How can we estimate and manage the cardiovascular risk of a patient with potentially elevated risk factors?

Cardiovascular Risk Assessment and Management Based on CT Results

Cardiovascular risk assessment should be performed using validated risk prediction models like SCORE2 (for ages 40-69) or SCORE2-OP (for ages ≥70), along with evaluation of risk modifiers and additional testing when appropriate. 1

Risk Assessment Framework

Primary Risk Assessment Tools

• Use SCORE2 for individuals aged 40-69 years and SCORE2-OP for individuals aged ≥70 years to predict 10-year risk of fatal and non-fatal cardiovascular disease (CVD) events 1
• Patients with a 10-year CVD risk ≥10% are considered at high risk and should receive BP-lowering treatment 1, 2
• For patients with type 2 diabetes and elevated blood pressure (BP), consider SCORE2-Diabetes to identify lower-risk individuals (<10% 10-year CVD risk), particularly in those <60 years 1

High-Risk Conditions (Automatically Consider High Risk)

• Moderate or severe chronic kidney disease 1
• Established CVD (coronary heart disease, cerebrovascular disease, peripheral arterial disease, heart failure) 1, 2
• Hypertension-mediated organ damage (HMOD) 1
• Diabetes mellitus (with some exceptions for younger patients) 1
• Familial hypercholesterolaemia 1

Risk Modifiers to Consider

• Sex-specific risk modifiers (for women): history of pregnancy complications (gestational diabetes, gestational hypertension, pre-term delivery, pre-eclampsia, stillbirths, recurrent miscarriage) 1
• Shared risk modifiers: high-risk ethnicity (e.g., South Asian), family history of premature atherosclerotic CVD, socioeconomic deprivation, autoimmune inflammatory disorders, HIV, severe mental illness 1, 2
• These risk modifiers should be used to "up-classify" individuals with borderline increased 10-year CVD risk (5% to <10%) 1

Advanced Risk Assessment for Borderline Cases

If risk assessment remains uncertain after evaluating traditional risk factors and modifiers, consider additional testing:

• Coronary artery calcium (CAC) score 1, 2, 3
• Carotid or femoral plaque assessment using ultrasound 1
• Biomarkers: high-sensitivity cardiac troponin or B-type natriuretic peptide 1
• Arterial stiffness using pulse wave velocity 1

These additional tests may help reclassify patients with borderline increased risk (5-10%) 1, 3

Management Based on Risk Assessment

For Confirmed Hypertension (≥140/90 mmHg)

• Immediately initiate both lifestyle interventions and pharmacological therapy regardless of CVD risk 1, 2
• Target systolic BP of 120-129 mmHg if tolerated 1, 2

For Elevated BP (120-139/70-89 mmHg)

• If high CVD risk (≥10%): Start with lifestyle interventions for 3 months, then add pharmacological therapy if BP remains ≥130/80 mmHg 1, 2
• If not at high risk (<10%): Continue lifestyle interventions and monitor 1

Lipid Management

• For high-risk individuals: Target total cholesterol <4.5 mmol/L (175 mg/dL) and LDL cholesterol <2.5 mmol/L (100 mg/dL) 1, 2
• Consider statin therapy for all high-risk patients 1, 2, 4

Common Pitfalls in Risk Assessment

• Relying solely on individual risk factors rather than using validated risk prediction models 3, 5
• Failing to consider risk modifiers that may significantly impact overall risk 1, 3
• Not communicating risk effectively to patients (percentages or frequencies with graphical representation are most effective) 6
• Delaying pharmacological therapy when indicated in high-risk patients 2
• Not recognizing that hypertension clusters with other metabolic risk factors (dyslipidemia, insulin resistance, glucose intolerance, obesity) 7

Implementation Strategy

1. Calculate 10-year CVD risk using SCORE2 or SCORE2-OP 1
2. Identify presence of high-risk conditions that automatically place patient at high risk 1
3. Consider risk modifiers for borderline risk patients 1
4. Use additional testing (CAC score, etc.) if risk assessment remains uncertain 1, 3
5. Implement appropriate management strategy based on risk level and BP category 1, 2
6. Monitor and reassess risk periodically 1

This structured approach to cardiovascular risk assessment using CT results and other clinical information will help guide appropriate management decisions to reduce morbidity and mortality from cardiovascular disease 1, 2.