Slide 1 - Journal of the American College of Cardiology by pengxiuhui

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									 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 November
15, 2010, available at:
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.
09.001

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                  Frederick G. Kushner, MD, FACC, FAHA†‡‡
George A. Beller, MD, MACC, FAHA                  Michael S. Lauer, MD, FACC, FAHA
Emelia J. Benjamin, MD, ScM, FACC, FAHA*†         Leslee J. Shaw, PhD, FACC, FAHA, FASNC§§
Matthew J. Budoff, MD, FACC, FAHA‡§║              Sidney C. Smith, Jr., MD, FACC, FAHA║║¶¶
Zahi A. Fayad, PhD, FACC, FAHA¶                   Allen J. Taylor, MD, FACC, FAHA##
Elyse Foster, MD, FACC, FAHA#                     William S. Weintraub, MD, FACC, FAHA
Mark A. Hlatky, MD, FACC, FAHA§**                 Nanette K. Wenger, MD, MACC, FAHA
John McB. Hodgson, MD, FACC, FAHA, FSCAI ‡§**††
*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 Repres entative;
‡‡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/efficac y 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
    I IIa IIb III   I IIa IIb III   I IIa IIb III




    I IIa IIb III   I IIa IIb III   I IIa IIb III




    I IIa IIb III   I IIa IIb III   I IIa IIb III




    I IIa IIb III   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)
         Effect on performance of added testing
             • Noninvasive, invasive
             • Post-test referral bias
         Effect on initiation of interventions
             • Lifestyle
             • Pharmacologic
         Effect on outcomes
             • Short-term
             • Long-term
         Effect on individual undergoing testing
             • Financial
             • Emotional
         Cost of test or procedure
            • Financial
            • Test risks
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
 Guideline for Cardiovascular Risk
Assessment in Asymptomatic Adults


 Recommended Approaches to
      Risk Stratification
Recommended Approaches to Risk
        Stratification


 General Approaches to Risk
        Stratification
        Recommendations for General
       Approaches to Risk Stratification

I IIa IIb III   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.
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          Age, sex, total         Age, sex, total-     Age, LDL            Age, HbA1C (with           Age, systolic blood
 considered            cholesterol, HDL        HDL cholesterol      cholesterol, HDL    diabetes), smoking,        pressure, total
                       cholesterol,            ratio, smoking,      cholesterol,        systolic blood pressure,   cholesterol, HDL
                       smoking, systolic       systolic blood       smoking, systolic   total cholesterol, HDL     cholesterol, smoking,
                       blood pressure,         pressure             blood pressure,     cholesterol, hsCRP,        hsCRP, parental history
                       antihypertensive                             family history,     parental history of MI     of MI at <60 y of age
                       Medications                                  diabetes,           at <60 y of age
                                                                    triglycerides
 Endpoints             CHD (MI and             Fatal CHD            Fatal/nonfatal      MI, ischemic stroke,       MI, stroke, coronary
                       CHD death)                                   MI or sudden        coronary                   revascularization,
                                                                    cardiac death       revascularization,         cardiovascular death
                                                                    (CHD and CVD        cardiovascular death       (CHD and CVD
                                                                    combined)           (CHD and CVD               combined)
                                                                                        combined)
 URLs for risk         http://hp2010.nhlbi     http://www.heartsc   http://www.chd-     http://www.reynoldsris     http://www.reynoldsris
 calculators           hin.net/atpiii/calcul   ore.org/pages/welc   taskforce.com/co    kscore.org/                kscore.org/
                       ator.asp?usertype=      ome.aspx             ronary_risk_asse
                       prof                                         ssment.html
         Note: Table 2 in full-text Guideline
Recommended Approaches to Risk
        Stratification


 Family History and Genomics
           Recommendations for Family
           History and Genomic Testing

I IIa IIb III   Family history of atherothrombotic cardiovascular
                disease (CVD) should be obtained for
                cardiovascular risk assessment in all
                asymptomatic adults.

I IIa IIb III
                Genotype testing for CHD risk assessment in
                asymptomatic adults is not recommended.
Recommended Approaches to Risk
        Stratification


Lipoprotein and Apolipoprotein
        Assessments
      Recommendation for Lipoprotein
      and Apolipoprotein Assessments

I IIa IIb III   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.
Recommended Approaches to Risk
        Stratification


   Other Circulating Blood
   Markers and Associated
         Conditions
       Recommendation for Natriuretic
               Peptides

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)
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)
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.
I IIa IIb III   In asymptomatic high-risk adults, measurement
                of CRP is not recommended for cardiovascular
                risk assessment.

I IIa IIb III   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.
    Recommendation for Measurement
         of Hemoglobin A1C

I 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)

I IIa IIb III   In asymptomatic adults with hypertension or
                diabetes, urinalysis to detect microalbuminuria
                is reasonable for cardiovascular risk
                assessment.

I IIa IIb III   In asymptomatic adults at intermediate risk
                without hypertension or diabetes, urinalysis to
                detect microalbuminuria might be reasonable for
                cardiovascular risk assessment.
     Recommendation for Lipoprotein-
       associated Phospholipase A2

I IIa IIb III   Lipoprotein-associated phospholipase A2 (Lp-
                PLA2) might be reasonable for cardiovascular
                risk assessment in intermediate-risk
                asymptomatic adults.
Recommended Approaches to Risk
        Stratification


Cardiac and Vascular Tests for
     Risk Assessment in
    Asymptomatic Adults
          Recommendations for Resting
              Electrocardiogram

I IIa IIb III   A resting electrocardiogram (ECG) is
                reasonable for cardiovascular risk assessment
                in asymptomatic adults with hypertension or
                diabetes.

I IIa IIb III   A resting ECG may be considered for
                cardiovascular risk assessment in
                asymptomatic adults without hypertension or
                diabetes.
    Recommendation for Transthoracic
          Echocardiogram

I IIa IIb III   Echocardiography to detect left ventricular
                hypertrophy may be considered for
                cardiovascular risk assessment in asymptomatic
                adults with hypertension.

I IIa IIb III   Echocardiography is not recommended for
                cardiovascular risk assessment of CHD in
                asymptomatic adults without hypertension.
Recommendation for Measurement of
  Carotid Intima-Media Thickness

I IIa IIb III   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.
      Recommendation for Brachial /
     Peripheral Flow-mediated Dilation

I IIa IIb III   Peripheral arterial flow-mediated dilation studies
                are not recommended for cardiovascular risk
                assessment in asymptomatic adults.
            Recommendation for Specific
            Measures of Arterial Stiffness

I IIa IIb III   Measures of arterial stiffness outside of
                research settings are not recommended for
                cardiovascular risk assessment in asymptomatic
                adults.
Recommendation for Measurement of
      Ankle-Brachial Index

I IIa IIb III   Measurement of ankle-brachial index is
                reasonable for cardiovascular risk
                assessment in asymptomatic adults at
                intermediate risk.
           Recommendation for Exercise
               Electrocardiography

I IIa IIb III   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.
                Recommendation for Stress
                    Echocardiography

I IIa IIb III    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.)
      Recommendations for Myocardial
           Perfusion Imaging
I IIa IIb III   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.

I IIa IIb III   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.)
Recommendations for Calcium Scoring
            Methods
I IIa IIb III   Measurement of CAC is reasonable for
                cardiovascular risk assessment in asymptomatic
                adults at intermediate risk (10% to 20% 10-year
                risk.

I IIa IIb III   Measurement of CAC may be reasonable for
                cardiovascular risk assessment persons at low
                to intermediate risk (6% to 10% 10-year risk).

I IIa IIb III   Persons at low risk (<6% 10-year risk) should
                not undergo CAC measurement for
                cardiovascular risk assessment.
     Recommendation for Coronary
   Computed Tomography Angiography

I IIa IIb III   Coronary computed tomography angiography is
                not recommended for cardiovascular risk
                assessment in asymptomatic adults.
         Recommendation for Magnetic
         Resonance Imaging of Plaque

I IIa IIb III   Magnetic resonance imaging for detection of
                vascular plaque is not recommended for
                cardiovascular risk assessment in asymptomatic
                adults.
Recommended Approaches to Risk
        Stratification


  Special Circumstances and
    Other Considerations
   Risk Assessment Considerations for
     Patients with Diabetes Mellitus
I IIa IIb III   In asymptomatic adults with diabetes, 40 years of
                age and older, measurement of CAC is reasonable
                for cardiovascular risk assessment.

I IIa IIb III   Measurement of hemoglobin A1C may be considered
                for cardiovascular risk assessment in asymptomatic
                adults with diabetes.

I IIa IIb III   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.
   Risk Assessment Considerations for
               Women
 There is frequent reporting of underutilization of diagnostic and
 preventive services among female patients. Therefore, it is
 recommended that:

I IIa IIb III   A global risk score should be obtained in all
                asymptomatic women.

I IIa IIb III   Family history of CVD should be obtained for
                cardiovascular risk assessment in all
                asymptomatic women.
 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 (continued)
                 - 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

								
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