“There’s strong evidence that the basic risk assessment we’ve been advocating for years has a very, very strong ability to predict risk,” Dr. Philip Greenland of Northwestern University, Chicago, said in a press statement. “When new tests compete for attention we have to ask, ‘Do they add any new information?’”
In their preamble to the 54-page document published in the December 14/21 issue of the Journal of the Americal College of Cardiology, Dr. Greenland, the Chair of the writing committee, and his colleagues state: “The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions.”
However, they add, “The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate.”
That said, the panel goes on to recommend that global risk scores using multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of coronary heart disease. The document compares a sample of some scores, such as Framingham, SCORE and PROCAM, and provides information on risk calculators.
While family history is an important component of risk, the panel states, “Genotype testing for CHD risk assessment in asymptomatic adults is not recommended.” Furthermore, for this population, measurement of lipoproteins parameters beyond a standard lipid profile is not necessary.
Other tests deemed to have no value for asymptomatic adults include coronary CT angiography, magnetic resonance imaging for detection of vascular plaque, stress echocardiography and flow-mediated dilation.
The value of measuring C-reactive protein is less cut-and dried. For example, it maybe useful in deciding on the need for statin therapy in older patients but is not recommended for younger low-risk subjects.
For asymptomatic patients with hypertension or diabetes, or those at intermediated risk without these conditions, urinalysis for microalbuminuria is reasonable for assessing cardiovascular risk, the experts advise.
Other tests that may provide useful information — usually in patients at intermediate risk — include coronary artery calcium scoring, resting ECG, ankle-brachial index, carotid intima-media thickness and conventional echocardiography.
“There are a lot of tests out there and a lot of claims that these tests are valuable for risk assessment,” Dr. Greenland said. “This guideline puts it all in perspective.”
J Am Coll Cardiol 2010;56.