play a central role in opportunistic risk assessment, prescribing preventive medications, coordinating chronic disease management plans (MBS Item 721/723), and facilitating referral to cardiac rehabilitation.

Introduction & Australian Epidemiology

Cardiovascular disease (CVD) encompasses a broad spectrum of conditions affecting the heart and blood vessels, including coronary heart disease (CHD), stroke, peripheral arterial disease, rheumatic heart disease, and heart failure. CVD is the leading cause of death in Australia and a major driver of morbidity, disability, and healthcare expenditure. General practitioners are ideally placed to identify at-risk individuals, implement evidence-based preventive strategies, and coordinate long-term management for those living with established disease.

According to the Australian Institute of Health and Welfare (AIHW), an estimated 1.2 million Australians aged 18 years and over have one or more heart, stroke, or vascular conditions. In 2021, CVD accounted for approximately 42,900 deaths (25% of all deaths), with coronary heart disease and stroke being the principal contributors. Although age-standardised CVD mortality has declined significantly over the past four decades due to improvements in acute care and risk-factor reduction, the absolute burden is rising as the population ages and the prevalence of obesity, diabetes, and physical inactivity increases.

The burden of CVD is not distributed equally. Aboriginal and Torres Strait Islander peoples experience CVD mortality rates approximately 1.5–2 times those of non-Indigenous Australians, with even greater disparities in remote and very remote areas. Socioeconomic disadvantage, limited access to primary care, higher prevalence of smoking, diabetes, and chronic kidney disease, and lower rates of medication adherence all contribute to this disparity. People from South Asian, Middle Eastern, and Pacific Islander backgrounds also carry a higher baseline cardiovascular risk, which is not always captured by standard risk calculators.

The total cost of CVD to the Australian health system exceeds billion annually, making it the most expensive disease group. Effective primary and secondary prevention in general practice represents one of the highest-value interventions available in the Australian healthcare system. The National Vascular Disease Prevention Alliance (NVDPA), the Royal Australian College of General Practitioners (RACGP), and the National Heart Foundation of Australia (NHF) have collaborated to produce the Australian Cardiovascular Disease Risk Calculator and accompanying clinical guidelines to support evidence-based, systematic risk assessment in primary care.

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Key principle: CVD prevention in Australia is a lifelong endeavour. Risk assessment should be conducted opportunistically during routine consultations, at health assessments (MBS Item 701/703/705/707/715), and whenever a patient presents with new risk factors. A single elevated reading should not trigger treatment without confirmation and comprehensive risk stratification.

Risk Factors for CVD

Cardiovascular risk factors are traditionally divided into modifiable and non-modifiable categories. Understanding and systematically addressing these factors is essential for effective prevention. Importantly, risk factors tend to cluster and interact multiplicatively rather than additively — a patient with three moderate risk factors may be at substantially higher risk than a patient with a single severe risk factor.

Non-Modifiable Risk Factors

Risk Factor	Details	Clinical Implication
Age	Men ≥45 years; Women ≥55 years (or post-menopausal)	Threshold for CV risk assessment in NVDPA guidelines
Male sex	Higher risk at younger ages; women's risk increases post-menopause	Women with premature menopause (<40 years) have elevated risk
Family history	First-degree relative with premature CVD (<55 years in men, <65 years in women)	May warrant earlier screening; consider familial hypercholesterolaemia
Ethnicity	Aboriginal and Torres Strait Islander, South Asian, Pacific Islander, Middle Eastern	Earlier and more intensive risk-factor screening; lower treatment thresholds

Modifiable Risk Factors

Hypertension

Hypertension is the single greatest population-attributable risk factor for CVD in Australia. Approximately 6 million Australians aged 18 years and over have measured hypertension (≥140/90 mmHg), though many remain undiagnosed. Office blood pressure should be confirmed with ambulatory blood pressure monitoring (ABPM, MBS Item 11610) or home blood pressure monitoring (HBPM) before initiating treatment, as white-coat hypertension affects 10–15% of the population. Stage 1 hypertension (systolic 140–159 / diastolic 90–99 mmHg) in a low-risk patient may be managed with lifestyle modification alone for 3–6 months, while stage 2 (≥160/100 mmHg) or high-risk patients should commence pharmacotherapy promptly.

Dyslipidaemia

Elevated low-density lipoprotein cholesterol (LDL-C) is a causative factor in atherosclerosis. In Australia, approximately 7.0 million adults have abnormal lipid levels. Fasting lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides) is recommended as part of cardiovascular risk assessment. Remnant cholesterol and lipoprotein(a) [Lp(a)] are emerging risk enhancers that may refine risk estimation, particularly in patients with a family history of premature CVD or an unexpectedly elevated LDL-C.

Cigarette Smoking

Smoking doubles to quadruples CVD risk and is the most preventable cause of cardiovascular death in Australia. While smoking rates have declined nationally (11% of adults in 2022), rates remain disproportionately high among Aboriginal and Torres Strait Islander peoples (approximately 36%) and in lower socioeconomic groups. Even light smoking (1–5 cigarettes/day) significantly increases risk; there is no safe level of exposure. Second-hand smoke exposure also contributes to cardiovascular risk.

Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) confers a 2–4-fold increase in CVD risk. Cardiovascular events are the leading cause of death in people with diabetes. Risk is further amplified by co-existent hypertension, dyslipidaemia, obesity, and microalbuminuria. Newer glucose-lowering agents — particularly sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) — have demonstrated cardiovascular benefit independent of glycaemic lowering and are now recommended as part of integrated cardiometabolic management.

Obesity and Physical Inactivity

Obesity (BMI ≥30 kg/m²) and physical inactivity are independent CVD risk factors that also contribute to hypertension, dyslipidaemia, insulin resistance, and systemic inflammation. Waist circumference (>94 cm in men, >80 cm in women for increased risk; >102 cm in men, >88 cm in women for substantially increased risk) is a practical measure of central adiposity. Less than one in four Australian adults meets the physical activity guidelines of ≥150 minutes of moderate-intensity or ≥75 minutes of vigorous-intensity activity per week.

Other Modifiable Factors

Chronic kidney disease (CKD): eGFR <60 mL/min/1.73 m² or albumin-creatinine ratio (ACR) ≥3 mg/mmol independently increases CVD risk; CKD is classified as a clinically determined high-risk condition when eGFR <45.
Atrial fibrillation: Independent risk factor for stroke; requires CHA₂DS₂-VASc scoring and anticoagulation assessment.
Sleep apnoea: Obstructive sleep apnoea is associated with resistant hypertension and increased CVD risk.
Psychosocial factors: Depression, social isolation, chronic stress, and low socioeconomic status are recognised CVD risk modifiers (NHMRC level B evidence).
Alcohol: Heavy alcohol consumption (>14 standard drinks/week) increases blood pressure, triglycerides, and risk of cardiomyopathy; no level of alcohol consumption is cardioprotective.

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Smoking cessation is the single most effective CVD prevention intervention: Cessation at any age reduces risk. Within 1 year of quitting, excess CVD risk is reduced by approximately 50%. All patients who smoke should be offered brief intervention (Ask, Advise, Help), nicotine replacement therapy (NRT), varenicline, or bupropion, and referral to Quitline (13 7848).

Absolute Cardiovascular Risk Assessment

Absolute cardiovascular risk (CVR) assessment estimates the probability of a cardiovascular event (myocardial infarction, stroke, or cardiovascular death) occurring within a defined time period, typically 5 years. This approach is superior to treating individual risk factors in isolation because it accounts for the synergistic effect of multiple co-existing risk factors. The National Vascular Disease Prevention Alliance (NVDPA) recommends the use of the Australian Cardiovascular Risk Calculator for all asymptomatic adults aged 45–74 years (and from 18 years for Aboriginal and Torres Strait Islander peoples).

When to Assess

All adults aged 45–74 years (≥30 years for Aboriginal and Torres Strait Islander peoples) should have an absolute CVD risk assessment as part of routine preventive care.
Adults aged 75+ years are generally considered to be at high absolute risk; formal calculation is less useful but risk-factor modification remains essential.
Assessment should be repeated every 2 years for low-risk individuals, and annually for moderate-risk individuals.
Patients with new risk factors (e.g., newly diagnosed diabetes, new smoking, significant weight gain) should be reassessed promptly.
Health assessments under MBS Items 701, 703, 705, 707, 715, and 721/723 provide structured opportunities for CVD risk assessment.

Components of the Australian CVR Calculator

The calculator uses the following variables, derived from the Framingham Heart Study and recalibrated to Australian population data:

Variable	Details
Age	30–74 years (calculator range)
Sex	Male / Female
Systolic blood pressure	Office or confirmed measurement (mmHg)
Total cholesterol	Fasting lipid (mmol/L)
HDL cholesterol	Fasting lipid (mmol/L)
Smoking status	Current smoker / Non-smoker / Ex-smoker
Diabetes mellitus	Yes / No (type 1 or type 2)
Left ventricular hypertrophy (LVH)	ECG-confirmed LVH (optional; adds significant points if present)
eGFR	Where available; CKD automatically classifies as high risk if eGFR <45
Family history of premature CVD	First-degree relative, men <55 years, women <65 years

Risk Categories and Clinical Actions

Low Risk

<5% (5-year risk)

Lifestyle advice and education. Reassess every 2 years. Address modifiable factors to maintain low risk. No pharmacotherapy typically required unless BP persistently ≥160/100 mmHg or LDL-C ≥5.0 mmol/L.

Setting: General practice — routine review

Moderate Risk

5–<10% (5-year risk)

Intensive lifestyle intervention plus consideration of pharmacotherapy. BP target <140/90 mmHg (or <130/80 if diabetic). Consider statin therapy if LDL-C ≥2.0 mmol/L after lifestyle measures. Reassess annually.

Setting: General practice — active management

High Risk

≥10% (5-year risk) or clinically determined high risk

Pharmacotherapy indicated in addition to lifestyle modification. BP target <130/80 mmHg. Statin therapy (high-intensity) for LDL-C target <2.0 mmol/L (or ≥50% reduction). Antiplatelet therapy only if secondary prevention. Regular follow-up every 3–6 months.

Setting: General practice — intensive management; consider cardiology referral

Clinically Determined High-Risk Conditions

The following conditions automatically classify a patient as high absolute CVD risk, regardless of calculated 5-year score:

Established atherosclerotic CVD (prior MI, stroke, TIA, peripheral arterial disease, revascularisation)
Diabetes mellitus with microalbuminuria (ACR ≥3.0 mg/mmol) or aged ≥65 years
Moderate-to-severe CKD (eGFR <45 mL/min/1.73 m²)
Systolic BP ≥180 mmHg or diastolic BP ≥110 mmHg
Total cholesterol >7.5 mmol/L (familial hypercholesterolaemia suspected)
Aboriginal and Torres Strait Islander peoples aged ≥50 years with any two risk factors

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Important: The Australian CVR Calculator should not be used for patients who already have established CVD — these patients are automatically at high risk and require secondary prevention (see below). The calculator is a tool for primary prevention in asymptomatic individuals.

Lifestyle Modification

Lifestyle modification is the cornerstone of both primary and secondary CVD prevention. Evidence consistently demonstrates that healthy lifestyle behaviours can reduce CVD risk by 50–80%, even in the presence of genetic predisposition. GPs should provide brief, targeted lifestyle counselling at every opportunity and refer to allied health professionals, community programmes, and state-based Heart Foundation services where appropriate.

Smoking Cessation

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Every cigarette matters: There is no safe level of smoking. Even reducing the number of cigarettes is less effective than complete cessation. The goal is complete abstinence, not reduction.

Brief intervention (3As): Ask about smoking status at every visit; Advise of the health benefits of quitting; Assist with a quit plan and pharmacotherapy.
Nicotine replacement therapy (NRT): Patches (16-hour or 24-hour), gum, lozenges, inhalers, or nasal spray. Combination NRT (patch + short-acting form) is more effective than monotherapy.
Varenicline (Champix®): Most effective single-agent pharmacotherapy. 0.5 mg PO daily for 3 days → 0.5 mg PO BD for 4 days → 1 mg PO BD for 11 weeks. Total course 12 weeks; may repeat once. ✔ PBS General Benefit
Bupropion (Zyban®): 150 mg PO BD for 7–9 weeks. Alternative when varenicline contraindicated. ✔ PBS General Benefit
Referral: Quitline 13 7848 (free telephone coaching); QuitCoach (online); Aboriginal Quitline 13 7848 (culturally appropriate service).

Physical Activity

Target: ≥150 minutes of moderate-intensity or ≥75 minutes of vigorous-intensity aerobic activity per week, plus resistance training ≥2 days per week.
Cardiac rehabilitation: Referral to an accredited cardiac rehabilitation programme (MBS Item 699 — pending) is recommended for all patients following an acute cardiac event. Programmes typically run 6–8 weeks and include supervised exercise, education, and psychosocial support.
Sedentary behaviour: Prolonged sitting is an independent risk factor. Advise breaking up long sitting periods every 30 minutes with light activity.
Exercise prescription: Can be provided by GPs under chronic disease management plans (MBS Item 721) with referral to exercise physiologists or physiotherapists.

Diet and Nutrition

The evidence-based dietary pattern with the strongest cardiovascular benefit is the Mediterranean diet, supplemented by principles of the Dietary Approaches to Stop Hypertension (DASH) diet. Key recommendations include:

≥5 serves of vegetables and ≥2 serves of fruit daily.
Wholegrain cereals, legumes, and nuts as staple foods.
Extra virgin olive oil as the principal added fat.
Fish (oily fish rich in omega-3 fatty acids) ≥2 times per week.
Limit processed meats (sausages, bacon, salami), refined carbohydrates, sugar-sweetened beverages, and added salt (target <5 g/day or <2000 mg sodium/day).
Unflavoured dairy (milk, yoghurt, cheese) preferred over flavoured varieties.
Refer to an accredited practising dietitian (APD) for individualised counselling, available via MBS Group Allied Health items (MBS Item 10950–10970) under a GP Management Plan.

Weight Management

Target BMI 18.5–24.9 kg/m²; waist circumference <94 cm (men) or <80 cm (women).
A modest weight loss of 5–10% of body weight produces clinically meaningful improvements in blood pressure, lipid profile, and glycaemic control.
Consider referral to the Life! programme (Victoria) or state-equivalent programmes for structured lifestyle intervention.
Pharmacotherapy for obesity (orlistat, liraglutide 3.0 mg, semaglutide 2.4 mg) may be considered when lifestyle measures alone are insufficient — refer to bariatric medicine guidelines.

Alcohol Reduction

Follow NHMRC guidelines: no more than 10 standard drinks per week and no more than 4 standard drinks on any one day.
Advise that for CVD risk reduction, less is better; no level of alcohol consumption is cardioprotective.
Screen for alcohol use disorder with AUDIT-C; refer to specialist services if dependency suspected.

Psychosocial Wellbeing

Screen for depression and anxiety using validated tools (PHQ-9, GAD-7). Depression is common after acute cardiac events and independently worsens prognosis.
Social isolation and chronic stress are independent CVD risk factors. Encourage social connectedness and stress-reduction strategies.
Mental Health Treatment Plans (MBS Item 2710/2712) enable referral to psychologists for evidence-based therapy.

Secondary Prevention of CHD

Secondary prevention aims to reduce the risk of recurrent cardiovascular events in patients with established atherosclerotic CVD (coronary heart disease, ischaemic stroke, transient ischaemic attack, peripheral arterial disease). Patients with established CVD are classified as automatically high risk and require lifelong, comprehensive risk-factor management. Evidence demonstrates that systematic secondary prevention reduces recurrent events by 20–50% and mortality by 25–40%.

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Treatment gap: Australian data consistently show suboptimal utilisation of evidence-based secondary prevention medications. Up to 40% of patients post-ACS are not discharged on optimal medical therapy, and adherence declines significantly after 12 months. GPs play a critical role in ensuring medication persistence and regular review.

Pharmacological Secondary Prevention

The following medications represent the core pharmacological regimen for secondary prevention of CHD. All should be initiated unless contraindicated or not tolerated.

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Aspirin

Aspirin 100® · Cartia® · Generic · Antiplatelet

Adult dose 100 mg PO daily, indefinitely

Paediatric dose Not indicated for paediatric CVD prevention

Duration Lifelong (as monotherapy after DAPT course completed)

Renal adjustment No adjustment required; caution in severe CKD (bleeding risk)

Key considerations Contraindicated in aspirin allergy, active GI bleeding, severe bleeding disorder. Use with PPI if history of GI ulceration.

PBS status ✔ PBS General Benefit

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Clopidogrel

Plavix® · Iscover® · Generic · P2Y12 inhibitor

Adult dose 75 mg PO daily (in combination with aspirin for DAPT)

Duration 6–12 months post-ACS or PCI with stent (per cardiologist advice), then stop; aspirin continues lifelong

Renal adjustment No dose adjustment; use with caution in severe hepatic impairment

Key considerations Check for CYP2C19 poor metaboliser status if available. Avoid with active bleeding. Monitor for signs of bruising or bleeding.

PBS status ✔ PBS General Benefit

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Ticagrelor

Brilinta® · AstraZeneca · P2Y12 inhibitor (reversible)

Adult dose 90 mg PO BD (in combination with aspirin 75–100 mg for DAPT)

Duration Up to 12 months post-ACS (per cardiologist guidance)

Renal adjustment No dose adjustment required

Key considerations Dyspnoea common (~15%) but usually self-limiting. Avoid in patients with history of intracranial haemorrhage. Do not stop abruptly without cardiology review.

PBS status ⚠ PBS Authority Required

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Atorvastatin

Lipitor® · Generic · HMG-CoA reductase inhibitor (high-intensity statin)

Adult dose 80 mg PO daily (first-line high-intensity statin for secondary prevention)

Paediatric dose 10–20 mg PO daily (familial hypercholesterolaemia, ≥10 years, specialist initiation)

Duration Lifelong

Renal adjustment No dose adjustment required

Hepatic adjustment Contraindicated in active liver disease or unexplained persistent LFT elevation (>3× ULN)

Key considerations Target LDL-C <2.0 mmol/L or ≥50% reduction from baseline. Monitor LFTs at baseline, 3 months, then annually. Report unexplained muscle pain/weakness (risk of myopathy/rhabdomyolysis). Alternative: rosuvastatin 20–40 mg PO daily.

PBS status ✔ PBS General Benefit

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Perindopril

Coversyl® · Generic · ACE inhibitor

Adult dose 5 mg PO daily (starting), titrate to 10 mg PO daily

Duration Lifelong (post-MI, heart failure, or high-risk CVD)

Renal adjustment Start 2.5 mg daily if eGFR <30 mL/min/1.73 m²; monitor potassium and creatinine

Key considerations Contraindicated in pregnancy, bilateral renal artery stenosis, angioedema history. Monitor renal function and potassium 1–2 weeks after initiation or dose change. Alternative if ACE-I intolerant (cough): candesartan or valsartan (ARB).

PBS status ✔ PBS General Benefit

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Metoprolol succinate

Betaloc® · Generic · Beta-1 selective blocker

Adult dose 50–100 mg PO daily (controlled release) or 25–50 mg PO BD (immediate release); titrate to 200 mg daily

Duration At least 12 months post-MI; lifelong if heart failure or ongoing angina

Renal adjustment No dose adjustment required

Key considerations Do not withdraw abruptly (risk of rebound tachycardia and angina). Contraindicated in severe bradycardia, second/third-degree heart block, decompensated heart failure. Alternative: bisoprolol, carvedilol (if concurrent HFrEF).

PBS status ✔ PBS General Benefit

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Ezetimibe

Ezetrol® · Generic · Cholesterol absorption inhibitor

Adult dose 10 mg PO daily (add-on to statin if LDL-C target not achieved)

Duration Lifelong (in combination with statin)

Renal adjustment No dose adjustment

Key considerations Consider when LDL-C remains above target despite maximally tolerated statin. IMPROVE-IT trial showed incremental benefit in post-ACS patients. Alternative/add-on: PCSK9 inhibitors (evolocumab, alirocumab) — Specialist Authority Required.

PBS status ⚠ PBS Authority Required (when added to statin)

Quick Reference — Post-ACS Secondary Prevention

Medication

Drug

Duration

Notes

Antiplatelet (DAPT)

Aspirin 100 mg + Clopidogrel 75 mg or Ticagrelor 90 mg BD

6–12 months (then aspirin alone)

Duration per cardiologist; bleeding risk assessment

Statin

Atorvastatin 80 mg or Rosuvastatin 20–40 mg

Lifelong

LDL-C target <2.0 mmol/L; add ezetimibe or PCSK9i if needed

ACE inhibitor / ARB

Perindopril 5–10 mg or Ramipril 5–10 mg

Lifelong

Especially if anterior MI, LVSD, DM, HTN, CKD

Beta-blocker

Metoprolol 50–200 mg or Bisoprolol 5–10 mg

≥12 months (lifelong if LVSD)

Consider withdrawal after 12 months if preserved LVEF

PPI (if indicated)

Pantoprazole 40 mg or Esomeprazole 20 mg

Duration of DAPT

GI protection if history of PUD, dual antithrombotic, or ≥65 years

Additional Secondary Prevention Measures

Influenza vaccination: Annual influenza vaccination is recommended for all patients with established CVD (NHMRC Grade A recommendation). Influenza is a recognised trigger for acute MI.
Blood pressure target: <130/80 mmHg for all patients with established CVD, with individualised targets in the elderly.
Glycaemic targets: HbA1c ≤53 mmol/mol (7.0%) for most patients with diabetes and CVD. Use SGLT2 inhibitors or GLP-1 RAs with proven cardiovascular benefit (empagliflozin, liraglutide, semaglutide).
Cardiac rehabilitation: All patients post-ACS or revascularisation should be offered cardiac rehabilitation. Programme completion is associated with a 25–30% reduction in cardiovascular mortality.
Chronic Disease Management (CDM): Utilise GP Management Plans (MBS Item 721) and Team Care Arrangements (MBS Item 723) to coordinate multidisciplinary care.
Psychosocial support: Screen for depression (PHQ-9), anxiety, and cardiac-specific distress. Depression post-MI affects 15–20% of patients and independently worsens prognosis.
Driving restrictions: Patients should be advised not to drive for 2 weeks following uncomplicated MI and 4 weeks following coronary artery bypass grafting (CABG) — per Austroads guidelines.

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Medication adherence: Australian data show that adherence to secondary prevention medications falls to approximately 50% at 2 years post-event. Strategies to improve adherence include simplifying medication regimens (once-daily dosing where possible), using combination pills (e.g., aspirin + atorvastatin), regular GP follow-up, medication reminders, and patient education about the purpose of each medication.

Special Populations

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Pregnancy

ACE inhibitors / ARBs

Contraindicated in pregnancy. Teratogenic — cause renal agenesis, oligohydramnios, fetal death. Discontinue and substitute with labetalol, methyldopa, or nifedipine for hypertension management.

Statins

Contraindicated in pregnancy. Discontinue at least 1 month before planned conception. No demonstrated benefit in women of childbearing age unless very high cardiovascular risk under specialist care.

Aspirin

Low-dose aspirin (100–150 mg daily) is indicated for pre-eclampsia prevention (from 12 weeks gestation in high-risk women) but not for CVD prevention in pregnancy.

Breastfeeding

Perindopril and enalapril are considered compatible with breastfeeding. Statins are not recommended during breastfeeding.

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Paediatrics

Familial hypercholesterolaemia (FH)

Children with confirmed heterozygous FH should commence statin therapy from age 8–10 years under specialist supervision. Atorvastatin 10–20 mg PO daily is the usual starting dose. Lifestyle modification is the cornerstone for all children.

Kawasaki disease

Children with a history of Kawasaki disease require long-term cardiovascular follow-up, particularly if coronary artery aneurysms developed. Aspirin therapy may be ongoing (3–5 mg/kg/day) for those with persistent aneurysms.

Aspirin

Not recommended for primary CVD prevention in children. Reye syndrome risk.

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Elderly (≥75 years)

Blood pressure targets

Individualise targets; SBP <150 mmHg is generally appropriate. Avoid excessive lowering (J-curve phenomenon) — falls risk and orthostatic hypotension are significant concerns. Assess standing BP routinely.

Statin therapy

Continue statins if already prescribed for secondary prevention. For primary prevention in patients >75 years, the evidence is less clear; consider life expectancy, frailty, polypharmacy, and patient preferences. Shared decision-making is essential.

Antiplatelet therapy

Bleeding risk increases with age. Use the HAS-BLED score to assess bleeding risk. PPI co-prescription is recommended for patients on dual antithrombotic therapy who are ≥65 years.

Polypharmacy

Conduct regular medication reviews (MBS Item 900) to deprescribe medications that are no longer of benefit. Consider Home Medicines Review (MBS Item 900) for patients on ≥5 medications.

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Chronic Kidney Disease

ACE inhibitors / ARBs

Indicated in CKD with albuminuria (ACR ≥3.0 mg/mmol) for renoprotection and cardiovascular risk reduction. Monitor potassium and creatinine within 1–2 weeks of initiation or dose change. Accept up to 25% rise in creatinine from baseline.

Statins

Atorvastatin preferred (no renal dose adjustment). No dose adjustment for rosuvastatin until eGFR <30 (start at 5 mg daily). Avoid simvastatin >10 mg with concomitant amlodipine or diltiazem.

SGLT2 inhibitors

Empagliflozin 10 mg or dapagliflozin 10 mg daily — indicated in CKD (eGFR ≥20 mL/min/1.73 m²) regardless of diabetes status for cardiorenal protection (CREDENCE, DAPA-CKD, EMPA-KIDNEY trials).

Aspirin

Use with caution; increased bleeding risk in advanced CKD. Discuss risk–benefit on an individual basis.

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Hepatic Impairment

Statins

Contraindicated in active liver disease or unexplained persistent transaminase elevation (>3× ULN). Use cautiously in compensated cirrhosis with regular LFT monitoring.

ACE inhibitors / ARBs

Use with caution in severe hepatic impairment; risk of hepatorenal syndrome. No specific dose adjustment but monitor closely.

Antiplatelet agents

Increased bleeding risk in patients with thrombocytopenia or coagulopathy related to liver disease. Individual risk–benefit assessment required.

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Immunocompromised

HIV-positive patients

HIV infection is an independent CVD risk factor. Risk calculators may underestimate risk. Certain antiretroviral agents (protease inhibitors) worsen lipid profiles. Interactions between antiretrovirals and statins are common — consult HIV specialist. Atorvastatin and rosuvastatin are preferred; avoid simvastatin with protease inhibitors.

Transplant recipients

Cardiovascular disease is the leading cause of mortality in renal transplant recipients. Calcineurin inhibitors (ciclosporin, tacrolimus) cause hypertension and dyslipidaemia. Statin–ciclosporin interactions increase myopathy risk — use lower statin doses with monitoring.

Autoimmune/inflammatory disease

Rheumatoid arthritis, SLE, psoriasis, and inflammatory bowel disease are associated with accelerated atherosclerosis. Consider these patients at increased cardiovascular risk and screen more frequently.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Cardiovascular disease is the leading cause of death among Aboriginal and Torres Strait Islander peoples, accounting for approximately 22% of all deaths. CVD mortality rates are 1.5–2 times higher than those of non-Indigenous Australians, with even greater disparities in remote and very remote communities. The onset of CVD occurs approximately 10–15 years earlier in Aboriginal and Torres Strait Islander peoples, and the burden of risk factors — including smoking, diabetes, obesity, chronic kidney disease, rheumatic heart disease, and socioeconomic disadvantage — is substantially higher.

Importantly, the NVDPA and RACGP recommend that cardiovascular risk assessment for Aboriginal and Torres Strait Islander peoples commence from age 18 years (rather than 45 years for the general population), reflecting the earlier onset and higher prevalence of risk factors. All Aboriginal and Torres Strait Islander adults should have an annual health check (MBS Item 715 — Indigenous Health Assessment), which includes cardiovascular risk assessment, blood pressure measurement, lipid profile, blood glucose or HbA1c, renal function, and ACR.

Risk factor prevalence

Smoking rates ~36% (vs ~11% nationally); diabetes prevalence ~3–4 times higher; obesity rates approximately double; chronic kidney disease prevalence significantly elevated in remote communities.

Rheumatic heart disease

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are rare in the non-Indigenous population but remain a significant cause of CVD morbidity and mortality in Aboriginal and Torres Strait Islander peoples, particularly in the Northern Territory, Queensland, and Western Australia. Secondary prophylaxis with benzathine penicillin G (BPG) 4-weekly IM injections is essential. See RHDAustralia guidelines (www.rhdaustralia.org.au).

Remote and rural access

Limited access to specialist cardiology services, cardiac catheterisation, and cardiac rehabilitation. Telehealth consultations (MBS Items 99200–99215) and fly-in/fly-out (FIFO) specialist outreach are critical. Aboriginal Community Controlled Health Organisations (ACCHOs) provide culturally safe primary care and should be the first point of contact wherever possible.

Medication access and adherence

Closing the Gap (CTG) PBS co-payment measure ensures PBS medicines are available at no cost or reduced cost for Aboriginal and Torres Strait Islander peoples registered with CTG. Remote Area Aboriginal Health Workers and Practitioners can assist with medication management. Ensure medicines are available through Remote Area Aboriginal Health Services and community pharmacies. Long-acting injectable formulations (e.g., depot frusemide) may improve adherence where oral medication challenges exist.

Cultural safety

Provide care in a culturally safe environment. Recognise the impact of intergenerational trauma, racism, and social determinants of health. Use yarning-based approaches to build rapport. Ensure availability of Aboriginal and Torres Strait Islander health workers in the clinical team. Acknowledge kinship obligations and the role of family in health decision-making.

Key preventive strategies

Smoking cessation through culturally specific programmes (e.g., Tackling Indigenous Smoking); healthy food access in remote communities (community stores policy); rheumatic fever secondary prophylaxis programmes; integrated chronic disease management through ACCHOs; use of absolute CVD risk tools from age 18 years; social and emotional wellbeing programmes.

📚 References

1. National Vascular Disease Prevention Alliance (NVDPA). Absolute Cardiovascular Disease Risk Management — Guidelines for Assessment and Management of Absolute Cardiovascular Disease Risk. Canberra: NVDPA; 2012.
2. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th edn. Melbourne: RACGP; 2016.
3. Australian Institute of Health and Welfare (AIHW). Heart, Stroke and Vascular Disease — Australian Facts. AIHW Cat. No. CVD 87. Canberra: AIHW; 2023.
4. National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand. Reducing Risk in Heart Disease: An Expert Guide to Clinical Practice for Secondary Prevention of Coronary Heart Disease. Melbourne: NHF; 2012.
5. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–952.
6. National Health and Medical Research Council (NHMRC). Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Canberra: NHMRC; 2020.
7. Department of Health and Aged Care (DoHAC). MBS Online — Medicare Benefits Schedule. Canberra: Australian Government. Available at: www.mbsonline.gov.au. Accessed 2024.
8. Budoff MJ, Young R, Burke GB, et al. Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease (ASCVD) events: the multi-ethnic study of atherosclerosis (MESA). Eur Heart J. 2018;39(25):2401–2408.
9. CKD Prognosis Consortium. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet. 2022;400(10365):1788–1801.
10. RHDAustralia (ARF/RHD writing group). National Agreement — Australian Guidelines for Prevention, Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 3rd edn. Darwin: Menzies School of Health Research; 2020.
11. Australian Bureau of Statistics (ABS). National Aboriginal and Torres Strait Islander Health Survey, 2018–19. ABS Cat. No. 4715.0. Canberra: ABS; 2019.
12. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089–1134. [Note: cited for methodology — primary CVD reference below]
13. Zomer E, Liew D, Owen A, et al. Cardiovascular disease risk management in Australian general practice. Aust Fam Physician. 2019;48(12):866–870.
14. Visseren FLJ, Mach F, Smulders R, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42(34):3227–3337.
15. Piece of Mind (IMPACT) Collaboration. Cardiovascular disease risk management in Australia: room for improvement. Med J Aust. 2023;218(7):318–324.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).