About the Scottish CVD Risk Factors Programme

National cardiovascular disease (CVD) prevention and risk factors toolkit

The CVD Risk Factors programme is part of a wider suite of Scottish work that sits with the Preventative and Proactive care (PPC) programme. PPC is working to support transforming our models of care to be more preventative, proactive and focused on early intervention.

Mission and aims

The 5 modifiable risk factors to find>optimise>reduce are:

  • 1 High blood pressure
  • 2 High lipids
  • 3 High blood sugar
  • 4 Obesity
  • 5 Smoking

Additionally, there are non-modifiable factors which place people at higher CVD Risk –

  • Ethnicity (Black and South Asian)
  • Taking certain medications e.g. antipsychotics
  • Family history - related to early CVD death, familial hypercholesterolaemia, lipoprotein (a).

Action plan to reduce CVD risks

Our aim is to make improvements across the whole system of health care to help us to find CVD risk factors sooner, work with the person on their risk reduction plan and to ultimately reduce a person’s risk. The programme also will be working to raise awareness and understanding of cardiometabolic health and reducing CVD risk, and to support citizens and communities to be more in control of their health and managing any risk factors. The CVD Risk Factor work will be building on work already underway in linked national strategies. The graphic below shows the areas where improvements can be made:

Diagram of CVD risk factor improvement opportunities. Text: Improving & Quality Assuring (already £ core NHS) CVD risk care to people we already know have at least 1 risk factor (or at higher risk of having risk factors); or who have a pre-existing CVD diagnosis. Increased finding of new risk factors with people. Citizen: Increased knowledge and self-assessment and care. In NHS: increased opportunistic care + new offers of health checks. Closing the gap in care reach: Reaching and reducing risk factors with people who have highest inequalities - through increased outreach, longer and/or more feasible approaches of care + closing the gap in knowledge and citizen led health. CVD, avoidable deaths, life expectancy and healthy life expectancy, Sustainable quality healthcare

The headline principles to guide the healthcare systems actions are:

  • RISKS: Find>Optimise>Reduce
  • Identification and management of any one risk factor > should lead to the consideration of all CVD related risk factors
  • Every Contact Counts – always consider CVD risk factors, possibilities for opportunistic checks, conversations about risk factors
  • The use of ASSIGN v2 in the recommended cohorts
  • Reaching the missing – people with the highest risks are most likely to be those who are unable to use our services as they are routinely structured – and we must apply proportionate universalism to do more to reach them, to work in different ways e.g. beyond the practice doors.