Coronary heart disease risk stratification

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Risk calculators and risk factors for Coronary heart disease risk stratification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Risk stratification among patients with and at risk for coronary artery disease is critical so that the level of aggressiveness of management can match the risk of future events. The magnitude of risk is often clearer in the patient who has had a vascular event than in the assessment of primary risk assessment (who will have a future event who does not yet have evidence of CHD).

Risk Equivalents in Primary Prevention

• Aortic aneurysm
• Diabetes
• Framingham Risk Score (FRS) of > 20%
• Peripheral vascular disease (PVD) (defined as claudication, an Ankle Brachial Index (ABI) of < 0.9)
• Symptomatic carotid artery disease (defined as prior stroke or TIA)

CV Risk Factors in the Setting of Primary Prevention

• Cigarette smoking
• Family history of premature coronary artery disease (CAD)
• High LDL (defined as LDL > 130 mg /dl)
• Hypertension ( defined as a BP ≥140/90 mm Hg or if the patient is on antihypertensive drugs)
• Low HDL (defined as HDL < 40 mg/dL males, < 50 mg/dL in females)
• Older Age (men ≥45 years old; women ≥55 years old)

Risk Stratification Tests in Primary Prevention

All these tests provide the greatest information to guide decision making in the intermediate risk patient. Among patients who are low risk or high risk, these tests likely do not change management decisions. These tests reclassify risk beyond risk factors in about 25% of patients.

Carotid Intimal Medial Thickness

Recommendation for Measurement of Carotid Intima-Media Thickness IIa B Measurement of carotid artery intima-media thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk.

C Reactive Protein

The odds ratio for events among patients in the highest tertile are 2 times higher than those in the lowest tertile.

ACC/AHA Guidelines- Pocket Guideline: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults (DO NOT EDIT)

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Risk Stratification and Genomics Global Risk Scoring Recommendation Class I 1. Global risk scores (such as the Framingham Risk Score) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD. These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to targe preventive interventions. (Level of Evidence: B) Family History Recommendation Class I 1. Family history of atherothrombotic CVD should be obtained for cardiovascular risk assessment in all asymptomatic adults. (Level of Evidence: B) Genotypes Recommendation Class III: 1. Genotype testing for CHD risk assessment in No Benefit asymptomatic adults is not recommended. (Level of Evidence: B) Lipoproteins and Circulating Blood Markers Lipoprotein and Apolipoprotein Assessments Recommendation Class III: 1. Measurement of lipid parameters, including No Benefit lipoproteins, apolipoproteins, particle size, and density, beyond standard fasting lipid profile is not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C) Natriuretic Peptides Recommendation Class III: 1. Measurement of natriuretic peptides is not No Benefit recommended for CHD risk assessment in asymptomatic adults. (Level of Evidence: B) C-Reactive Protein Recommendations Class IIa 1. In men 50 years of age or older or women 60 years of age or older with low-density lipoprotein cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy. (Level of Evidence: B) Class IIb 1. In asymptomatic intermediate-risk men 50 years of age or younger or women 60 years of age or younger, measurement of CRP may be reasonable for cardiovascular risk assessment. (Level of Evidence: B) Class III: 1. In asymptomatic high-risk adults, measurement of No Benefit CRP is not recommended for cardiovascular risk assessment. (Level of Evidence: B) 2. In low-risk men younger than 50 years of age or women 60 years of age or younger, measurement of CRP is not recommended for cardiovascular risk assessment. (Level of Evidence: B) Hemoglobin A1C Recommendation Class IIb 1. Measurement of hemoglobin A1C may be reasonable for cardiovascular risk assessment in asymptomatic adults without a diagnosis of diabetes. (Level of Evidence: B) Lipoprotein-Associated Phospholipase A2 Recommendation Class IIb 1. Lipoprotein-associated phospholipase A2 might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults. (Level of Evidence: B) Microalbuminuria Recommendations Class IIa 1. In asymptomatic adults with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk assessment. (Level of Evidence: B) Class IIb 1. In asymptomatic adults at intermediate risk without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment. (Level of Evidence: B) Cardiac and Vascular Tests Resting Electrocardiogram Recommendations Class IIa 1. A resting electrocardiogram (ECG) is reasonable for cardiovascular risk assessment in asymptomatic adults with hypertension or diabetes. (Level of Evidence: C) Class IIb 1. A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes. (Level of Evidence: C) Transthoracic Echocardiography Recommendations Class IIb 1. Echocardiography to detect left ventricular hypertrophy may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension. (Level of Evidence: B) Class III: 1. Echocardiography is not recommended for No Benefit cardiovascular risk assessment of CHD in asymptomatic adults without hypertension. (Level of Evidence: C) Carotid Intima-Media Thickness Recommendation Class IIa 1. Measurement of carotid artery intima-media thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk. Published recommendations on required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high-quality results. (Level of Evidence: B) Brachial/Peripheral Flow-Mediated Dilation Recommendation Class III: 1. Peripheral arterial flow-mediated dilation studies No Benefit are not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: B) Specific Measures of Arterial Stiffness Recommendation Class III: 1. Measures of arterial stiffness outside of research No Benefit settings are not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C) Ankle-Brachial Index Recommendation Class IIa 1. Measurement of ankle-brachial index is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk. (Level of Evidence: B) Exercise Electrocardiography Recommendation Class IIb 1. An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity. (Level of Evidence: B) Stress Echocardiography Recommendation Class III: 1. Stress echocardiography is not indicated for No Benefit cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacological stress echocardiography is primarily used for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known CAD or the assessment of patients with known or suspected valvular heart disease.) (Level of Evidence: C) Myocardial Perfusion Imaging Recommendations Class IIb 1. Stress myocardial perfusion imaging (MPI) may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or asymptomatic adults with a strong family history of CHD or when previous risk assessment testing suggests a high risk of CHD, such as a coronary artery calcium (CAC) score of 400 or greater. (Levelof Evidence: C) Class III: 1. Stress MPI is not indicated for cardiovascular risk No Benefit assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress MPI is a technology primarily used and studied for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known coronary artery disease.) (Level of Evidence: C) Calcium Scoring Methods Recommendations Class IIa 1. Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk). (Level of Evidence: B) Class IIb 1. Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year risk). (Level of Evidence: B) Class III: 1. Persons at low risk (<6% 10-year risk) should not No Benefit undergo CAC measurement for cardiovascular risk assessment. (Level of Evidence: B) Coronary Computed Tomography Angiography Recommendation Class III: 1. Coronary computed tomography angiography is No Benefit not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C) Magnetic Resonance Imaging of Plaque Recommendation Class III: 1. Magnetic resonance imaging for detection of No Benefit vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C) Additional Considerations Patients With Diabetes Recommendations Class IIa 1. In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment. (Level of Evidence: B) Class IIb 1. Measurement of hemoglobin A1C may be considered for cardiovascular risk assessment in asymptomatic adults with diabetes. (Level of Evidence: B) 2. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests a high risk of CHD, such as a CAC score of 400 or greater. (Level of Evidence: C) Women Recommendations Class I 1. A global risk score should be obtained in all asymptomatic women. (Level of Evidence: B) 2. Family history of CVD should be obtained for cardiovascular risk assessment in all asymptomatic women. (Level of Evidence: B)

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