Lithuanian CVD Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-cvd/ and changes regularly. See the Directory of published versions

Workflow

Cardiovascular disease prevention and assessment workflow

This page describes the clinical and programme pathway for Lithuanian CVD prevention and early diagnosis, aligned with the national risk assessment questionnaire and prevention measures plan (including later achievement evaluation). It matches the high-level process model used for programme design: primary assessment → investigations → optional specialist review → integrated risk interpretation → prevention plan → longitudinal follow-up.

FHIR resources from this IG appear mainly from step 4 onward (risk and plan); earlier steps rely heavily on LT Base, LT VitalSigns, LT Lab, and LT Lifestyle for demographics, vitals, labs, and behavioural data.

1. Primary care assessment and data collection

The pathway starts with a primary care CVD assessment visit (patient present). The general practitioner or nurse collects cardiovascular history and risk factors, records vital signs and anthropometrics (e.g. blood pressure, heart rate, BMI, waist circumference), and may initiate risk estimation using an appropriate model (e.g. SCORE2 / SCORE2-OP). An ECG may be performed when indicated.

• Context: Patient, practitioner, organisation, and encounter are typically represented with LT Base (and related) profiles.
• Measurements: Blood pressure, weight, height, BMI, etc. use LT VitalSigns (and general Observation patterns) where profiled there.
• Central obesity is assessed as a risk factor based on waist circumference (WaistCircumference from LT VitalSigns, thresholds: men >= 102 cm, women >= 88 cm) and recorded via RiskFactorStatusLtCvd with SNOMED 248311001 (Central obesity).
• Lifestyle factors (smoking, alcohol, activity, diet) often map to LT Lifestyle observations when captured in structured form.

This step supplies the inputs for formal risk documentation in step 4.

2. Diagnostic testing (data acquisition)

Based on the first assessment, laboratory tests and functional or imaging tests may be performed. These produce structured results but are not, by themselves, programme “conclusions”—they feed interpretation and risk calculation.

• Primary care laboratory tests use LT Lab profiles: lipid panel (TotalCholesterolLabLt, CholesterolHdlLabLt, CholesterolLdlLabLt, TriglyceridesLabLt), glucose (GlucoseVenousLabLt), HbA1c (HbA1cLabLt), creatinine, eGFR, and albumin/creatinine ratio.
• Cardiologist laboratory tests (ordered at specialist evaluation) also use LT Lab profiles: ApolipoproteinBLabLt (Apo B), LipoproteinALabLt (Lp(a) — mass and molar methods), PotassiumLabLt (K+), ASTLabLt (GOT), ALTLabLt (GPT), and HsCRPLabLt (high-sensitivity CRP for CVD risk).
• Results are referenced conceptually when building the CVD risk assessment and risk group in the next steps.

3. Specialist evaluation (if applicable)

If indicated (e.g. high or very high SCORE2 risk), the patient may attend cardiology or another specialist. The specialist reviews primary-care data and test results and may order additional diagnostic tests, captured by this IG:

• EKGLtCvd — 12-lead ECG with SampledData waveform and detailed interpretation (normal, abnormal, ST-T changes, atrial fibrillation/flutter, LBBB, supraventricular arrhythmia, extrasystole). Free-text “Other” findings use Observation.note.
• EchocardiographyLtCvd — Heart ultrasound capturing ejection fraction (%), EF category (preserved >= 50%, mildly reduced 41-49%, reduced <= 40%), and optional pathology (ICD-10).
• ArterialStiffnessLtCvd — Pulse wave velocity (PWV) carotid-femoral in m/s; normal < 10 m/s.
• CarotidUltrasoundLtCvd — Carotid artery ultrasound with right/left plaque categories (none, present, < 50%, 50-69%, > 70%) and intima-media thickness (IMT; pathological > 1.5 mm).
• AnkleBrachialIndexLtCvd — ABI for diabetic patients and smokers; right/left values with PAD severity (normal > 0.9, mild/moderate 0.41-0.90, severe <= 0.40).
• CoronaryCalciumScoreLtCvd — Agatston score with 6-level interpretation (0 through > 1000). Ordered when medication need is unclear or statins are not tolerated.

This IG does not define a dedicated “referral” profile; ServiceRequest / Encounter patterns from Base or EU packages may apply. Outputs feed step 4.

4. Clinical interpretation and risk stratification

Available data are integrated into a coherent CVD assessment for the programme:

• CVDRiskAssessmentLtCvd — structured SCORE2-style cardiovascular risk (percentage) and qualitative risk degree (bound value set).
• RiskGroupObservationLtCvd — programme risk group for heart and vessel diseases (e.g. for recall and reporting), consistent with national criteria where automation or manual confirmation applies.
• CvdChronicConditionLtCvd — accompanying chronic diseases relevant to CVD risk from the programme list.
• RiskFactorStatusLtCvd — risk factors (including total count where used).
• EKGLtCvd — ECG when captured as part of this assessment context (supports detailed findings: ST-T changes, arrhythmias, conduction disorders).
• Cardiovascular diagnostics (when performed at specialist evaluation): EchocardiographyLtCvd, ArterialStiffnessLtCvd, CarotidUltrasoundLtCvd, AnkleBrachialIndexLtCvd, CoronaryCalciumScoreLtCvd.

Together, these correspond to the questionnaire sections for chronic diseases, risk factors, objective findings, ECG, and risk group, plus the numeric risk estimate.

5. Prevention and management planning

For patients assigned to an eligible risk group, a CVD prevention measures plan is created: lifestyle counselling (nutrition, physical activity, smoking cessation, healthy weight), target LDL cholesterol and blood pressure, and documentation of regular use of prescribed medications (antilipid, antihypertensive, etc.) as required by the programme forms.

• CarePlanLtCvd carries the structured plan. RiskGroupExtLtCvd can repeat or align risk group on the plan when needed.
• Lifestyle extensions referenced from the plan may align with LT Lifestyle (e.g. physical activity, dietary notes).
• MedicationStatement resources (often base or lifestyle screening context) can represent current medications linked to the patient.

Example instances in this IG illustrate care plans and related observations.

6. Follow-up and achievement evaluation

CVD prevention is longitudinal. At follow-up visits (possibly at another institution or with another clinician), achievement evaluation is recorded: e.g. achieved LDL, current blood pressure, whether targets were met, smoking status, BMI, and evaluator comments.

• New Observations (vitals, labs) and updated CarePlan or Goal-related documentation represent this phase; the same profile set applies to new instances over time, not a separate “achievement” resource type.
• Programme indicators (e.g. participation in healthy lifestyle training) may appear as additional observations or questionnaire fields as national forms specify.

Programme document bundle (CVD report + composition)

For a single exchangeable record that mirrors pathology and imaging reporting patterns in other Lithuanian IGs, this guide defines CvdReportLtCvd and CvdCompositionLtCvd. The DiagnosticReport lists Observation results (SCORE2, risk group, EKG, follow-up LDL and BP); the Composition groups assessment, prevention plan (e.g. CarePlan), and achievement evaluation with section narratives and entry references. See CVD programme report for the full pattern and example instances.

Illustrative examples on the FHIR CI build for vitals and lifestyle data that feed assessment include: blood pressure, body height, tobacco use, and alcohol consumption (LT VitalSigns and LT Lifestyle).

ESPBI electronic forms (Questionnaire)

The national risk assessment and prevention / achievement forms can be represented as Questionnaire / QuestionnaireResponse — independent of the CvdReport bundle. Illustrative definitions and examples are on Questionnaires.

Overview diagram

flowchart LR
  step1["Primary Care Assessment"]
  step2["Diagnostic Testing"]
  step3["Specialist Evaluation"]
  step4["Risk Stratification"]
  step5["Prevention Plan"]
  step6["Follow-Up"]
  step1 --> step2
  step2 --> step3
  step3 --> step4
  step1 --> step4
  step4 --> step5
  step5 --> step6
  step6 --> step4

The loop from FollowUp back to RiskStratification reflects reassessment and plan updates over time.

This workflow supports standardised exchange of questionnaire, plan, and follow-up data while keeping a clear separation between raw measurements (vitals, labs), programme interpretation (risk score, risk group), and care planning (this IG’s focus in steps 4–6).

DSTU1 to R5 migration notes

The legacy ESPBI system uses three DSTU1 Atom feed documents (SKL01, SKL02, SKL03). This section documents structural changes for migration to FHIR R5.

Document types

DSTU1 Form	LOINC Code	R5 Profile
SKL01 — Risk Assessment Questionnaire	83539-7	​CvdRiskAssessmentCompositionLtCvd
SKL02 — Prevention Plan	77442-2	​CvdPreventionPlanCompositionLtCvd
SKL03 — Achievement Evaluation	78710-1	​CvdAchievementCompositionLtCvd

The combined CvdCompositionLtCvd (LOINC 51848-0) can be used when all three sections are bundled into a single document.

Risk factor structure changes

In DSTU1, each risk factor (hypertension, dyslipidemia, etc.) is represented as a pair of Observations:

1. A main Observation using method.coding to identify the risk factor type (e.g., SNOMED 38341003 for hypertension) and valueCodeableConcept from risk-probability (certain/negligible) to indicate presence
2. A related treatment status Observation (shared across risk factors via <related>) using SNOMED 1156601009 with treatment status as value

In R5, each risk factor maps to a single RiskFactorStatusLtCvd Observation with components:

• code identifies the risk factor type (replaces DSTU1 method)
• component[risk] carries the risk probability (replaces DSTU1 valueCodeableConcept)
• component[treatment] carries treatment status (replaces DSTU1 related Observation)
• component[medication] optionally identifies specific medication

The DSTU1 pattern of sharing one treatment Observation across multiple risk factors is replaced by independent component values per risk factor.

Lifestyle risk factors

DSTU1 encodes smoking, physical activity, nutrition, alcohol, and family history as generic risk factor Observations (code 80943009) differentiated by method.coding (esveikata classifier). In R5, these map to dedicated profiles from the LT Lifestyle IG (e.g., TobaccoUseLtLifestyle, PhysicalActivityLtLifestyle, NutritionLtLifestyle).