Distribution of cardiovascular disease risk based on the updated 2023 guideline-recommended Australian cardiovascular disease risk algorithm and comparison with the 2012 algorithm

Objective Australian guidelines on cardiovascular disease (CVD) risk assessment and management, including risk prediction algorithms, were updated in 2023. We quantified CVD risk using the 2023 algorithm, compared this to the previous 2012 algorithm, and considered implications for preventive pharmacotherapy. Design Comparative analysis. Setting, participants Data from 115,873 people aged 45-74 years without existing CVD from MedicineInsight, a longitudinal primary-care database covering 8% of Australian general practices. Main outcomes We applied 2023 and 2012 risk algorithms to estimate and categorise individual-level CVD risk into low, intermediate, and high. Risk re-classification in accordance with the 2023 algorithm was not possible. Cohen’s kappa and Bland-Altman plots assessed agreement and concordance.

Using the 2023 CVD risk algorithm and revised thresholds, 9.7% of participants were high (≥10% 5-year risk or clinically-determined high risk); 26.4% were intermediate (5-<10% 5-year risk), and 63.9% were low CVD risk (15% 5-year risk or clinically-determined high risk); 11.6% intermediate (10-15% 5-year risk); and 70.8% low risk (<10% 5-year risk). Differences in proportions at high risk were largely driven by changes to clinically-determined high risk criteria. Overall, there was moderate-to-substantial agreement (kappa=0.62) and concordance (Kendall’s tau-b=0.74) between the algorithms.

Proportions estimated at low risk and not routinely recommended pharmacotherapy align with international standards and were similar between guidelines. Although fewer people would be recommended pharmacotherapy on the basis of high risk under the updated versus previous guidelines, this reflects better estimates of contemporary risk using the 2023 equation and does not account for re-classification. Pharmacotherapy is considered for those at intermediate risk depending on clinical context under the 2023 guidelines. To ensure continued reduction of the CVD burden across the population, we emphasise the application of re-classification factors and benefits of pharmacotherapy for those at intermediate risk. The known Australian CVD prevention guidelines were updated in 2023, replacing 2012 guidelines. They recommend preventive pharmacotherapy for people at high 5-year CVD risk (≥10%) and considering it for intermediate risk (5-<10%). The new 9.7% of participants were classified as high, 26.4% as intermediate, and 63.9% as low CVD risk under the 2023 guidelines, using large-scale primary-care data. This compares with 17.6% high, 11.6% moderate and 70.8% low risk under 2012 guidelines. The implications Updated CVD risk algorithms more accurately reflect contemporary risk. Pharmacotherapy should be discussed systematically with people at intermediate CVD risk under the 2023 guidelines. Competing Interest Statement Emily Banks, Rod Jackson, Ellie Paige, Mark Woodward and Anushka Patel were members of the Algorithm Expert Subgroup that interpreted the evidence and made recommendations to the Guideline Expert Steering Group on aspects related to the risk equation and overall algorithm as part of the updating of the Australian guidelines on cardiovascular disease risk assessment and management. Emily Banks was the chair of the Algorithm Expert Subgroup and a member of the Guideline Expert Steering Group. Garry Jennings was Co-Chair of the Guideline Expert Steering Group updating the Australian guidelines on CVD risk assessment and management. He is Chief Medical Adviser to the National Heart Foundation of Australia. Anushka Patel is a non-remunerated Director and Chair of George Medicines, which has received investment and grants to develop fixed-dose combination therapies for cardiovascular disease prevention. Funding Statement Emily Banks and Anushka Patel are supported by National Health and Medical Research Council of Australia (NHMRC) Investigator Grants (APP2017742 and APP2016801, respectively). Rosemary Wyber is supported by an NHMRC Investigator Fellowship (2025252). Ellie Paige is supported by a Future Leader Fellowship (107210) from the National Heart Foundation of Australia (2024-2027). Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Australian National University Human Research Ethics Committee (reference 2021/424) and the Aboriginal Health & Medical Research Council of NSW (reference 1730/20) gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability The de-identified NPS MedicineWise data used for this study are not publicly available, but requests for the data can be made by contacting the Australian Commission on Safety and Quality in Health Care. The beta-coefficients for AUS-PREDICT and AUS-T2D-PREDICT used in this study for estimating CVD risk using the 2023 guidelines are not publicly available, but are available on application to the Heart Foundation of Australia (cvdriskteam{at}heartfoundation.org.au).