Could you provide a template for a cardiovascular prevention consultation note?

Cardiovascular Prevention Consultation Note Template

Use a structured template that systematically addresses the 10 key domains from the 2019 ACC/AHA Primary Prevention Guidelines to ensure comprehensive risk assessment and documentation of evidence-based interventions 1.

Chief Concern

• Reason for cardiovascular prevention consultation
• Patient's primary health goals and concerns

Risk Assessment

ASCVD 10-Year Risk Calculation (Ages 40-75)

• Pooled Cohort Equations (PCE) score: ____%
• Risk category: Low (<5%), Borderline (5-7.4%), Intermediate (7.5-19.9%), High (≥20%)

Risk-Enhancing Factors Present

Document if any of the following apply 2:

• Family history of premature ASCVD (men <55y, women <65y)
• Primary hypercholesterolemia (LDL-C 160-189 mg/dL)
• Metabolic syndrome (≥3 criteria: waist circumference, triglycerides >150, BP, glucose, low HDL-C)
• Chronic kidney disease (eGFR 15-59 mL/min/1.73 m²)
• Chronic inflammatory conditions (psoriasis, RA, lupus, HIV/AIDS)
• Premature menopause (<40y) or pregnancy complications (preeclampsia)
• High-risk ethnicity (South Asian ancestry)
• Persistently elevated triglycerides (≥175 mg/dL, nonfasting)
• If measured: hs-CRP ≥2.0 mg/L, Lp(a) ≥50 mg/dL, apoB ≥130 mg/dL, ABI <0.9

Coronary Artery Calcium Score (if obtained)

• CAC score: _____ Agatston units
• Percentile for age/sex: _____
• Impact on treatment decision: _____

Current Cardiovascular Risk Factors

Blood Pressure

• Current BP: ___/___mmHg
• Target: <130/80 mmHg 1
• Current antihypertensive medications and doses
• Nonpharmacological interventions discussed/implemented

Lipids

• Total cholesterol: ___ mg/dL
• LDL-C: ___ mg/dL
• HDL-C: ___ mg/dL
• Triglycerides: ___ mg/dL
• Non-HDL-C: ___ mg/dL
• Statin indication present: Yes/No (LDL ≥190, diabetes age 40-75, sufficient ASCVD risk) 1
• Current lipid-lowering therapy and doses

Diabetes Status

• Hemoglobin A1c: ____%
• Fasting glucose: ___ mg/dL
• Type 2 diabetes present: Yes/No
• Current diabetes medications (prioritize metformin first-line, then SGLT2i or GLP-1 RA) 1

Tobacco Use

• Current tobacco use: Yes/No (cigarettes, e-cigarettes, smokeless)
• Pack-year history: _____
• Readiness to quit: _____
• Cessation assistance provided: counseling/pharmacotherapy 1

Body Composition

• Height: ___ Weight: ___ BMI: ___
• Waist circumference: ___ cm
• Overweight/obesity present: Yes/No

Lifestyle Assessment

Physical Activity 2

• Current activity level (minutes/week):
  • Moderate intensity (brisk walking 2.4-4 mph, biking 5-9 mph): ___ min/week
  • Vigorous intensity (jogging/running, biking ≥10 mph, swimming laps): ___ min/week
• Target: ≥150 min/week moderate OR ≥75 min/week vigorous 1
• Sedentary time per day: ___ hours

Diet Quality

• Current dietary pattern: _____
• Intake assessment:
  • Vegetables/fruits: servings/day ___
  • Whole grains: servings/day ___
  • Nuts/legumes: servings/week ___
  • Fish: servings/week ___
  • Processed meats: servings/week ___
  • Sweetened beverages: servings/day ___
  • Trans fats/refined carbohydrates: frequency ___
• Target: Mediterranean or DASH-style diet emphasizing vegetables, fruits, nuts, whole grains, lean protein, fish; minimize trans fats, processed meats, refined carbohydrates, sweetened beverages 1

Sleep

• Average sleep duration: ___ hours/night
• Sleep quality issues: _____

Clinician-Patient Risk Discussion

Document shared decision-making conversation:

• Patient's understanding of their ASCVD risk: _____
• Patient's preferences regarding preventive interventions: _____
• Barriers to lifestyle modification discussed: _____
• Social determinants of health affecting treatment decisions: _____

Assessment & Plan

Primary Prevention Interventions

Lifestyle Modifications (ALL patients) 1:

• Diet: Specific dietary changes recommended _____
• Physical activity: Specific exercise prescription _____
• Weight management: Target weight loss ___% if BMI ≥25
• Tobacco cessation: Specific plan _____
• Alcohol: Limit if excessive consumption

Pharmacological Therapy:

• Statin therapy: Initiated/Continued/Not indicated

  • Indication: _____
  • Specific agent and dose: _____

• Antihypertensive therapy: Initiated/Continued/Not indicated

  • Target BP <130/80 mmHg
  • Specific agents and doses: _____

• Diabetes medications: Initiated/Continued/Not indicated

  • Metformin first-line, consider SGLT2i or GLP-1 RA 1
  • Specific agents and doses: _____

• Aspirin: NOT recommended for routine primary prevention (lack of net benefit) 1

Follow-up Plan

• Repeat lipid panel: _____
• Repeat A1c (if diabetic): _____
• BP monitoring plan: _____
• Next appointment: _____
• Referrals needed: _____

Patient Education Provided

• Written materials given: _____
• Team-based care resources: _____
• Patient's questions addressed: _____

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This template systematically captures the evidence-based elements required for comprehensive cardiovascular prevention while ensuring documentation supports quality measurement and team-based care coordination 1, 2.