Fundamentals of CVD Risk Assessment: Guideline Topline for Primary Care
Assessment of CVD risk is the foundation of primary prevention and integral to primary care. Brush up on the fundamental tools of risk estimation from the ACC/AHA guidelines.
CLINICAL FOCUS: PREVENTIVE CARDIOLOGY
Assessment of atherosclerotic cardiovascular disease (ASCVD) risk, the foundation of primary prevention, is a critical guide for decision-making about potential interventions, including pharmacotherapy.
The American College of Cardiology (ACC)/American Heart Association (AHA) 2019 clinical practice guidelines emphasize the essential roles of clinician-patient discussions and a patient-centered approach to all treatment decisions whether the topic is lifestyle change or initiating medication.
In this Guideline Topline slide show, get a concise summary of the recommended tools for evaluating patient CVD risk, refining the risk, and for placing the patient at the center of therapeutic choice.
ACC/AHA RECOMMENDS RISK ESTIMATION. Adults aged 40-75 yrs being evaluated for CVD prevention should undergo 10-yr ASCVD risk estimation followed by a clinician–patient risk discussion before pharmacologic therapy is started (eg, statin, antihypertensive agent, aspirin).
POOLED COHORT EQUATIONS (PCE). PCE were introduced in 2013 as sex- and race-specific tools for estimating 10-yr absolute rates of ASCVD events in a primary prevention population and to calculate absolute risk/benefit of statin therapy. PCE differ from Framingham, with focus on estimating risk of stroke in addition to CHD.
FOCUS ON MODIFIABLE RISK FACTORS. Modifiable ASCVD risk factors: hypertension, obesity, smoking, diet, exercise, cholesterol levels, alcohol intake, diabetes control. Associated risk can be reduced with lifestyle and pharmacologic interventions.
MATCH INTERVENTION WITH LEVEL OF RISK. Estimation of 10-yr absolute ASCVD risk allows the clinician to better match the intensity of preventive interventions with the patient’s absolute risk. Anticipated benefit of treatment can be maximized and potential harm from overtreatment minimized. The risk estimate should be the start of decision making but not the sole factor considered.
REFINE WITH RISK-ENHANCING FACTORS. For adults with borderline (5% to < 7.5%) or intermediate (≥ 7.5% to < 20%) 10-yr ASCVD risk, additional risk-enhancing factors may be used to refine the risk estimate to guide decisions about potential intervention.
CAC SCORING HELPS RECLASSIFY. CAC scoring may also be useful to refine risk assessment and intervention decisions in patients with borderline or intermediate estimated 10-yr ASCVD risk. CAC scoring has demonstrated superior discrimination and risk reclassification when compared with other subclinical imaging markers or biomarkers.
PCE ALTERNATIVES. PCE were best validated among non-Hispanic whites and non-Hispanic blacks in the US so may over- or underestimate risk in other racial/ethnic or non-US populations. Consider alternatives, including: Framingham CVD risk score, Reynolds risk scores, SCORE (Systematic COronary Risk Evaluation), and QRISK/JBS3.
RISK ASSESSMENT FOR HTN, CHOLESTEROL. To facilitate therapeutic decisions about preventive interventions for management of stage 1 hypertension: categorize adults as <10% or >10% 10-yr ASCVD risk. For management of blood cholesterol: categorize adults as having a 10-yr ASCVD risk that is low, borderline, intermediate, or high.
START RISK ASSESSMENT EARLY. After age 20 yrs, measuring traditional risk factors at least every 4-6 yrs is reasonable. Most adults aged 20-39 yrs* are unlikely to have a sufficiently elevated 10-yr risk to warrant pharmacologic intervention.
*PCE did not include them.
