Deanfield J, Sattar N, Simpson I, Wood D, Bradbury K, Fox K, Boon N, Winocour P, Feher M, Doherty P, Buckley J, Jennings C, Keenan J, Weissberg P, Knapton M, Williams B, Poulter N, Stevens P, Taal M, Grant P, Home P, Rees A, Neely D, Wheeler D, Goldsmith D, Potter J, Jackson S, Spiegelhalter D, Pearson M, Boyle R, Connolly S, Hobbs R, Hingorani A, Sivers F, and Stansby G

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Algorithm for cardiovascular disease risk assessment and management

algorithm for cardiovascular disease risk assessment and management

Cardiovascular disease risk assessment

JBS3 calculator

  • Use JBS3 risk calculator ( to estimate both 10-year risk and lifetime risk of cardiovascular disease (CVD; see algorithm above)
  • The calculator also demonstrates, for the individual’s ‘risk profile’, how a delay in initiating risk factor reduction (e.g. smoking cessation) greatly reduces the lifetime benefits
  • There is no ‘correct’ way to communicate risks for estimation of CVD risk level or use of preventative interventions—use the appropriate visual displays that will mean the most to the individual
  • When total cholesterol (TC) exceeds 7.5 mmol/l the calculator will highlight the possibility of familial hypercholesterolemia (FH), where further assessment is indicated

Lifestyle interventions

Smoking cessation

  • Professional support on how to stop smoking should be given, at every available opportunity, with provision of self-help material and referral to more intensive support, e.g. stop smoking services
  • Patients should be offered behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective
  • Nicotine replacement therapy, varenicline, or bupropion should be offered to people who are planning to stop smoking, as part of an abstinent-contingent treatment in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date)
  • People who have heart or respiratory diseases, and those who live with them, should be made aware of the risks to them of both active and passive smoking
  • For specific recommendations on quitting smoking in pregnancy and following childbirth, see NICE public health guidance 26 (


  • Advice on consuming a diet associated with the lowest risk of CVD should be provided based on the following principles:
    • intake of saturated fat should be <10% of total fat intake (preferably in lean meat and low-fat dairy products)
    • replace saturated fat with polyunsaturated fat where possible
    • consume five portions per day of fruit and vegetables
    • consume at least two servings of fish (preferably oily) per week
    • consider regular consumption of whole grains and nuts
    • keep salt consumption <6 g/day
    • limit alcohol intake to <21 units per week for men and <14 units per week for women
    • avoid/reduce consumption of: processed meats; refined carbohydrates; sugar-sweetened beverages; and calorie-rich, but nutritionally poor, snacks

Physical activity and exercise training

  • Emphasise walking, cycling, and other aerobic physical daily activities, at moderate intensity, as part of an active lifestyle, for at least 150 minutes per week in bouts of ≥10 minutes, or 75 minutes per week of vigorous physical activity; or a combination of the two
  • Muscle strengthening activities should be performed on at least two occasions per week
  • For the general population and those at low to moderate risk of CVD:
    • exercise training, with a warm-up and cool down period, should be performed at moderate to high intensity two to three times per week for 30–40 mins each time
    • the mode of exercise should be aerobic and, where possible, continuous allowing for a steady progression in effort
  • For patients with established CVD and those considered at higher risk of CVD:
    • a more structured approach is needed, and in all cases assessment and specific goal setting, with risk stratification, delivered by professionals skilled in health-related exercise, is preferable
    • increase in community-based exercise initiatives are recommended for patients at risk of CVD
    • cardiac rehabilitation programmes are recommended for patients with established CVD and in those following a CVD event

Childhood and adult obesity recommendations

  • Multidisciplinary approaches to obesity management in children and young people are required with a ‘lifetime risk’ message. These may include interventions during the early postpartum period as well as regular monitoring of childhood weight and family counselling
  • With appropriate training, all healthcare professionals should be able to Ask, Assess, and then Advise patients on evidence-based ways to target weight change


  • Non-high-density lipoprotein (non-HDL) cholesterol, measured from a non-fasting blood sample as total cholesterol (TC) minus HDL cholesterol (HDL-C), should be used in preference to low-density lipoprotein cholesterol (LDL-C) as the treatment goal for lipid-lowering therapy
  • All high-risk people should receive professional lifestyle support to reduce TC and LDL-C, raise HDL-C, lower triglycerides, and to reduce their CVD risk
  • Cholesterol-lowering drug therapy is recommended in:
    • patients with established CVD
    • individuals at high risk of CVD (i.e. diabetes, age>40years, CKD stages 3–5, or FH)
    • individuals with high 10-year CVD risk (threshold to be defined by NICE guidance)
    • individuals with high lifetime CVD risk estimated from heart age and other JBS3 calculator metrics, in whom lifestyle changes alone are considered insufficient by the physician and person concerned

Familial hypercholesterolaemia

  • Patients with FH are at high risk of premature CVD and need early ‘lifetime’ treatment. Referral to a specialist lipid clinic is recommended

Combination therapy

  • Other lipid-lowering drugs for further non-LDL-C lowering may be needed in some people, usually in combination with a statin or in place of a statin (statin intolerance). Most commonly used combination therapies involve statin plus either ezetimibe, a fibrate or, until recently, nicotinic acid:
    • ezetimibe monotherapy lowers LDL-C modestly (approximately 18.5%) and has very little effect on other lipoproteins
    • bile acid sequestrants—randomised controlled trials have shown that this class of drug reduces non-fatal and fatal coronary events. In people who can tolerate resins, treatment may be appropriate if there is severe elevation of LDL-C, as in FH
    • new therapies, e.g. proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are currently in development, but not yet licensed

Blood pressure (BP)

  • Hypertension should be suspected when office BP is persistently elevated, i.e., ≥140/90mmHg. Ambulatory blood pressure monitoring (ABPM) is recommended to confirm the diagnosis of hypertension (daytime mean ABPM ≥135/85mmHg)
  • All high-risk people should receive professional lifestyle support to reduce their BP, which may avoid the need for, or complement the use of, drug therapy for hypertension and reduce CVD risk
  • Offer pharmacological therapy to people with:
    • an office BP >160/100mmHg, a 24 h daytime ABPM average or home ABPM average of >150/95mmHg (stage 2 hypertension)
    • an office BP >140/90mmHg, but <160/100mmHg, a 24 h daytime ABPM average or home ABPM average of >135/85mmHg (stage 1 hypertension)
    • established CVD, hypertensive target organ damage, diabetes, CKD, or a high lifetime risk assessed by JBS3 calculator
  • People with stage 1 hypertension without established CVD, hypertensive target organ damage, diabetes, CKD, or a significant increase in lifetime risk assessed by JBS3 calculator, should receive advice on lifestyle interventions and be scheduled for annual BP and lifetime risk assessment to inform future need for therapy
  • Pharmacological treatment for patients with hypertension should follow the current NICE guidance (CG127) treatment algorithm
  • The recommendations of the NICE guideline CG107 Hypertension in pregnancy should be followed for pregnant women or women planning pregnancy (

Established CVD

  • For all patients with established CVD, an intensive approach to risk factor modification is recommended, including lifestyle intervention and the use of pharmacological therapy for secondary prevention based on NICE, SIGN, and European Society of Cardiology (ESC) guidance
  • Statins should be prescribed with a ‘lower is better’ approach to achieve values of at least <2.5 mmol/l for non-HDL-C (equivalent to <1.8 mmol/l for LDL-C)

Post-myocardial infarction

Antiplatelet therapy

  • Antiplatelet therapy with low-dose aspirin (75–100 mg) is recommended indefinitely after myocardial infarction (MI). In patients with true aspirin intolerance, clopidogrel 75 mg should be considered as an alternative
  • More potent antiplatelet agents (such as prasugrel or ticagrelor) are recommended as dual antiplatelet therapy, in combination with aspirin, in patients with acute coronary syndromes
  • Dual antiplatelet therapy is recommended for up to 12 months post-MI with a minimum of:
    • 1 month for patients also receiving a bare metal stent
    • 6 months for patients also receiving a drug eluting stent

Lipid-lowering therapy

  • Intensive statin therapy is recommended in all patients following MI in the absence of a contraindication or intolerance, irrespective of initial cholesterol values
  • Statins should be prescribed with a ‘lower is better’ approach to achieve values of at least <2.5 mmol,for non-HDL-C (equivalent to <1.8 mmol/l for LDL-C):
    • for those with true intolerance to statins, alternative agents including ezetimibe should be considered. Newer approaches to lower LDL-C, e.g. PCSK9 inhibitors, are in development

Beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists

  • Use of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and aldosterone antagonists post-MI is recommended, in line with existing NICE, SIGN, and ESC guidance



  • Statin therapy is recommended for patients with ischaemic stroke. Its introduction should be delayed for 2 weeks post-stroke, but there is no need to discontinue statins in patients already on therapy
  • Statin therapy should be avoided in individuals with a history of haemorrhagic stroke, particularly in those with inadequately controlled hypertension, unless there is a compelling indication, such as concomitant coronary artery disease

Blood pressure

  • Target level: <130/80mmHg is recommended. Care should be taken not to reduce BP rapidly in those with significant carotid/vertebrobasilar stenosis. Treatment should usually be started within 1–2 weeks of the acute event

Antithrombotic therapy

  • In the absence of atrial fibrillation (AF), recommendations for patients who have had an ischaemic stroke follow the current NICE guidelines:
    • after acute ischaemic stroke, patients should initially receive 300 mg of aspirin daily for 2 weeks, then be changed to long-term clopidogrel 75 mg daily. For patients who have a contraindication or intolerance to clopidogrel, modified-release dipyridamole plus aspirin is an alternative. For people who have a contraindication or intolerance to both clopidogrel and aspirin, modified-release dipyridamole alone is recommended
    • for patients who have had a transient ischemic attack (TIA), modified-release dipyridamole 200 mg twice daily plus aspirin 75–150 mg daily is an alternative treatment option to clopidogrel. For people who have a contraindication or intolerance to aspirin, modified-release dipyridamole alone is an alternative treatment option
  • In the presence of AF (valvular or non-valvular), patients with a TIA or ischaemic stroke:
    • should be anticoagulated with warfarin to achieve a target international normalised ratio on warfarin of 2.5 (range 2.0–3.0) or with one of the new oral anticoagulant agents
    • anticoagulation should not be started until brain imaging has excluded haemorrhage, and not usually until 14 days have passed from the onset of a disabling ischaemic stroke
    • anticoagulation should not be used for patients in sinus rhythm, unless a cardiac source of embolism has been identified

Peripheral arterial disease

  • Patients with peripheral arterial disease (PAD) should have intensive risk factor modification, including intensive statin therapy and BP managed in line with NICE guidelines
  • Patients with PAD should be:
    • screened for diabetes and CKD
    • encouraged to exercise; supervised exercise programmes should be available for appropriate patients
    • started on an antiplatelet agent, with clopidogrel being the first choice agent

Type 1 diabetes mellitus


  • All people with type 1 diabetes should receive professional lifestyle advice. Statins should be offered in type 1 diabetes for the following:
    • all patients with type 1 diabetes aged ≥50years
    • the majority aged 40–50years, unless short duration of diabetes (<5years) and absence of other CVD risk factors
    • those aged 30–40years with any of the following features:
      • long duration of diabetes (20years) and poor control (HbA1c >9% [75 mmol/mol])
      • persistent albuminuria (>30 mg/day) or eGFR<60 ml/min
      • proliferative retinopathy
      • treated hypertension
      • current smoking autonomic neuropathy
      • TC (>5 mmol/l ) with reduced HDL-C (<1 mmol/l for males and <1.2 mmol/l for females)
      • central obesity
      • family history of premature CVD (<50years)
    • those aged 18–30years should receive statins if persistent albuminuria is detected, with caution exercised in women of childbearing potential

Blood pressure

  • This should be maintained at 130/80mmHg, with consideration of lower values (120/75–80mmHg) in younger patients with type 1 diabetes (aged <40years) with persistent microalbuminuria
  • ACE inhibitors should be the drug of first choice


  • There is no role for aspirin in primary prevention of CVD in type 1 diabetes

Glycaemic control

  • Glycaemic control, to achieve and maintain an HbA1c of 48–58 mmol/l, should be considered the ideal approach to long-term care of type 1 diabetes

Type 2 diabetes mellitus


  • All people with type 2 diabetes should receive professional lifestyle advice
  • Statin therapy remains the best and only effective lipid-modifying agent to lessen CVD risk in type 2 diabetes
  • Statin therapy is recommended for all patients with type 2 diabetes >40years of age, irrespective of cholesterol value
  • Intensive statin therapy is recommended for diabetes patients with existing CVD, and those with persistent proteinuria or CKD with eGFR 30–60 ml/min. Intensive statin treatment is also recommended for patients who do not achieve non-HDL-C targets
  • Statins should also be considered for patients with type 2 diabetes aged <40years, if there is evidence of persistent albuminuria, eGFR <60ml/min, proliferative retinopathy, treated high BP, or autonomic neuropathy
  • Fibrates, used as monotherapy or in combination therapy, have not been shown to provide overall CVD benefit in type 2 diabetes, and should not be prescribed for CVD risk reduction:
    • fibrates show promise in prevention or treatment of retinopathy in type 2 diabetes in a manner independent of lipid-lowering action

Blood pressure

  • Lowering systolic BP in the majority of type2 diabetes patients to around 130mmHg appears beneficial. Pursuing lower targets does not reduce coronary event rates, although stroke incidence may be reduced
  • The degree of BP reduction appears to be the critical aspect in reducing CVD risk, rather than the method or agent used to lower BP:
    • drugs that block the renin–angiotensin system appear to reduce overall mortality as first-line therapy
    • ACE inhibitors and ARBs reduce development and progression of albuminuria and reduce major renal outcomes
    • however, blockade of the renin–angiotensin system with ACE inhibitors, ARBs, or direct renin inhibitors in any combination is associated with worse cardiorenal outcomes and should not be used

Glycaemic control

  • The effect of intensive glucose lowering cannot be conclusively quantified, but trial results suggest a 9% and 15% reduction in CVD and coronary heart disease, respectively, for around a 0.9% (10 mmol/mol) reduction in HbA1c
  • Recent trial findings and observational studies have noted that younger onset type 2 diabetes has an especially poor prognosis, requiring earlier intensive glucose lowering and reduction of all CVD risk factors, whereas intensive glucose lowering may not be appropriate in older patients and/or those with existing CVD
  • The CVD benefits of intensive glucose lowering are less than can be achieved with statins or BP-lowering therapy


  • Low dose aspirin is not recommended for primary prevention of CVD in patients with type 2 diabetes

Chronic kidney disease (CKD)

  • In CKD, the JBS3 risk calculator can be used to highlight the increased CVD risk and to guide appropriate risk factor modification


  • In adults with stages 3–5 CKD, lipid-lowering therapy with statins should be considered in all patients

Blood pressure

  • In adults with stages 3–5 CKD, with or without diabetes, BP should be treated to maintain <140mmHg systolic and <90mmHg diastolic
  • In adults with CKD, with or without diabetes, in whom urinary albumin excretion exceeds 30mg/day (equivalent to an albumin: creatinine ratio [ACR] of 3 mg/mmol), these targets should be reduced to <130mmHg systolic and <80mmHg diastolic
  • All antihypertensive agents are effective in adults with stages 3–5 CKD. ACE inhibitors or ARBs should be included in the antihypertensive regimen, particularly in people with albuminuria >30 mg/day (equivalent to an ACR of 3mg/mmol)


  • Routine use of aspirin is not recommended for primary prevention in CKD

Chronic inflammatory disease

  • Patients with rheumatoid arthritis (RA) are at increased (approximately 1.4 to 1.5-fold) risk for CVD events. The JBS3 risk calculator now incorporates the appropriate multiplier for CVD risk, based on the presence of RA
  • All patients with RA would benefit from CVD risk factor screening. Intensive management of traditional CVD risk factors should be undertaken in patients with RA, taking into account their CVD risk score
  • Optimisation of inflammation suppression with disease-modifying anti-rheumatic drugs may also help reduce CVD risk
  • CVD risk may be lowered by use of the minimum effective glucocorticoid dose for the shortest possible time
  • Where anti-inflammatory drugs are indicated for symptoms, in those patients with an average gastroduodenal damage risk, the use of a conventional non-steroidal anti-inflammatory drug with gastroprotective agent is preferable to use of a cyclooxygenase-2 selective inhibitor
  • Patients with chronic inflammatory disease at high absolute 10-year CVD risk, as defined by NICE, and at high lifetime risk using the JBS3 calculator, should be treated with statin therapy
  • The use of a risk multiplier for CVD risk assessment in autoimmune conditions other than RA should be considered on a patient by patient basis, depending on disease severity

Sleep apnoea

  • Lifestyle advice to support weight loss should be offered to all patients with a diagnosis of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) who are obese or overweight
  • Patients with significant daytime sleepiness and confirmed OSAHS should be offered continuous positive airway pressure treatment
  • CVD risk factors should be assessed using the JBS3 risk calculator and managed according to JBS3 recommendations in these patients


full guidelines available from…

Deanfield J, Sattar N, Simpson I et al. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014; 100: ii1–ii67. March 2014. Reproduced with kind permission from BMJ and Heart. Content not influenced by pharmaceutical companies.
First included: June 2014.


Lead image: magicmine/