Cardiovascular Risk Assessment (CVRA)
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​Last updated on 26 September 2024


Coronary artery disease (CAD) and cerebrovascular disease contributed to 19.7% and 5.8% of all deaths respectively in 20221. Cardiovascular Risk Assessment (CVRA) comprises non-modifiable risk factors, lifestyle factors and biochemical screening tests.


  1. ​​​The goal of CVRA is to identify modifiable risk factors, support behavioural change and inform medical management when necessary. For risk factors, recommended screening tests and screening frequencies for residents 40 years and above, see Table 1A below. Refer to Table 1B​ for residents aged 18 to 39 years old.

  2. A practical flow for assessing and stratifying cardiovascular risk can be based on:

    • ​Medical conditions that confer very high to high risk; and

    • Estimated 10-year cardiovascular risk score for people who have one or more risk factors but are otherwise healthy using the SG-FRS-2023 10-year coronary artery disease (CAD) risk model​ 2,3

  3. Subsequent clinical management should be based on shared decision-making. Consider risk enhancers , potential benefits, tolerability of side effects of pharmaceutical therapies, life expectancy, and patient's preferences.

Table 1A. For residents 40 years and above.4

No Risk Factors Screening Test/Question Fre​quency
1 Age​ 
 At first visit/enrolment
2 Gender​ 
 At first visit/enrolment
3 Ethnicity​ 
 At first visit/enrolment
4 Family History of premature CVD ​ 
 At first visit/enrolment and as required
5 Smoking​ Do you smoke?  Once a year
6 Physical Inactivity Physical Activity Questions  Once a year
​ ​7  ​ Obesity+
​ BMI ​ Once a year
​ Waist circumference ​ Once a year
​ 8​ Hyperlipidaemia+

​Fasting Lipid Panel

OR

Non-fasting Lipid Panel 

​ Once every 3 years; screen more frequently for individuals with family history of premature CAD or familial hyperlipidaemia
​ 9​  ​​ Hypertension+
 		​ ​SBP & DBP ​ ​Once every 2 years
Pulse rate  Once every 2 years
​ 10​ Diabetes mellitus (DM)​+

​HbA1c ​

OR

Fasting Plasma Glucose 

​​

Once every 3 years or more often ​

+ Risk factors for metabolic syndrome​

Shaded green: Subsidies under Screen for Life (SFL) programmes are available.

This care protocol focuses on Category 1 screening recommendations recommended by the Screening Test Review Committee ​, where there is good and robust evidence that these tests are clinically effective and cost effective for use at the population level. Government subsidies under the Screen for Life (SFL) programme are available for obesity, hyperlipidaemia, hypertension and diabetes mellitus screening tests (risk factors 7 to 10) in the green boxes in Table 1A, and they are done as a bundle once every 3 years​ – details in the Financing section.​​​


  1. Assess the presence of medical conditions that confer risk, and other CV risk factors. In the absence of established conditions that confer a very high to high level of risk, calculate the patient's 10-year coronary artery disease risk using the cardiovascular disease (CVD) risk calculator​.

  2. Record the CVRA in the patient's medical records.

  3. For all patients, recommend the following lifestyle interventions where appropriate.

    • Smoking cessation

    • Weight management

    • >150 minutes of moderately intense exercise per week and minimise sedentary behaviour.​

      Adjust the patient's LDL-cholesterol targets, where appropriate, based on their 10-year CAD risk score ​. 

  4. ​​Refer to the appropriate Chronic Care Protocols on Hypertension, Lipid Disorders, Pre-DM, DM or DHL (Multimorbidity)​ for further guidance on the management of conditions detected during screening.​

Management Workflows for CVRA

GPs should proactively check if their enrolled patients have undergone the nationally recommended CVRA screening tests as part of SFL (green boxes in Table 1A). If they have not done so, GPs should encourage their patients to do so. If they have completed their screening with private providers (e.g. as part of workplace screening), GPs should request that the patient share the results with them. Where tests were performed within PHIs or under SFL, GPs may refer to NEHR for the results of their patients.

As good clinical practice, GPs should consider face-to-face follow-up consultations and closer monitoring of patients who have borderline or abnormal screening results from previous screening, and patients who may have normal results but present with other risk factors such as gestational DM or family history of risk factors such as DM. All patients with risk factors, borderline or abnormal results should be provided lifestyle modification advice as part of holistic clinical management. Patients screened under SFL6 would be eligible for a fully subsidised post screening follow-up visit. Repeat screenings are also subsidised under SFL for patients who require them – please refer below for the management workflows.  

​
Repeat Screens for DM

A. Fasting Plasma Glucose

  1. If the first FPG result is abnormal, GPs may either offer the repeat FPG or confirmatory Oral  Glucose Tolerance Test (OGTT) depending on their patient's profile in accordance with SFL's diagnostic workflow .​

  2. ​​Under SFL, GPs may conduct up to one repeat screening (i.e. total of two tests) for DM screening. The cost of the repeat test (up to 1 repeat) is covered under SFL and patients should not be charged. GPs should continue to exercise their clinical judgement on the necessity of additional evidence-based screening tests for individuals. GPs should reference SFL's diagnos​​tic workflow ​​ ​before deciding if a second repeat test should be submitted. Any repeat tests should only be conducted if clinically indicated.

B. HBA1C

  1. If the first HbA1c screening result is 6.1% to 6.9%, GP should proceed to do a FPG or OGTT to determine whether patient has i) pre-DM, ii) DM or iii) no DM. The cost of the repeat test (up to 1 repeat) is covered under SFL and patients should not be charged.

  2. Summary of SFL's HBA1C screening guidelines ​​.​  

The timeline for conducting the screening/ repeat screening/follow-up for DM is as indicated in Table 3.

Table 3: Timeline for conducting the screening/repeat screening/follow-up sessions as well as for SFL claim submissions.

Screenin​g Test Eligibility 1st Repeat
(if indicat​ed)		 2nd Repeat
(if indicated)		 Follow up
Cardiovascular Risk Screening As per screening eligibility in Table 1A To be conducted no later than 6 months after initial screening visit date. To be conducted no later than 6 months after 1st repeat screening visit date To be conducted no later than 6 months after last screening visit date

 

Repeat Screens for Hyperlipidaemia

Doctors may consider a repeat fasting lipid panel for patients with abnormal screening results from a non-fasting lipid panel. This is especially when there is uncertainty over the potential validity of results (e.g. high fat consumption prior to the test, or borderline TG or LDL-cholesterol​ levels). However, such follow-up tests would be considered as disease management, and the cost of these tests will not be covered under SFL. Prevailing CHAS/CDMP chronic subsidies may be applicable instead.​

The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* are required for Healthier SG Annual Service Fee payments. 


Screening

  1. ​Screening Type*

    • ​Chronic Disease Screening: FPG/ Hba1c

    • Cardiovascular Screening: Lipid Panel

  2. Date of Screening*


Blood Glucose

  1. HbA1c (%)* OR Fasting Plasma Glucose (FPG) (mmol/L or mg/dL)*

  2. Oral Glucose Tolerance Test (OGTT) (mmol/L or mg/dL)

  3. Date*


Blood Pressure

  1. Systolic BP (mmHg)*

  2. Diastolic BP (mmHg)*

  3. Date*


Lipid Profile 

  1. LDL-Cholesterol (mmol/L or mg/dL)* 

  2. HDL-Cholesterol​ (mmol/L or mg/dL)*

  3. Triglycerides (mmol/L or mg/dL)* 

  4. Total Cholesterol (mmol/L or mg/dL)* 

  5. Date* 


Weight

  1. BMI (kg/m2), calculated from height*, weight*

  2. Waist circumference (in cm; mandatory to fill if weight is not feasible. Otherwise, optional field to fill)*

  3. Weight not feasible (if applicable)*

  4. Date*


Smoking History

  1. Smoking Status* (Never smoker, Ex-smoker, Current smoker)*

  2. Year started smoking (if smoker) 

  3. No. of sticks smoked/day (For never smoker or ex-smoker, input 0)* 

  4. Stage of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation (iv) Action, or (v) Maintenance

  5. Fagerstrom Test Score - For patients who are prepared to quit and are actively participating in a structured smoking cessation counselling programme, GPs can consider administering the Fagerstrom test to determine degree of nicotine dependence

  6. Date of Smoking Assessment​


Fully Subsidised Screening Tests Under Healthier SG

For Singapore Citizens (SCs) enrolled in Healthier SG, screening tests for obesity, hyperlipidaemia, hypertension and DM (see green boxes in Table 1A) will be fully subsidised at their enrolled GP, only if conducted in line with SFL scheme eligibility criteria and as per the recommended frequency of once every 3 years (see ScreenforLife.gov.sg) under the SFL programme. This also includes any repeat test for DM* (up to 1 repeat).​ 

Healthier SG GPs therefore do not need to collect payments from SCs enrolled to their clinics for these screening tests. Instead, Healthier SG GPs should claim for the full remuneration using the same process and to the same bank account as for payments made under the SFL scheme. GPs are advised to check the enrollee’s eligibility for the screening subsidies using the subsidy eligibility tool for SFL in MOH Healthcare Claims Portal (MHCP)​.​

Details on GP remuneration for providing SFL screenings to eligible SCs can be found in the prevailing CHAS agreement. Details on the GP Annual Service Fee can be found in the Healthier SG Enrolment Programme Agreement.