Cardiovascular%20disease%20prevention Diagnosis

Diagnosis

Evaluation

Atherosclerotic cardiovascular disease (ASCVD) risk assessment is essential for primary prevention
- CVD includes coronary heart disease (CHD), heart failure, peripheral artery disease (PAD) and stroke
For patients 20-39 years old, traditional ASCVD risk factors may be assessed at least every 4-6 years
Patients ≥40 years old should be evaluated for the absolute risk of CVD at every routine physician visit
Patients 20-39 years old and those between 40-59 years old with low 10-year ASCVD risk (<7.5%) may be assessed for long-term/lifetime risk

Coronary Risk Charts for Determination of CVD Risk

Age, gender, smoking status, diabetes mellitus (DM), blood pressure (BP), and lipid levels are used to determine the CVD risk
Overall CVD risk is more important than the presence or absence of specific risk factors
Risk assessment tools that may be used to estimate CVD risk for patients who have not experienced symptomatic CVD or other atherosclerotic diseases include Framingham Risk Assessment Tool, Multi-Ethnic Study of Atherosclerosis (MESA) 10-year ASCVD risk with coronary artery calcification calculator, Systematic Coronary Risk Estimation (SCORE), Reynold’s Risk Score, and United Kingdom Prospective Diabetes Study (UKPDS) risk engine in individuals with type 2 DM
After estimating the 10-year fatal and non-fatal CVD risk in apparently healthy individuals, the following should be considered: Risk modifiers (ethnicity, family history, genetics, frailty, body composition, psychosocial factors, socioeconomic determinants, environmental factors, blood or urine biomarkers, imaging findings), lifetime risk and treatment benefit, polypharmacy and patient preferences

Risk Stratification

Major Risk Factors

Age (men ≥45 years; women ≥55 years)
Cigarette smoking
Apolipoprotein-B-containing lipoproteins (most abundant of which is LDL)
- Primary hypercholesterolemia (LDL-C 160-189 mg/dL [4.1-4.8 mmol/L]; non-HDL-C 190-219 mg/dL [4.9-5.6 mmol/L])
Increased serum total cholesterol level
Chronic kidney disease (CKD)
Diabetes mellitus
- For individuals with high HDL-C (>60 mg/dL), subtract 1 risk factor from the total
- History of gestational diabetes in women
Hypertension (elevated BP or on antihypertensive medication)
- History of preeclampsia or pregnancy-induced hypertension in women
Metabolic syndrome
Family history of premature ASCVD (male 1st-degree relative <55 years; female 1st-degree relative <65 years)

Additional Risk Factors

Dyslipidemic triad (hypertriglyceridemia; low HDL-C; and an excess of small, dense LDL-C)
Fasting/postprandial hypertriglyceridemia
Family history of hyperlipidemia
Obesity, abdominal obesity
Elevated apo B
Elevated LDL particle number
Elevated small dense LDL-C
Polycystic ovarian syndrome (PCOS) in women
History of premature menopause
South Asian ancestry

Nontraditional Risk Factors

Elevated lipoprotein (a)
Elevated clotting factors
Elevated inflammation markers, eg high-sensitivity C-reactive protein (CRP)
Chronic inflammatory conditions, eg HIV, psoriasis, rheumatoid arthritis
Elevated triglyceride (TG)-rich remnants
Elevated homocysteine levels
Apo E4 isoform
Elevated uric acid
Ankle-brachial index <0.9

Patients with the following conditions are considered CHD risk equivalents:

Type 2 DM
- There was insufficient evidence to support type 1 DM as a CHD risk equivalent, although type 1 DM with proteinuria may increase the risk for ischemic cardiovascular disease
Patients with other forms of symptomatic atherosclerotic disease, such as PAD, abdominal aortic aneurysm (AAA), and symptomatic carotid artery disease
Large-vessel atherosclerotic ischemic stroke
Framingham Heart Score risk ≥20%

Note that CVD risk may be higher than indicated in the coronary risk chart in the following:

Patients approaching the next age, BP or cholesterol category
Sedentary or obese patients
Those with family history of premature CHD or stroke in a 1st-degree relative (male <55 years; female <65 years)
Patients with low HDL-C or high TG
Patients with DM or impaired glucose tolerance
Those already on antihypertensive therapy
Patients with evidence of preclinical atherosclerosis

CARDIOVASCULAR DISEASE RISK CATEGORIES
Risk Category	ACC/AHA 2019	CCS 2021	ESC 2021
Risk Category	10-Year ASCVD Risk¹	FRS²	Apparently Healthy Individuals³	Patients with Risk Factors
Very High Risk	Not applicable	Not applicable	• <50 years: ≥7.5% • 50-69 years: ≥10% • ≥70 years: ≥15%	• Documented clinical ASCVD (eg previous acute myocardial infarction, acute coronary syndrome, coronary revascularization and other arterial revascularization procedures, TIA and stroke, aortic aneurysm and PAD) or unequivocally documented ASCVD finding (eg significant plaque) on imaging that does not include some increase in continuous imaging parameters (eg intima-media thickness of the carotid artery) • T2DM with established ASCVD and/or severe target organ damage (TOD)⁴ • Without diabetes or ASCVD but with severe CKD (eGFR <30 mL/min/1.73 m²) or eGFR 30-44 mL/min/1.73 m² and albumin-to-creatinine ratio (ACR) >30
High Risk	≥20%	≥20%	• <50 years: 2.5-<7.5% • 50-69 years: 5-<10% • ≥70 years: 7.5-<15%	• T2DM without ASCVD and/or severe TOD with moderate risk criteria not met⁴ • Without diabetes or ASCVD but with moderate CKD (eGFR 30-44 mL/min/1.73 m²) and ACR <30 or eGFR 45-59 mL/min/1.73 m² and ACR 30-300 or eGFR ≥60 mL/min/1.73 m² and ACR >300 • Familial hypercholesterolemia associated with markedly increased levels of cholesterol
Moderate Risk	Not applicable	Not applicable	• <50 years: <2.5% • 50-69 years: <5% • ≥70 years: <7.5%	• Patients with <10 years of well-controlled T2DM without TOD or other ASCVD risk factors⁴
Intermediate Risk	7.5% to <20%	10 to 19.9%	Not applicable
Borderline Risk	5% to <7.5%	Not applicable	Not applicable
Low Risk	<5%	<10%	• <50 years: <2.5% • 50-69 years: <5% • ≥70 years: <7.5%
T2DM = Type 2 Diabetes Mellitus ¹ASCVD risk estimator (http://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calculate/estimator/) estimates the 10-year ASCVD risk for asymptomatic individuals 40-75 years old. ²Based on the Framingham Risk Score (FRS) screening every 5 years for ages 40-75 years. ³Based on SCORE2 and SCORE2-Older Persons (SCORE2-OP) SCORE2 estimates the 10-year risk of fatal and non-fatal CVD events (eg stroke, MI) in apparently healthy individuals 40-69 years old with risk factors that are not treated or have been stable for several years; can be accessed in the ESC CVD Risk Calculation app. SCORE2-OP estimates the 5- and 10-year fatal and non-fatal CVD events (eg stroke, MI) adjusted for competing risks in apparently healthy individuals ≥70 years old. ⁴Patients >40 years old with type 1 DM may also be classified according to these criteria. References: Arnett DK, Blumenthal RS, Albert MA, et al. 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. Circulation. 2019. Pearson GJ, Thanassoulis G, Anderson TJ, et al. 2021 Canadian Cardiovascular Society (CCS) Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol. 2021. Visseren FLJ, Mach F, Smulders YM, et al; ESC National Cardiac Societies, ESC Scientific Document Group. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021.

History

Conventional risk factors include age, smoking, sedentary lifestyle, unhealthy diet (eg salt and fat intake), overweight/obesity, hypertension, DM, hypercholesterolemia or combination of clinical entities like metabolic syndrome
Current symptoms of atherosclerosis (eg angina, intermittent claudication, myocardial infarction [MI], TIA, or stroke)
Personal history of polycystic ovary syndrome, gout, chronic inflammatory conditions, sexual dysfunction, kidney disease, periodontitis
Use of drugs known to raise BP (eg oral contraceptives, NSAIDs, licorice, cocaine, amphetamine, Erythropoietin, Ciclosporin, and steroids)
Family history of high BP, DM, dyslipidemia, CHD, stroke, renal disease and premature CVD
- Risk of chronic heart disease increases as number of family members with chronic heart disease increases and the younger the age at which family members develop the disease (<55 years of age in 1st-degree male relatives or female relatives <65 years old)
Personal, psychosocial, occupational and environmental factors that can influence long-term care (eg depression, anxiety, type D personality, lack of social support, social isolation, and stressful conditions at work)
Alcohol consumption

Physical Examination

BP, pulse rate, ankle-brachial index
Height, weight, waist circumference
- Calculate body mass index (BMI) by dividing patient’s weight (kg) by the square of the height (m²)
Comprehensive physical examination
- CV: Heart size, apex beat displacement, signs of heart failure, disease in the carotid, renal and peripheral arteries, coarctation of aorta
- Lungs: Signs of congestion or lung disease
- Abdomen: Bruits, enlarged kidneys, liver and other masses
- Eyes: Optic fundi
- Central Nervous System (CNS): Evidence of CVD and complications of diabetes (ie neuropathy)
Examination for features of secondary hypertension (pheochromocytoma, Cushing’s syndrome)

Diagnostic Tests

May include a complete blood count (CBC), fasting blood glucose and/or HbA1c, serum lipids (total cholesterol [TC], low density lipoprotein-cholesterol [LDL-C], high density lipoprotein-cholesterol [HDL-C] and triglycerides [TG]), sodium, potassium, uric acid, creatinine and estimated glomerular filtration rate (eGFR), liver function tests (LFTs), urinalysis, 12-lead ECG
A chest X-ray may help in the detection of cardiomegaly and early pulmonary findings of heart failure

The following should be performed based on patient’s risk for dyslipidemia and diabetes (at least every 5 years or more frequent if risk factors are present)

Fasting serum lipoprotein profile
- If patient has not fasted prior to lipid profile: TC and HDL-C can still be measured
Fasting blood glucose
High-sensitivity C-reactive protein may be considered in intermediate- to high-risk patients with LDL-C levels of <130 mg/dL that needs further stratification
The following are not recommended for routine use but may be considered in select patients: Homocysteine level and lipoprotein (a) level, DNA-based tests, any serological or urinary biomarkers

Imaging

Coronary artery calcification (CAC) measurement and carotid intima-media thickness (CIMT) test may help in choosing best treatment strategy for patients
- CAC scoring is the best imaging modality to improve stratification of CVD risk
Echocardiography may be performed in patients with breathlessness or hypertension
Exercise stress testing may be considered in the CV assessment of an asymptomatic individual with an interpretable resting ECG, a high CAD pre-test likelihood, and an intermediate to high CV risk

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