Cardiovascular Risk Assessment (CVRA)
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Last updated on 23 August 2023


Coronary artery disease (CAD) and cerebrovascular disease contributed to 20.1% and 6.1% of all deaths respectively in 20211. 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 and recommended care components for residents 40 years and above, see Table 1A below. For risk factors and recommended care components for residents aged 18–39, refer to Table 1B​.

  2. The risk of cardiovascular disease should be estimated based on the global assessment of risk factors using the 10-year coronary artery disease risk score4 rather than individual risk factors.

  3. Clinical management should be based on a shared decision-making model, which should include a discussion with patients based on their global assessment risk score, personal preferences, and potential benefits and harms of pharmaceutical therapies.

Table 1A. For residents 40 years and above.8

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​+

​HbA1c ​

OR

Fasting Plasma Glucose 

​​

Once every 3 years or more often ​

+ Risk factors for metabolic syndrome​

This care protocol focuses on Category 1 screening recommendations made 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. Estimate 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.

    • Stop smoking

    • Weight management

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

  4. Adjust the patient's LDL-cholesterol targets, where appropriate, based on their 10-year CAD risk score ​ (adapted from MOH Clinical Practice Guidelines (CPG) on Lipids Dec 2016). For high risk and very high risk categories, please refer to the Chronic Care Protocols on Lipid Disorders​​ or DHL (Multimorbidity) Chronic Care Protocol​.

​
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 diabetes mellitus or family history of risk factors such as diabetes mellitus. All patients with risk factors, borderline or abnormal results should be provided lifestyle modification advice as part of holistic clinical management. Patients screened under SFL7 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 Diabetes Mellitus

A. Fasting Plasma Glucose

  1. If the first fasting plasma glucose (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 diabetes mellitus 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 Fasting Plasma Glucose (FPG) or Oral Glucose Tolerance Test (OGTT) to determine whether patient has no diabetes mellitus, pre-diabetes mellitus or diabetes mellitus. 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 diabetes mellitus 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 subsidy claims and Healthier SG payments. These are aligned to data being submitted for SFL claims.

Smoking History

  • Smoking Status* (Never smoker, Ex-smoker, Current smoker)

  • Year started smoking (if smoker) 

  • No. of sticks smoked/day* (if smoker) 

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

Lipid Profile 

  • LDL-cholesterol (mmol/L or mg/dL)* 

  • HDL-cholesterol​ (mmol/L or mg/dL)*

  • Triglycerides (mmol/L or mg/dL)* 

  • Total Cholesterol (mmol/L or mg/dL)* 

  • Date* 

Blood Pressure

  • Systolic BP (mmHg)*

  • Diastolic BP (mmHg)*

  • Date*

Blood Glucose

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

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

  • Date*

Weight

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

  • Waist circumference (in cm)

  • Date*

Review Date*


Free Screening Tests Under Healthier SG

For Singapore Citizens (SCs) enrolled in Healthier SG, screening tests for obesity, hyperlipidaemia, hypertension and diabetes mellitus (see green boxes in Table 1A) will be provided free of charge 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 diabetes mellitus* (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 enrolee’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.