Management of Individuals with Family History of Premature Cardiovascular Disease According to Canadian Cardiovascular Guidelines
Individuals with a family history of premature cardiovascular disease should receive early screening, risk assessment, and targeted interventions to reduce their elevated risk of cardiovascular events.
Definition of Family History of Premature CVD
- Family history of premature CVD is defined as CVD occurring in a first-degree male relative <55 years of age or a first-degree female relative <65 years of age 1
- The strength of risk increases with younger age of onset, increasing number of affected relatives, and closer genealogical proximity 1
Risk Assessment Considerations
- Family history of premature CVD is an independent risk factor that increases baseline CVD risk by 1.5-2.0 fold, even after adjusting for other risk factors 1
- Almost 75% of individuals with premature coronary heart disease (CHD) have a positive family history, highlighting opportunities for prevention 1
- Canadian Cardiovascular Society guidelines recommend doubling a person's estimated risk when they have a family history of premature ASCVD 1
- Family history modestly improves risk stratification and is most useful for reclassifying individuals at intermediate risk 1
Screening Recommendations
- Adults with a family history of premature CVD should begin lipid screening at age 20 rather than waiting until age 40 2
- Coronary artery calcium scoring (CACS) is considered appropriate for patients with a family history of premature CAD and a low global CAD risk score 1
- Children and adolescents with a family history of early CVD should have their blood pressure measured annually from age 3 and undergo lipid screening if family history is positive 1
Management Strategies
- Intensive risk factor modification should be implemented for individuals with a family history of premature CVD 1, 3
- Despite earlier referral and treatment, individuals with a family history of premature CVD still have excess mortality risk (HR=1.20,95% CI 1.04-1.38), indicating the need for sustained risk reduction efforts 4
- Screening for emerging risk factors may be beneficial, as individuals with family history of premature CHD often have subclinical disease and abnormal risk markers despite low Framingham risk scores 5
Risk Factors to Target
- Low HDL2 cholesterol levels are highly prevalent (72%) in individuals with family history of premature CHD 5
- Triglyceride-rich remnant lipoproteins are present in approximately 49% of patients with family history of premature CHD 5
- First-degree relatives of patients with premature CAD have high prevalence of multiple risk factors, with 76% of men and 50.3% of women having two or more atherosclerosis risk factors 6
Dose-Response Relationship
- Risk of premature CHD increases linearly with the number of affected family members 3
- With ≥2 cardiovascular deaths in a family, the incidence rate ratio for early cardiovascular disease increases to 3.30 (95% CI: 2.77 to 3.94) 7
Common Pitfalls to Avoid
- Relying solely on traditional risk scores, which may underestimate risk in those with family history of premature CVD 5
- Failing to collect comprehensive family history beyond just parental history 3
- Not maintaining sustained risk reduction efforts, as excess risk persists despite earlier referral and treatment 4
- Overlooking the need for screening in younger individuals with family history of premature CVD 2, 5