How do you risk stratify patients with suspected cardiovascular disease?

Risk Stratification for Patients with Suspected Cardiovascular Disease

Risk stratification for patients with suspected cardiovascular disease should incorporate all available information, including clinical variables, noninvasive and invasive testing results, and validated risk scores to classify patients as low (<1%), intermediate (1-3%), or high (>3%) yearly risk for cardiovascular death or nonfatal MI. 1

Clinical Risk Assessment

Initial Risk Stratification

• Demographic factors: Advanced age (>70 years), male sex, family history of premature CVD (first-degree male relatives <55 years, females <65 years) 1
• Medical history: Prior MI, prior revascularization, diabetes mellitus, hypertension, hyperlipidemia, smoking status 1
• Symptom characteristics: Nature, frequency, severity, and triggers of chest pain
• Physical examination findings: Signs of heart failure, abnormal heart sounds, vascular disease

Risk Scoring Systems

• Use validated risk prediction models:
  • Framingham Risk Score
  • SCORE (Systematic Coronary Risk Evaluation) for asymptomatic adults >40 years 1
  • Duke Treadmill Score for patients undergoing exercise testing 1
  • TIMI, PURSUIT, or GRACE scores for patients with acute coronary syndromes 1

Diagnostic Testing Strategy

For Low-Risk Patients (Annual risk <1%)

• Consider deferring testing in minimal-risk patients 2
• Exercise ECG if patient can exercise adequately and ECG is interpretable 1
• Coronary calcium scoring can help reclassify risk 1

For Intermediate-Risk Patients (Annual risk 1-3%)

• Non-invasive functional imaging:
  • Stress echocardiography
  • SPECT myocardial perfusion imaging
  • Stress cardiac MRI
  • PET myocardial perfusion imaging 1
• Anatomical imaging:
  • Coronary CTA (preferred in patients with lower calcium scores) 1, 3

For High-Risk Patients (Annual risk >3%)

• Invasive coronary angiography with invasive physiological guidance (FFR/iwFR) 1
• Especially indicated for:
  • Patients with high-risk clinical profiles
  • Symptoms refractory to medical therapy
  • Reduced LV function or heart failure
  • Noninvasive testing suggesting significant left main disease 1

Specific Risk Stratification Findings

High-Risk Indicators

• Left ventricular ejection fraction <35% 1
• Extensive ischemia on functional testing
• High coronary calcium score (>900) 3
• High-risk plaque features on CCTA (positive remodeling, low attenuation, napkin-ring sign) 1
• Reduced myocardial blood flow reserve (<2) on PET 1
• Multiple clinical risk factors (≥3) with positive stress test 4, 5

Intermediate-Risk Indicators

• Moderate ischemia on functional testing
• Moderate coronary calcium score
• 1-2 clinical risk factors with positive stress test 4, 5

Low-Risk Indicators

• Normal functional testing
• Low coronary calcium score
• No clinical risk factors 4, 5

Important Considerations

• Noninvasive test results alone are insufficient for adequate risk stratification; integration with clinical variables significantly improves risk prediction 1
• The reliability of non-invasive testing decreases with higher calcium scores (≥100) 3
• Routine invasive coronary angiography for risk stratification alone is not recommended in stable patients without specific high-risk features 1
• Risk stratification should be repeated when patients develop new or worsening symptoms 1

Pitfalls to Avoid

• Do not rely solely on a single test result for risk stratification; integrate all available information 1
• Do not perform invasive coronary angiography solely for risk stratification without appropriate clinical indications 1
• Do not assume normal stress test results exclude significant CAD in patients with high calcium scores or multiple risk factors 3
• Do not use carotid ultrasound IMT for cardiovascular risk assessment as it is not recommended 1
• Do not routinely assess circulating biomarkers for cardiovascular risk stratification in stable patients 1

Risk stratification is dynamic and should be reassessed periodically, especially when symptoms change or worsen, to guide appropriate management strategies that improve morbidity, mortality, and quality of life outcomes.