Residual Cardiovascular Risk: Assessment and Management Guide
A Cambridge Cardiac Care Secondary Prevention Initiative
Welcome to the Cambridge Cardiac Care Secondary Prevention Residual Risk Reduction Tool. This is a tool for primary care physicians and specialists to use in the management of patients with Atherosclerotic Cardiovascular Disease (ASCVD) with the goals of:
- Helping to determine the risk of recurrent cardiovascular events and mortality among ASCVD patients based on the REACH Risk calculator.
- Providing education about potential novel therapies in high risk ASCVD patients based on recent landmark clinical trials.
These statements are for information and educational purposes only. They do not represent specific endorsements nor recommendations. Please consult local guidelines, product monographs and health care practitioners in individual cases.
CV Event REACH Score
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20-month risk of next CV event
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CV Death REACH Score
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20-month risk of next CV death
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Your Patient's Risk of CV Event
and CV Death in 20 Months
REACH Secondary Risk Calculator
CV Event
CV Death
This graph displays the 20-month risk of a CV event or CV death for your patient, compared to a patient of the same age, sex and place of residence but with no other factors that increase CV risk (eg. Smoking, CHF, diabetes, atrial fibrillation, PAD, and cerebrovascular disease). The goal is to help identify patients at higher risk than the average ASCVD patient.
While there is no guideline-defined residual risk percentage at which clinicians should add additional therapeutic measures, for certain patient populations, there are evidence-based therapies shown to reduce the risk of morbidity and mortality (as outlined below):
Wilson, P. W., D'Agostino, R., Sr, Bhatt, D. L., Eagle, K., Pencina, M. J., Smith, S. C., Alberts, M. J., Dallongeville, J., Goto, S., Hirsch, A. T., Liau, C. S., Ohman, E. M., Röther, J., Reid, C., Mas, J. L., Steg, P. G., & REACH Registry (2012). An international model to predict recurrent cardiovascular disease. The American journal of medicine, 125(7), 695–703.e1.
Cambridge Cardiac Care Secondary Prevention Residual Risk Reduction Strategy
Using the CCC Secondary Prevention Residual Risk Strategy
For certain patient populations, there are evidence-based therapies to reduce the risk of MI, strokes and cardiovascular death. Based on your patient’s risk factors, these therapies have been identified below. Note that non-pharmacological measures including smoking cessation and cardiac rehabilitation represent an important intervention for many ASCVD patients.
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Smoking Cessation Counselling11: Consider offering smoking cessation counselling in patients who are currently smoking.
Data from the prospective cohort 11, "Cooperative Cardiovascular Project" in elderly patients who smoked after an Acute Myocardial Infarction showed a reduction in 30-day, 60-day and two-year mortality with Smoking Cessation Counselling offered during hospitalization. -
Pharmacological Therapies12: Consider offering nicotine replacement therapy (NRT), bupropion or varenicline.
A Cochrane systematic review and meta-analysis12 of smoking cessation therapies found NRT, bupropion and varenicline to each be superior to placebo with regards to odds of quitting smoking. Combination use of NRT outperformed single formulations. There was no evidence of increased incidence of neuropsychiatric or cardiovascular adverse events with bupropion and varenicline in patients prescribed these therapies for smoking cessation. There are currently no studies showing change in mortality or cardiovascular events with pharmacological therapies for smoking cessation.
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Cardiac Rehabilitation13, 14: Consider offering cardiac rehabilitation to all patients with a
new diagnosis of cardiovascular disease.
In an observational cohort study of patients with a new diagnosis of ACS, stable angina, CHF, and cardiothoracic surgery including CABG, valve surgery and PCI, cardiac rehabilitation participation was associated with a reduction in all-cause mortality compared to non-participation. The GOSPEL randomized control trial14 showed reduction in the combined endpoint of CV death, MI, stroke, hospitalization for angina and CHF or urgent revascularization with a multifactorial educational and behavioral program after recent MI.
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Ezetimibe1: Consider adding ezetimibe in patients with LDL higher than 1.8 mmol/L on statin therapy.
The IMPROVE-IT study showed reduction in the composite endpoint of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization by adding ezetimibe on top of simvastatin therapy in patients with a recent ACS. -
PCSK9 inhibitor2,3 (evolocumab and alirocumab): Consider adding PCSK9 inhibitors in patients with persistent LDL higher than 1.8mmol/L on statin therapy.
The FOURIER2 study showed reductions in the composite endpoint of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization with evolocumab on top of background statin therapy. Similar results were noted with alirocumab in the ODYSSEY outcomes study3.
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Icosapent Ethyl4: Consider adding Icosapent Ethyl in patients on statin therapy with Triglycerides greater than 1.5 but less than 5.6 mmol/L.
In patients with elevated triglycerides, the REDUCE-IT study showed reductions in the composite endpoints of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina by adding Icosapent Ethyl patients already on statin therapy.
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SGLT2 inhibitor5,6,7(empagliflozin, canagliflozin and dapagliflozin): Consider adding SGLT2 inhibitors to all diabetic patients on top of metformin with a history of coronary disease regardless of HbA1C.
The EMPA-REG5 study showed reductions in the composite endpoint of cardiovascular mortality, MI, or stroke as well as all cause mortality and CHF hospitalizations with empagliflozin in patients with diabetes and high CV risk. Similar results were shown in the CANVAS6 study with canagliflozin. The DECLARE7 study showed reductions in CHF hospitalizations with dapagliflozin in all diabetic patients. -
GLP1 Agonist8,9 (liraglutide, semaglutide): Consider adding GLP1 agonists to T2DM patients on metformin and SGLT2 inhibitors with an HbA1C greater than 7.0%.
The LEADER study8 showed reductions in the composite endpoint of cardiovascular mortality, MI, or stroke in patients with T2DM, an HbA1C greater than 7% and an increased risk of CV events with liraglutide on top of metformin therapy. The SUSTAIN-69 study showed non-inferiority of semaglutide to placebo in patients with T2DM. -
Dual pathway inhibition10 (low dose rivaroxaban + ASA): Consider adding low-dose rivaroxaban to ASA and standard therapy in diabetic patients with high residual secondary risk, especially with polyvascular disease (eg. CAD and CVA or PAD).
Subgroup analysis of the COMPASS study10 showed a reduction of the composite endpoint of cardiovascular death, MI or stroke with low dose rivaroxaban and aspirin compared to aspirin alone in diabetic patients and patients with CAD and CVA or PAD.
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Dual pathway inhibition10 (vascular dose rivaroxaban + ASA): Consider adding 2.5mg BID rivaroxaban to 81mg ASA in patients with CAD and CVA or PAD.
Subgroup analysis of the COMPASS study10 showed a reduction of the composite endpoint of cardiovascular death, MI or stroke with 2.5mg BID "vascular dose" rivaroxaban and aspirin compared to aspirin alone in patients with CAD and CVA or PAD.
- Cannon, C. P., et al. (2015). Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. New England Journal of Medicine, 372(25), 2387-2397. doi:10.1056/nejmoa1410489
- Sabatine, M. S., et al. (2017). Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. New England Journal of Medicine, 376(18), 1713-1722. doi:10.1056/nejmoa1615664
- Schwartz, G. G. et al. (2018). Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome. New England Journal of Medicine, 379(22), 2097-2107. doi:10.1056/nejmoa1801174
- Bhatt, D. L., et al. (2019). Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. New England Journal of Medicine, 380(1), 11-22. doi:10.1056/nejmoa1812792
- Zinman, B., et al. (2015). Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. New England Journal of Medicine, 373(22), 2117-2128. doi:10.1056/nejmoa1504720
- Neal, B., et al. (2017). Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. New England Journal of Medicine, 377(7), 644-657. doi:10.1056/nejmoa1611925
- Wiviott, S. D., et al. (2019). Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. New England Journal of Medicine, 380(4), 347-357. doi:10.1056/nejmoa1812389
- Marso, S. P., et al. (2016). Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. New England Journal of Medicine, 375(4), 311-322. doi:10.1056/nejmoa1603827
- Marso, S. P., et al. (2016). Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. New England Journal of Medicine, 375(19), 1834-1844. doi:10.1056/nejmoa1607141
- Eikelboom, J. W., et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. New England Journal of Medicine, 377(14), 1319-1330. doi:10.1056/nejmoa1709118
- Houston TK, Allison JJ, Person S, Kovac S, Williams OD, Kiefe CI. Post-myocardial infarction smoking cessation counseling: associations with immediate and late mortality in older Medicare patients. Am J Med. 2005 Mar;118(3):269-75. doi: 10.1016/j.amjmed.2004.12.007. PMID: 15745725.
- Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta‐analysis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329. DOI: 10.1002/14651858.CD009329.pub2
- Eijsvogels TMH, Maessen MFH, Bakker EA, et al. Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands. JAMA Netw Open. 2020;3(7):e2011686. doi:10.1001/jamanetworkopen.2020.11686
- Giannuzzi P, Temporelli PL, Marchioli R, et al. Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. Arch Intern Med. 2008;168(20):2194-2204. doi:10.1001/archinte.168.20.2194
These statements are for information and educational purposes only. They do not represent specific endorsements nor recommendations. Please consult local guidelines, product monographs and health care practitioners in individual cases.
Developed by Avinash Pandey and Cambridge Cardiac Care Inc.