Table 2.

Box table summarizing key clinical recommendations regarding cardiovascular risk assessment and management in patients with SMI

1. Overall goals

(a) To establish equality in the management of cardiovascular risk factors and treatment of cardiovascular disease and ensure sufficient accessibility to cardiovascular examinations for patients with SMI, comparable with the standards observed in the general population.

(b) To adhere to contemporary international cardiovascular treatment guidelines in the management of patients with SMI.

2. Primary prevention strategy goals

(a) Hypertension is frequent in patients with SMI, but antihypertensive treatment is often underutilized or patients are undertreated. Patients should be screened for hypertension early and regularly. Blood pressure control and timely initiation of sufficient antihypertensive treatment are essential to mitigate cardiovascular disease risk in these patients.

(b) Dyslipidaemia plays an important role in the premature development of atherosclerotic cardiovascular disease in patients with SMI. Patients, even without other risk-enhancing factors, may potentially benefit from a more aggressive approach to lipid management. Although statin treatment is equally effective in lowering LDL-C levels in patients with SMI as in the general population, statins are underutilized in these patients.

(c) Diabetes is common at an early stage in patients with SMI, often exacerbated by antipsychotic treatment by altering glucose metabolism and promoting weight gain. Regular monitoring of HbA1c levels to assess long-term glucose control is important. Treatment plans should be tailored to both individual needs and comorbidities including ischaemic heart disease, heart failure, or nephropathy, where SGLT2 inhibitors or GLP-1 RAs are indicated. Management should extend beyond medications to include lifestyle modifications and collaborative care.

(d) Smoking rates are increased in patients with SMI, and smoking cessation interventions are generally underutilized. Specialized treatment such as bupropion and varenicline shows improved long-term efficacy and high safety in these patients.

(e) Physical inactivity, obesity, unhealthy diet, and substance misuse in patients with SMI are also highly prevalent cardiovascular risk factors. Clinicians are strongly encouraged to actively screen for these risk-enhancing factors and implement targeted management strategies by providing guidance on lifestyle interventions, patient education, and integrated care approaches.

3. Secondary prevention strategy goals

(a) Patients with SMI may potentially benefit more from the standard secondary prevention treatment that is offered to the general population following a diagnosis of cardiovascular disease.

(b) The largest treatment gap is potentially within post-ACS care, where patients with SMI and myocardial infarction are less likely to receive aspirin, P2Y12 inhibitors, beta-blockers, statins, ACEIs/ARBs, or MRAs compared with the general population. The majority of patients with SMI have a lower likelihood of undergoing invasive coronary procedures. When treated sufficiently, no differences in post-myocardial infarction mortality are observed between patients with SMI and the general population.

4. Integrated healthcare goals

(a) Multidisciplinary care models bridging the gap between mental health, primary care, and cardiology can contribute to more comprehensive and effective management of the excess cardiovascular risk in patients with SMI. A comprehensive and individualized approach to managing risk factors is essential for optimizing cardiovascular health in the SMI population.

ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers; ACS, acute coronary syndrome; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; HbA1c, glycated haemoglobin; LDL-C, LDL cholesterol; MRAs, mineralocorticoid receptor antagonists; SGLT2, sodium–glucose cotransporter 2; SMI, severe mental illness.