by Dr Dan Ewald
Lead Clinical Adviser, NCPHN
In the July 2018 Journal of the American Medical Association United States Preventive Services Task Force (USPSTF) “concludes that the current evidence is insufficient to assess the balance of benefits and harms of adding the ABI, hsCRP level, or CAC score to traditional risk assessment for CVD in asymptomatic adults to prevent CVD events”.1 This is after a systematic review of the evidence for any benefit or harm from expanding the traditional cardiovascular disease (CVD) risk assessment based on Framingham data.
The USPSTF reviewed the evidence on using non-traditional risk factors in CVD risk assessment, focusing on the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) level, and coronary artery calcium (CAC) score. The evidence didn’t support using these tests to risk classifying the general population. These three risk markers were chosen as being the most likely candidates to be useful additions to current CVD risk calculators.
The gaps in the evidence included:2
- Lack of evidence for the clinical meaning of an improvement in risk based on the additional markers.
- Treatment based on the new markers has not been shown to change outcomes.
This has triggered significant debate about the value of Coronary Artery Calcium Scores.3 CAC has been shown to be a good predictor of CVD risk, however it only ends up changing the risk classification in few people when used as an add-on to traditional Framingham based risk calculation. Hence it is not supported as a population screening tool. Perhaps it is most useful in those with borderline/unclear risk. If you adhere to the recommendations from the AHA that benefits of primary prevention with statin therapy outweigh harms at an absolute risk estimate of 7.5% in 10 years, then there seems to be a role for CAC being able to show many (41%)4 of these moderate risk patients are actually at low risk based on CAC score. The number needed to treat with primary prevention stating therapy at 7.5% 10 years risk is variously estimated to be 15 for 10 years to 62 for 5 years, which seems very dependent on the statistical approach taken .5, 6
Click here to visit the HealthPathway for Absolute Cardiovascular Disease Risk Assessment (CVRA).
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Username: manchealth
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For further information about HealthPathways email [email protected] or [email protected].
References
1. JAMA. 2018;320(3):272-280. doi:10.1001/jama.2018.8359
2. Editorial.Viewing the Value of Coronary Artery Calcium Testing From Different Perspectives
Tamar S. Polonsky, MD, MSCI; Philip Greenland, MD. JAMA. 2018;320(3):272-280. doi:10.1001/jama.2018.8359
3. Editorial July 17, 2018 USPSTF Recommendations for Assessment of Cardiovascular Risk With Nontraditional Risk FactorsFinding the Right Tests for the Right Patients John T. Wilkins, MD, MS; Donald M. Lloyd-Jones, MD, ScM JAMA. 2018;320(3):242-244. doi:10.1001/jama.2018.9346
4. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis).J Am Coll Cardiol. 2015 Oct 13;66(15):1657-68. doi: 10.1016/j.jacc.2015.07.066.
5. 2013 ACC/AHA Cholesterol Guideline and Implications for Healthy People 2020 Cardiovascular Disease Prevention Goals Brent M. Egan, et.al. J Am Heart Assoc. 2016;5:e003558 doi: 10.1161/JAHA.116.003558
6. Effectiveness of Statins as Primary Prevention in People With Different Cardiovascular Risk: A Population‐Based Cohort Study. Maria Garcia‐Gil, et.al. First published: 01 December 2017
https://doi.org/10.1002/cpt.954. Accessed 18-7-18