Reducing Vascular Risk

Does This Patient Require Vascular Protective Medication?

To be used for vascular protection, even if the baseline blood pressure or LDL-C is at target

Does the patient have macrovascular disease?

  • Cardiac ischemia (silent or overt)
  • Peripheral arterial disease
  • Cerebrovascular/Carotid disease
Yes No

Does the patient have microvascular disease?

  • Retinopathy
  • Nephropathy (ACR ≥ 2.0)
  • Neuropathy
Yes No

What is the patient’s age?


Does the patient…

Have diabetes > 15 years
Warrant statin therapy based on the 2012 Canadian Cardiovascular Society (CCS) Lipid Guidelines

Based on the information provided, vascular protected medication is not recommended.

STATIN1 + ACEi or ARB2 +
ASA (Clopidogrel if ASA intolerant)



The above vascular protective medications have the potential to cause embryopathy: ACEi/ARBs in the 2nd trimester and beyond (controversial effects in the 1st trimester), Statins throughout pregnancy. Therefore, these medications should only be used in the presence of proper preconception counseling and reliable contraception in women of childbearing age. A woman’s pregnancy plans should be discussed at every visit.

  • Statins should be stopped prior to conception
  • ACEi or ARBs should be stopped either prior to conception or immediately upon detection of pregnancy

Do not use ACEi or ARBs if at high risk of hypotension.

ASA should not be used for the primary prevention of cardiovascular disease in people with diabetes. ASA may be used for secondary prevention.

1 If baseline LDL-C is already ≤ 2.0 mmol/L, target an LDL-C reduction of 50% or more. If baseline LDL-C is not at target, continue dose adjustment or add additional lipid therapy until target is reached.

2 ACE-inhibitor or ARB (angiotensin receptor blocker) should be given at doses that have demonstrated vascular protection (ie. perindopril 8 mg once daily (EUROPA trial), ramipril 10 mg once daily (HOPE trial), telmisartan 80 mg once daily (ONTARGET trial))

Risk Assessment Algorithm:Download PDF

Additional Resources: Canadian Cardiovascular Society (CCS) Guideline Resources

This is only to be used as a decision support tool and is subject to these terms.
For more information, please see the disclaimer.