2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance

Citation This slide set was adapted from the 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults (Journal of the American College of Cardiology). Published ahead of print on XXX, 2010, available at: http://XXX.com The full-text guidelines are also available on the following Web sites: ACC (www.cardiosource.org) and, AHA (www.americanheart.org)

Special Thanks To Slide Set Editors Nanette K. Wenger, MD and Philip Greenland, MD The Guideline for CV Risk Assessment in Asymptomatic Adults Writing Committee Members Philip Greenland, MD, FACC, FAHA, Chair Joseph S. Alpert, MD, FACC, FAHA George A. Beller, MD, MACC, FAHA Emelia J. Benjamin, MD, ScM, FACC, FAHA*† Matthew J. Budoff, MD, FACC, FAHA‡§║ Zahi A. Fayad, PhD, FACC, FAHA¶ Elyse Foster, MD, FACC, FAHA# Mark A. Hlatky, MD, FACC, FAHA§** John McB. Hodgson, MD, FACC, FAHA, FSCAI‡§**†† Frederick G. Kushner, MD, FACC, FAHA†‡‡ Michael S. Lauer, MD, FACC, FAHA Leslee J. Shaw, PhD, FACC, FAHA§§ Sidney C. Smith, Jr., MD, FACC, FAHA║║¶¶ Allen J. Taylor, MD, FACC, FAHA## William S. Weintraub, MD, FACC, FAHA Nanette K. Wenger, MD, MACC, FAHA *ACCF/AHA Task Force on Performance Measures Liaison; †Recused from Section 2.4.5., Lipoprotein-Associated Phospholipase A2; ‡ Recused from Section 2.5.11., Coronary Computed Tomography Angiography; §Recused from Section 2.6.1., Diabetes Mellitus; ║SAIP Representative; ¶SCMR Representative; #ASE Representative; **Recused from Section 2.5.10., Computed Tomography for Coronary Calcium; †† SCAI Representative; ‡‡Recused from Section 2.3., Lipoprotein and Apolipoprotein Assessments; §§ASNC Representative; ║║ACCF/AHA Task Force on Practice Guidelines Liaison; ¶¶Recused from Section 2.4.2., Recommendations for Measurement of C-Reactive Protein; ##SCCT Representative.

Classification of Recommendations and Levels of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

Icons representing the Classification and Evidence Levels for Recommendations IIa IIb III B I IIa IIb III I IIa IIb III I IIa IIb III A B I IIa IIb III I IIa IIb III I IIa IIb III A B I IIa IIb III I IIa IIb III I IIa IIb III A B I IIa IIb III I IIa IIb III

Key Considerations when Testing for CV Risk Efficacy of test procedure in assignment of risk status Short-term risk Long-term risk Independent statistical association with risk beyond traditional readily available inexpensive risk markers Incremental predictive value of test Effect on reclassification of risk compared to traditional risk factors alone Accuracy and reproducibility of test Requirement for serial testing, which may be indicated to assess risk accurately for some tests 2010 ACCF/AHA Guideline, JACC 55:e27, 2010

Key Considerations when Testing for CV Risk (continued) Cost of test or procedure Financial Test risks Effect on performance of added testing Noninvasive, invasive Post-test referral bias Effect on initiation of interventions Lifestyle Pharmacologic Effect on individual undergoing testing Emotional Effect on outcomes Short-term Long-term

Opportunity for Early Preventive Interventions Long asymptomatic latent period of Coronary Heart Disease (CHD) Half of all cardiovascular sudden death not preceded by cardiac symptoms, diagnoses High prevalence of atherosclerotic risk factors in US population Methodology available to evaluate prognostic value of risk factors, risk markers Target intensity of intervention to severity of risk Lower the high burden of coronary death in asymptomatic adults

Recommended Approaches to Risk Stratification Guideline for Cardiovascular Risk Assessment in Asymptomatic Adults Recommended Approaches to Risk Stratification

General Approaches to Risk Stratification Recommended Approaches to Risk Stratification General Approaches to Risk Stratification

Recommendations for General Approaches to Risk Stratification Global risk scores (such as the Framingham Risk Score [FRS]) 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 target preventive interventions. B I IIa IIb III

Comparison of a Sample of Global Coronary and Cardiovascular Risk Scores Framingham SCORE PROCAM (Men) Reynolds (Women) Reynolds (Men) Sample size 5345 205,178 5389 24,558 10,724 Age, range (y) 30 to 74; M:49 19 to 80; M:46 35 to 65; M:47 >45; M:52 >50; M:63 Mean follow-up (y) 12 13 10 10.2 10.8 Risk factors considered Age, sex, total cholesterol, HDL cholesterol, smoking, systolic blood pressure, antihypertensive Medications Age, sex, total- HDL cholesterol ratio, smoking, systolic blood pressure Age, LDL family history, diabetes, triglycerides Age, HbA1C (with diabetes), smoking, systolic blood pressure, total cholesterol, HDL cholesterol, hsCRP, parental history of MI at <60 y of age Age, systolic blood pressure, total cholesterol, smoking, hsCRP, parental history of MI at <60 y of age Endpoints CHD (MI and CHD death) Fatal CHD Fatal/nonfatal MI or sudden cardiac death (CHD and CVD combined) MI, ischemic stroke, coronary revascularization, cardiovascular death MI, stroke, coronary URLs for risk calculators http://hp2010.nhlbi hin.net/atpiii/calcul ator.asp?usertype= prof  http://www.heartsc ore.org/pages/welc ome.aspx  http://www.chd- taskforce.com/co ronary_risk_asse ssment.html http://www.reynoldsris kscore.org/    Note: Table 2 in full-text Guideline

Family History and Genomics Recommended Approaches to Risk Stratification Family History and Genomics

Recommendations for Family History and Genomic Testing Family history of atherothrombotic cardiovascular disease (CVD) should be obtained for cardiovascular risk assessment in all asymptomatic adults. Genotype testing for CHD risk assessment in asymptomatic adults is not recommended. B I IIa IIb III B I IIa IIb III

Lipoprotein and Apolipoprotein Assessments Recommended Approaches to Risk Stratification Lipoprotein and Apolipoprotein Assessments

Recommendation for Lipoprotein and Apolipoprotein Assessments Measurement of lipid parameters, including lipoproteins, apolipoproteins, particle size, and density, beyond a standard fasting lipid profile is not recommended for cardiovascular risk assessment in asymptomatic adults. I IIa IIb III

Other Circulating Blood Markers and Associated Conditions Recommended Approaches to Risk Stratification Other Circulating Blood Markers and Associated Conditions

Recommendation for Natriuretic Peptides B I IIa IIb III Measurement of natriuretic peptides is not recommended for CHD risk assessment in asymptomatic adults.

Recommendations for Measurement of C-Reactive Protein (CRP) B I IIa IIb III In men 50 years of age or older or women 60 years of age or older with LDL 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.

Recommendations for Measurement of C-Reactive Protein (continued) B I IIa IIb III 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. In asymptomatic high-risk adults, measurement of CRP is not recommended for cardiovascular risk assessment. 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. B I IIa IIb III B I IIa IIb III

Recommendation for Measurement of Hemoglobin A1C IIa IIb III Measurement of hemoglobin A1C (HbA1C) may be reasonable for cardiovascular risk assessment in asymptomatic adults without a diagnosis of diabetes.

Recommendations on testing for Microalbuminuria (Urinary Albumin Excretion) In asymptomatic adults with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk assessment. In asymptomatic adults at intermediate risk without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment. B I IIa IIb III B I IIa IIb III

Recommendation for Lipoprotein-associated Phospholipase A2 Lipoprotein-associated phospholipase A2 (Lp-PLA2) might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults. B I IIa IIb III

Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults Recommended Approaches to Risk Stratification Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults

Recommendations for Resting Electrocardiogram A resting electrocardiogram (ECG) is reasonable for cardiovascular risk assessment in asymptomatic adults with hypertension or diabetes. A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or I IIa IIb III I IIa IIb III

Recommendation for Transthoracic Echocardiogram Echocardiography to detect left ventricular hypertrophy may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension. Echocardiography is not recommended for cardiovascular risk assessment of CHD in asymptomatic adults without hypertension. B I IIa IIb III I IIa IIb III

Recommendation for Measurement of Carotid Intima-Media Thickness 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. B I IIa IIb III

Recommendation for Brachial / Peripheral Flow-mediated Dilation Peripheral arterial flow-mediated dilation studies are not recommended for cardiovascular risk assessment in asymptomatic adults. B I IIa IIb III

Recommendation for Specific Measures of Arterial Stiffness Measures of arterial stiffness outside of research settings are not recommended for cardiovascular risk assessment in asymptomatic adults. I IIa IIb III

Recommendation for Measurement of Ankle-Brachial Index IIa IIb III Measurement of ankle-brachial index is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk.

Recommendation for Exercise Electrocardiography 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. B I IIa IIb III

Recommendation for Stress Echocardiography Stress echocardiography is not indicated for 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 subjects with valvular heart disease.) I IIa IIb III

Recommendations for Myocardial Perfusion Imaging Stress 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 high risk of CHD, such as a coronary artery calcium (CAC) score of 400 or greater. Stress MPI is not indicated for cardiovascular risk 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.) I IIa IIb III I IIa IIb III

Recommendations for Calcium Scoring Methods Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk. Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year risk). Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment. B I IIa IIb III B I IIa IIb III B I IIa IIb III

Recommendation for Coronary Computed Tomography Angiography Coronary computed tomography angiography is not recommended for cardiovascular risk assessment in asymptomatic adults. I IIa IIb III

Recommendation for Magnetic Resonance Imaging of Plaque Magnetic resonance imaging for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. I IIa IIb III

Special Circumstances and Other Considerations Recommended Approaches to Risk Stratification Special Circumstances and Other Considerations

Risk Assessment Considerations for Patients with Diabetes Mellitus In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment. Measurement of hemoglobin A1C may be considered for cardiovascular risk assessment in asymptomatic adults with diabetes. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests high risk of CHD, such as a CAC score of 400 or greater. B I IIa IIb III B I IIa IIb III I IIa IIb III

Risk Assessment Considerations for Women There is frequent reporting of underutilization of diagnostic and preventive services among female patients. Therefore, it is recommended that: B I IIa IIb III A global risk score should be obtained in all asymptomatic women. Family history of CVD should be obtained for cardiovascular risk assessment in all asymptomatic women. B I IIa IIb III

Guideline for Cardiovascular Risk Assessment in Asymptomatic Adults Summary of Tests Not Recommended for Assessing CV Risk in Asymptomatic Adults

Procedural Tests Not Recommended for Asymptomatic Adults ~ Non-cardiac tests ~ Genotype testing (III B) Lipid parameters including lipoproteins, apolipoproteins, particle size and density assessments beyond standard fasting lipid profile (III C) Natriuretic peptide measurement (III B) C-Reactive Protein measurement in asymptomatic high-risk adults (III B) CRP in low-risk men younger than 50 years of age or women 60 years of age (III B)

Procedural Tests Not Recommended for Asymptomatic Adults (cont Procedural Tests Not Recommended for Asymptomatic Adults (cont.) ~ Cardiac or Vascular tests ~ Transthoracic echocardiogram for asymptomatic adults without hypertension (III C) Brachial/peripheral arterial flow mediated dilation studies (III B) Measures of arterial stiffness outside of research settings (III C) Stress echocardiography in low- or intermediate-risk adults (III C) Stress myocardial perfusion imaging in low- or intermediate-risk adults (III C) Coronary artery calcium scoring in low risk adults (<6% 10 year risk) (III B) Coronary computed tomography angiography (CCTA) (III C) Detection of coronary artery plaque by magnetic resonance imaging (III C)

Limited Data Role of novel biomarkers/imaging studies in risk assessment of selected populations – asymptomatic adults Selected populations Women Older adults Racial and ethnic minorities Diabetes Chronic kidney disease Geographic, environmental, neighborhood risk

Unmet Needs Ascertainment among tests of value Whether test/procedure useful to motivate patients to adhere to recommended interventions Whether test/procedure useful to guide therapy Whether test/procedure useful as a repeat measure to monitor effects of therapy Whether test/procedure of value in improving health outcomes

Risk Assessment: Clinical Implications Designed to aid clinician in informed decision-making about lifestyle and pharmacologic interventions to reduce CV risk Patients broadly characterized into low-, intermediate- and high-risk subsets Intensity, type of treatments based on assessments of risk

Risk Assessment: Clinical Implications (continued) Initial step: Ascertainment of global risk score and family history of atherosclerotic CV disease Class I recommendations Simple, inexpensive If a patient is low-risk – no further testing is necessary If a patient is high-risk (CHD, CHD risk equivalents) – he/she is candidate for intensive preventive interventions – no incremental benefit added testing If a patient is intermediate-risk – additional testing can further define risk status IIa - benefit exceeds cost and risk IIb - less robust evidence for benefit, but shown to be helpful in selected patients III - not recommended for use; has no or limited evidence of benefit, or can cause harm