Digital phenotyping and additive multimorbidity scoring to operationalise very-high-risk secondary prevention in primary care

Background Patients with established atherosclerotic cardiovascular disease (ASCVD) frequently remain at high residual risk due to suboptimal lipid control and clustering of cardiometabolic comorbidities. Scalable, implementation-ready approaches to systematically identify and prioritise these individuals in UK primary care remain elusive(1). We evaluated a digitally enabled phenotyping strategy, combined with a pragmatic additive cardiovascular risk management (CVRM) care-gap score, to quantify modifiable residual burden. Methods Within a primary care population of 10,306 adults, a standardised electronic search (CVDPL2F) identified patients with established ASCVD (CHD, PCI/stent, PAD, stroke/TIA), excluding familial hypercholesterolaemia and those using inclisiran, with LDL-C >1.8 mmol/L or non-HDL >2.5 mmol/L (2). Structured EHR data were extracted cross-sectionally. A CVRM care-gap score was defined as: baseline 2 (ASCVD + LDL above target) plus 1 point each for diabetes (HbA1c >53 mmol/mol), hypertension (SBP >140 mmHg), CKD (eGFR <60), and obesity (BMI >30 kg/m²). Risk modifiers (smoker, COPD, heart failure, AF, fatty liver) were flagged but not scored. Primary analysis quantified multimorbidity burden and treatment gaps. Results Of 10,306 patients, n=173 (1.7%) met criteria. Mean age 71.1±12.2 years; 57.2% male. Mean LDL-C 2.7mmol/L; 44.5% >2.6 mmol/L. SBP >140 mmHg in 7.5%; diabetes in 24.9% (HbA1c >53: 11.6%); CKD in 26.0%; BMI >30 in 24.9%. Mean CVRM score 3.2±0.7; 33.5% scored 4 or more. Two or more risk modifiers were present in 34.7% of cases. Conclusion Digital phenotyping identified a concentrated, very-high-risk ASCVD cohort with substantial multimorbidity and modifiable care gaps. The CVRM score provides a scalable prioritisation framework for structured community-based secondary prevention. A prospective longitudinal evaluation is underway to quantify intervention intensity (pharmacological and lifestyle) and the associated change in mean CVRM score, providing an objective measure of individualised care-gap modification within primary care.