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July 17, 2018

Risk Assessment for Cardiovascular Disease With Nontraditional Risk Factors

JAMA. 2018;320(3):316. doi:10.1001/jama.2018.9122

The US Preventive Services Task Force (USPSTF) recently published recommendations on risk assessment for cardiovascular disease using nontraditional risk factors.

What Is Cardiovascular Disease?

Cardiovascular disease (CVD) refers to the buildup of plaque, which can cause blockages inside important blood vessels in the body. These blood vessels can include the arteries of the heart (coronary heart disease), brain (cerebrovascular disease), or legs (peripheral arterial disease). Cardiovascular disease can cause heart attacks, strokes, and death. Coronary heart disease is the leading cause of death in the United States.

Traditional risk factors for CVD include older age, smoking, high blood pressure, being overweight or obese, diabetes, high cholesterol, and a family history of heart disease. In general, people with a higher risk of CVD benefit more from screening and treatment. Based on these traditional risk factors, several risk assessment tools are available to help doctors decide who should be screened. Examples include the Framingham Risk Score and the Pooled Cohort Equations. However, doctors are always looking to improve on their assessment of CVD risk by adding more risk factors to the picture.

What Are Nontraditional Risk Factors for CVD?

Examples of other “nontraditional” risk factors that are sometimes used for risk assessment include the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) level, and the coronary artery calcium (CAC) score. The ABI is calculated by comparing blood pressure values measured at the ankle and the arm (brachial artery). High-sensitivity CRP is a protein involved in inflammation that is measured by its level in a person’s blood. The CAC score measures the amount of calcium in the blood vessels of the heart based on a computed tomographic scan of the chest.

What Is the Patient Population Under Consideration for Using Nontraditional Risk Factors to Assess CVD Risk?

This USPSTF recommendation applies to adults who do not have any symptoms of or a diagnosis of CVD.

What Are the Potential Benefits and Harms of Using Nontraditional Risk Factors to Assess CVD Risk?

The potential benefit of adding nontraditional risk factors to risk assessment tools that use traditional risk factors is more accurate risk assessment, which would ultimately lead to better prevention of heart attacks, strokes, and death in people who have no symptoms of CVD. There is some evidence that adding the 3 nontraditional risk factors described above may improve the accuracy of risk assessment in certain groups of people. However, based on current evidence, it is unclear whether this ultimately prevents CVD events such as heart attacks, strokes, and death. The main potential harm is the low-dose radiation exposure necessary to obtain the CAC score. Other potential harms include unnecessary diagnostic testing for CVD, which can be invasive, as well as unnecessary lifelong treatment with medications for CVD.

How Strong Is the Recommendation to Use Nontraditional Risk Factors to Assess CVD Risk?

Based on current evidence, it is unclear whether the potential benefits of adding ABI, hsCRP, or CAC score measurement in risk assessment for CVD in people with no symptoms outweighs the potential harms.

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Article Information

Source: US Preventive Services Task Force. Risk assessment for cardiovascular disease with nontraditional risk factors: US Preventive Services Task Force recommendation statement [published online July 10, 2018]. JAMA. doi:10.1001/jama.2018.8359