How is cardiovascular risk assessed?

Cardiovascular Risk Assessment

Cardiovascular risk should be assessed using the ACC/AHA Pooled Cohort Equations to calculate 10-year risk of atherosclerotic cardiovascular disease (ASCVD) in asymptomatic adults aged 40-79 years, incorporating age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, diabetes status, and smoking status. 1

Primary Risk Assessment Tools

Pooled Cohort Equations (Recommended Standard)

• Calculate 10-year risk of hard ASCVD events (myocardial infarction, coronary death, or stroke) using race- and sex-specific equations that include: age, total cholesterol, HDL cholesterol, systolic blood pressure (treated or untreated), diabetes mellitus, and current smoking 1
• The equations provide separate calculations for non-Hispanic white and black men and women, improving accuracy over previous models 1
• Risk categories: Low risk (<5%), borderline risk (5-7.4%), intermediate risk (7.5-19.9%), and high risk (≥20%) 1

Alternative Risk Models

• Framingham Risk Score remains acceptable for estimating 10-year coronary heart disease risk, though it excludes stroke and may underestimate or overestimate risk in certain populations 1
• Reynolds Risk Score incorporates high-sensitivity C-reactive protein and family history, potentially improving risk prediction in some populations 1
• For Colombian populations specifically, use the Pooled Cohort Equations with a correction factor (C-statistic 0.767) to avoid overestimation 2

Traditional Risk Factors to Assess

The following modifiable and non-modifiable factors must be documented 1:

• Age and sex (men develop CVD approximately 10 years earlier than women) 1
• Blood pressure (hypertension present in 93.2% of dyslipidemic patients in some populations) 2, 3
• Lipid profile: total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides 1
• Diabetes mellitus (present in 28.5% of dyslipidemic populations) 2
• Current smoking status 1, 3
• Obesity (BMI and waist circumference) 3, 4
• Physical inactivity 3, 4

When Additional Testing May Be Considered

For Intermediate-Risk Patients (7.5-19.9% 10-year risk)

The USPSTF found insufficient evidence to recommend routine use of these tests, but they may provide additional risk stratification in select cases 1:

• Coronary artery calcium (CAC) score: A score of 0 indicates lower risk; elevated scores (thresholds vary) indicate higher risk. Obtained via CT imaging 1
• High-sensitivity C-reactive protein (hsCRP): Threshold >2-3 mg/L indicates increased inflammatory risk 1
• Ankle-brachial index (ABI): Value ≤0.9 indicates peripheral artery disease and higher CVD risk 1

Critical caveat: These tests carry risks including radiation exposure (CAC), false positives leading to unnecessary procedures, and patient anxiety without clear evidence of improved outcomes 1

Risk Assessment Algorithm

1. Low-risk patients (<5% 10-year risk): No further testing needed; focus on lifestyle modifications 1, 5

2. High-risk patients (≥20% 10-year risk or established CVD): Already candidates for intensive preventive interventions; additional testing provides no incremental benefit 1

3. Intermediate-risk patients (7.5-19.9% 10-year risk): Consider CAC scoring if treatment decision remains uncertain after initial risk calculation 1

4. Borderline-risk patients (5-7.4% 10-year risk): May benefit from risk-enhancing factors assessment (family history, chronic kidney disease, metabolic syndrome, inflammatory conditions) before considering pharmacotherapy 1

Common Pitfalls to Avoid

• Do not use the Pooled Cohort Equations without recognizing potential overestimation in modern populations with greater preventive therapy use, which may lead to overtreatment with statins 1
• Avoid applying risk calculators to patients <40 or >79 years, as they were not validated in these age groups 1
• Do not ignore family history, particularly premature CVD in first-degree relatives, which substantially modifies risk 1
• Recognize that risk calculators may be inaccurate in younger individuals with unique risk factors (familial hypercholesterolemia, chronic inflammatory conditions) 1
• For geographic populations outside the U.S., consider using region-specific calibrations (e.g., WHO cardiovascular disease risk charts for the Andean region) to avoid systematic over- or underestimation 2

The HEART Score: A Different Context

Important distinction: The HEART score is not a tool for general cardiovascular risk assessment in asymptomatic adults 6. It is specifically designed for emergency department evaluation of acute chest pain to stratify short-term risk of acute coronary syndrome 6. The HEART score incorporates: History, ECG findings, Age, Risk factors, and Troponin levels to identify low, intermediate, and high-risk patients presenting with undifferentiated chest pain 6.