Consultation between a male patient and a female doctor

The Challenge We Face with Cardiovascular Disease

General practice has a unique role to play in reducing heart attack and stroke risk.

In our July newsletter, we highlighted that many patients living with cardiovascular disease (CVD), or at risk of it, remain untreated or under-treated. The good news? They are already visible in general practice.

This places general practice in a powerful position to act early by:

  • Ensuring patients have up-to-date blood pressure and lipid results
  • Using the AusCVD calculator to assess absolute cardiovascular risk
  • Providing proactive preventive and management care

What can be done right now?

Primary Sense makes it possible to identify and support patients who may not yet have a CVD diagnosis but are at risk.

A practical first step:

Run the CVD reports in Primary Sense to identify patients aged 45–74 who have no CVD diagnosis but present with four key risk factors — smoking, high blood pressure, abnormal lipid levels, or diabetes.

This simple action can open the door to preventive conversations and earlier care.

What does the evidence say?

The evidence confirms the importance of acting now.

The Australian Institute of Health and Welfare (AIHW) July 2024 Report shows close to 60% of Australians aged 45–74 without a CVD diagnosis already have the necessary risk factors recorded in their GP record to enable a CVD risk assessment.

This highlights the significant opportunity to identify and manage high-risk patients through general practice.

 

Source: AIHW (2024) Practice Incentives Program Quality Improvement Measures: annual data update 2023-24. Practice Incentives Program Quality Improvement Measures: annual data update 2023–24, QIM 8: Risk factors recorded for CVD assessment – Australian Institute of Health and Welfare Accessed 1/9/2025. 

Funded by the Queensland Health Clinical Research Fellowship, the PHASES Linkage project connects general practice cardiovascular disease (CVD) risk data with hospitalisation and mortality data. This study aims to better understand how CVD risk impacts hospitalisation rates and assess the accuracy of the new CVD risk prediction equation in identifying high-risk individuals within Queensland’s population. 

The project will: 

  • Estimate the number of heart attacks and strokes that could be prevented with improved treatment for high CVD risk. 
  • Identify gaps in CVD prevention to inform future care strategies. 

Running in parallel with the PHASES project, PHASES Linkage highlights the power of data-driven insights to improve cardiovascular outcomes and reduce hospitalisations.