Prevention is the cornerstone to addressing CVD with early identification of modifiable risk factors.
Traditional risk factors known to correlate with increased risk of CVD are used in calculating absolute risk for cardiovascular disease or event. The categorization of the score into low, intermediate, and high risk helps providers understand the potential benefits of various lifestyle modifications, non-pharmaceutical interventions, and pharmaceutical treatments at each stage.
The most widely used algorithm in the US is thePooled Cohort Equations (PCE) that produces a 10 year risk for acute cardiovascular events.
Absolute CVD risk scores and other nontraditional risk factors help clinicians understand an asymptomatic patient’s risk for cardiovascular disease or acute cardiovascular events. Knowledge of this risk guides management decisions and improves health outcomes.
Cardiovascular disease (CVD) refers to different conditions affecting the heart and blood vessels, including coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease, and aortic atherosclerosis/aneurysms (Wilson, 2020). Heart attack and stroke are common colloquialisms that are ubiquitous for potentially devastating cardiovascular events. In 2011, the American Heart Association (AHA) predicted by 2030 roughly 40% of the US population would suffer from some form of cardiovascular disease (2017). Fifteen years earlier than predicted and just 4 years later in 2015, this projection was met with over 100 million Americans holding a diagnosis of some form of heart disease (AHA, 2017). Heart disease is the leading cause of death among men, women, and most ethnic groups in the United States, claiming over 600,000 lives a year (CDC, 2020).
The impacts of CVD exceed the obvious cost to physical health, but also affects individuals and society with significant economic ramifications. Given this burden and increasing prevalence in the US, expert groups stress the importance of prevention through assessing and addressing risk factors early, rather than after a serious cardiovascular event, to optimize cardiovascular and other health outcomes.
Cardiovascular Disease Risk Assessment With Traditional Risk Factors
Traditional risk factors for CVD include male sex, older age, hypertension, diabetes, obesity, current smoking, abnormal cholesterol levels, and physical inactivity (Curry et al., 2018). Accurate assessment of individual risk factors and progression to actual diagnosis is key to effective primary prevention in asymptomatic individuals. Despite lack of conclusive studies, expert groups advise using an individual’s “absolute/total CVD risk” to evaluate disease status, predict future CVD events, and guide management decisions (Studziński, Tomasik, Krzysztoń, Jóźwiak, & Windak, 2019). Absolute CVD risk is the actual risk of developing disease within a defined population and period of time, giving clinicians and patients a stratification framework for potential benefits of treatment decisions (Studziński, Tomasik, Krzysztoń, Jóźwiak, & Windak, 2019). The categorization of the score into low, intermediate, and high risk helps providers understand potential benefits of various lifestyle modifications, non-pharmaceutical interventions, and pharmaceutical treatments at each stage. The 2019 ACC/AHA guidelines are the most up-to-date recommendations on frequency of screening and timing of medication intervention.
There are several methods to calculate CVD absolute risk. The 2013 ACC/AHA Cardiovascular Risk Assessment Guidelines introduced a now widely used method: a race- and sex-specific Pooled Cohort Equations (PCE) predicting 10-year risk of an ASCVD event (Goff et al.) The 2018 Cholesterol Clinical Practice Guidelines and 2017 Hypertension Clinical Practice Guidelines also recommended PCE use for CVD risk calculation (Lloyd-Jones et al., 2019). The Framingham 10-year CHD Risk score and Reynolds Risk Score are other common calculations, but are limited due to the white male sample population and calibration specifically to heart disease rather than a cardiovascular event (Goff et al., 2013).
Nontraditional CVD Risk Factors and Other Assessment Tools
While algorithms provide absolute CVD risk, the score is only a piece of the puzzle. These methods often under or overestimate certain cohort groups, and some ethnicities are not well represented (Lloyd-Jones et al., 2019). Furthermore, the CVD risk assessment tools incorporate very specific data and are unmodifiable for other potential determinants of cardiovascular risk. Additional risk factors are especially important when the CVD risk score is “borderline” or “intermediate”, defined by the ACC/AHA guidelines as a 10 year CVD risk between 5% and 7.5% using their ASCVD risk calculator (Arnett et al., 2019). Clinicians should use risk score in conjunction with other significant factors such as diet, physical activity, socio-economic issues, other comorbidities, and family history of CVD; adjusting interventions as needed (Arnett et al., 2019).
Other screening tools and tests, such as the ankle brachial index and high sensitivity CRP testing, help clinicians further understand individual CVD risk when things are unclear (Curry et al., 2018). The newest ACC/AHA guidelines specifically advise the use of coronary artery calcium scan in individuals with borderline ASCVD risk score (Arnett et al., 2019).
In 2018, USPSTF sought to understand the role of electrocardiogram in assessing cardiovascular risk in asymptomatic individuals – given prominent use in diagnostic evaluations (Curry et al., 2018). There is inconclusive evidence to advise against or for screening ECG in asymptomatic adults at intermediate to high risk for CVD events, but adequate evidence to conclude with moderate certainty that screening ECGs in asymptomatic adults at low risk for CVD events produced no net benefit (Curry et al., 2018). The AHA notes low levels of cardiorespiratory fitness are associated with high rates of cardiovascular disease and may be a stronger predictor of mortality risk than traditional risk factors (Ross et al., 2016).
More research is needed to articulate the most effective ways to use these tools as screening tests in cardiovascular risk assessments and how they ultimately affect CVD mortality and morbidity outcomes. Clinicians are encouraged to continue in shared decision making with patients to combine their unique cardiovascular risk factors and develop a comprehensive, effective treatment plan.
To learn more and earn CE credit, register for our June 9-11 Virtual Conference, which has sessions on ASCVD and Dyslipidemia, as well as CV risk and treatment.
Arnett, D., Donna K. Arnett Search for more papers by this author, Blumenthal, R., Roger S. Blumenthal Search for more papers by this author, Albert, M., Michelle A. Albert Search for more papers by this author, . . . Al., E. (2019, March 17). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College OF CARDIOLOGY/AMERICAN Heart Association Task force on clinical practice guidelines. Retrieved February 9, 2021, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000678
CARDIOVASCULAR DISEASE: A COSTLY BURDEN FOR AMERICA PROJECTIONS THROUGH 2035 (pp. 6-11, Rep. No. American Heart Association CVD Burden Report). (2017). Washington, DC: The American Heart Association Office of Federal Advocacy.
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Risk assessment for cardiovascular disease with nontraditional risk factors. JAMA,320(3), 272. doi:10.1001/jama.2018.8359
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Screening for cardiovascular disease risk with electrocardiography. JAMA,319(22), 2308. doi:10.1001/jama.2018.6848
Goff, D. C., Lloyd-Jones, D. M., Bennett, G., Coady, S., D’Agostino, R. B., Gibbons, R., . . . Wilson, P. W. (2013). 2013 ACC/AHA guideline on the assessment of cardiovascular risk. Circulation,129(25 suppl 2). doi:10.1161/01.cir.0000437741.48606.98
Lloyd-Jones, D., Braun, L., Ndumele, C., Smith, S., Sperling, L., Virani, S., . . . A., P. (2019, June 01). Use of risk assessment tools to GUIDE decision-making in the primary prevention of ATHEROSCLEROTIC cardiovascular disease: A special report from the American Heart Association and American College of Cardiology. Retrieved February 13, 2021, from https://www.jacc.org/doi/10.1016/j.jacc.2018.11.005
Ross, R., Blair, S. N., Arena, R., Church, T. S., Després, J., Franklin, B. A., . . . Wisløff, U. (2016). Importance of Assessing Cardiorespiratory fitness in clinical Practice: A case for fitness as a CLINICAL Vital Sign: A scientific statement from the American Heart Association. Circulation,134(24). doi:10.1161/cir.0000000000000461
Studziński, K., Tomasik, T., Krzysztoń, J., Jóźwiak, J., & Windak, A. (2019, January 9). Effect of using cardiovascular risk scoring in routine risk assessment in primary prevention of cardiovascular disease: An overview of systematic reviews. Retrieved February 13, 2021, from https://www.ncbi.nlm.nih.gov/pubmed/30626326
Cardiovascular Risk Assessment: An Overview
Takeaways
Cardiovascular disease (CVD) refers to different conditions affecting the heart and blood vessels, including coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease, and aortic atherosclerosis/aneurysms (Wilson, 2020). Heart attack and stroke are common colloquialisms that are ubiquitous for potentially devastating cardiovascular events. In 2011, the American Heart Association (AHA) predicted by 2030 roughly 40% of the US population would suffer from some form of cardiovascular disease (2017). Fifteen years earlier than predicted and just 4 years later in 2015, this projection was met with over 100 million Americans holding a diagnosis of some form of heart disease (AHA, 2017). Heart disease is the leading cause of death among men, women, and most ethnic groups in the United States, claiming over 600,000 lives a year (CDC, 2020).
The impacts of CVD exceed the obvious cost to physical health, but also affects individuals and society with significant economic ramifications. Given this burden and increasing prevalence in the US, expert groups stress the importance of prevention through assessing and addressing risk factors early, rather than after a serious cardiovascular event, to optimize cardiovascular and other health outcomes.
Cardiovascular Disease Risk Assessment With Traditional Risk Factors
Traditional risk factors for CVD include male sex, older age, hypertension, diabetes, obesity, current smoking, abnormal cholesterol levels, and physical inactivity (Curry et al., 2018). Accurate assessment of individual risk factors and progression to actual diagnosis is key to effective primary prevention in asymptomatic individuals. Despite lack of conclusive studies, expert groups advise using an individual’s “absolute/total CVD risk” to evaluate disease status, predict future CVD events, and guide management decisions (Studziński, Tomasik, Krzysztoń, Jóźwiak, & Windak, 2019). Absolute CVD risk is the actual risk of developing disease within a defined population and period of time, giving clinicians and patients a stratification framework for potential benefits of treatment decisions (Studziński, Tomasik, Krzysztoń, Jóźwiak, & Windak, 2019). The categorization of the score into low, intermediate, and high risk helps providers understand potential benefits of various lifestyle modifications, non-pharmaceutical interventions, and pharmaceutical treatments at each stage. The 2019 ACC/AHA guidelines are the most up-to-date recommendations on frequency of screening and timing of medication intervention.
There are several methods to calculate CVD absolute risk. The 2013 ACC/AHA Cardiovascular Risk Assessment Guidelines introduced a now widely used method: a race- and sex-specific Pooled Cohort Equations (PCE) predicting 10-year risk of an ASCVD event (Goff et al.) The 2018 Cholesterol Clinical Practice Guidelines and 2017 Hypertension Clinical Practice Guidelines also recommended PCE use for CVD risk calculation (Lloyd-Jones et al., 2019). The Framingham 10-year CHD Risk score and Reynolds Risk Score are other common calculations, but are limited due to the white male sample population and calibration specifically to heart disease rather than a cardiovascular event (Goff et al., 2013).
Nontraditional CVD Risk Factors and Other Assessment Tools
While algorithms provide absolute CVD risk, the score is only a piece of the puzzle. These methods often under or overestimate certain cohort groups, and some ethnicities are not well represented (Lloyd-Jones et al., 2019). Furthermore, the CVD risk assessment tools incorporate very specific data and are unmodifiable for other potential determinants of cardiovascular risk. Additional risk factors are especially important when the CVD risk score is “borderline” or “intermediate”, defined by the ACC/AHA guidelines as a 10 year CVD risk between 5% and 7.5% using their ASCVD risk calculator (Arnett et al., 2019). Clinicians should use risk score in conjunction with other significant factors such as diet, physical activity, socio-economic issues, other comorbidities, and family history of CVD; adjusting interventions as needed (Arnett et al., 2019).
Other screening tools and tests, such as the ankle brachial index and high sensitivity CRP testing, help clinicians further understand individual CVD risk when things are unclear (Curry et al., 2018). The newest ACC/AHA guidelines specifically advise the use of coronary artery calcium scan in individuals with borderline ASCVD risk score (Arnett et al., 2019).
In 2018, USPSTF sought to understand the role of electrocardiogram in assessing cardiovascular risk in asymptomatic individuals – given prominent use in diagnostic evaluations (Curry et al., 2018). There is inconclusive evidence to advise against or for screening ECG in asymptomatic adults at intermediate to high risk for CVD events, but adequate evidence to conclude with moderate certainty that screening ECGs in asymptomatic adults at low risk for CVD events produced no net benefit (Curry et al., 2018). The AHA notes low levels of cardiorespiratory fitness are associated with high rates of cardiovascular disease and may be a stronger predictor of mortality risk than traditional risk factors (Ross et al., 2016).
More research is needed to articulate the most effective ways to use these tools as screening tests in cardiovascular risk assessments and how they ultimately affect CVD mortality and morbidity outcomes. Clinicians are encouraged to continue in shared decision making with patients to combine their unique cardiovascular risk factors and develop a comprehensive, effective treatment plan.
To learn more and earn CE credit, register for our June 9-11 Virtual Conference, which has sessions on ASCVD and Dyslipidemia, as well as CV risk and treatment.
Want To Learn More…
Heart Disease | cdc.gov
Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
USPSTF Final Recommendation Statement: Cardiovascular Disease: Risk Assessment With Nontraditional Risk Factors
Brachial-Ankle Pulse Wave Velocity and the Risk Prediction of Cardiovascular Disease: An Individual Participant Data Meta-Analysis
Coronary Calcium Score and Cardiovascular Risk
ASCVD Risk Estimator +
References:
Arnett, D., Donna K. Arnett Search for more papers by this author, Blumenthal, R., Roger S. Blumenthal Search for more papers by this author, Albert, M., Michelle A. Albert Search for more papers by this author, . . . Al., E. (2019, March 17). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College OF CARDIOLOGY/AMERICAN Heart Association Task force on clinical practice guidelines. Retrieved February 9, 2021, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000678
CARDIOVASCULAR DISEASE: A COSTLY BURDEN FOR AMERICA PROJECTIONS THROUGH 2035 (pp. 6-11, Rep. No. American Heart Association CVD Burden Report). (2017). Washington, DC: The American Heart Association Office of Federal Advocacy.
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Risk assessment for cardiovascular disease with nontraditional risk factors. JAMA, 320(3), 272. doi:10.1001/jama.2018.8359
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Screening for cardiovascular disease risk with electrocardiography. JAMA, 319(22), 2308. doi:10.1001/jama.2018.6848
Goff, D. C., Lloyd-Jones, D. M., Bennett, G., Coady, S., D’Agostino, R. B., Gibbons, R., . . . Wilson, P. W. (2013). 2013 ACC/AHA guideline on the assessment of cardiovascular risk. Circulation, 129(25 suppl 2). doi:10.1161/01.cir.0000437741.48606.98
Lloyd-Jones, D., Braun, L., Ndumele, C., Smith, S., Sperling, L., Virani, S., . . . A., P. (2019, June 01). Use of risk assessment tools to GUIDE decision-making in the primary prevention of ATHEROSCLEROTIC cardiovascular disease: A special report from the American Heart Association and American College of Cardiology. Retrieved February 13, 2021, from https://www.jacc.org/doi/10.1016/j.jacc.2018.11.005
National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. (2020, September 08). Heart disease facts. Heart Disease. Retrieved February 09, 2021, from https://www.cdc.gov/heartdisease/facts.htm
Ross, R., Blair, S. N., Arena, R., Church, T. S., Després, J., Franklin, B. A., . . . Wisløff, U. (2016). Importance of Assessing Cardiorespiratory fitness in clinical Practice: A case for fitness as a CLINICAL Vital Sign: A scientific statement from the American Heart Association. Circulation, 134(24). doi:10.1161/cir.0000000000000461
Studziński, K., Tomasik, T., Krzysztoń, J., Jóźwiak, J., & Windak, A. (2019, January 9). Effect of using cardiovascular risk scoring in routine risk assessment in primary prevention of cardiovascular disease: An overview of systematic reviews. Retrieved February 13, 2021, from https://www.ncbi.nlm.nih.gov/pubmed/30626326
Wilson, P., MD. (2020, May 29). Cardiovascular disease risk assessment for primary prevention in adults: Our approach. Retrieved February 08, 2021, from https://www.uptodate.com/contents/cardiovascular-disease-risk-assessment-for-primary-prevention-in-adults-our-approach?search=cardiovascular+risk+assessment&source=search_result&selectedTitle=1~125&usage_type=default&display_rank=1#H1
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