What is the recommended approach to screen adults aged 40‑75 for cardiovascular disease risk, including which measurements, laboratory tests, risk calculators, and screening intervals?

Cardiovascular Disease Screening in Adults Aged 40–75

Begin comprehensive cardiovascular risk screening at age 40 for all adults, measuring blood pressure, fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides), fasting glucose or HbA1c, BMI, waist circumference, and documenting smoking status, diet, physical activity, and family history; calculate 10-year ASCVD risk using the Pooled Cohort Equations and repeat this full assessment every 5 years, or every 1–2 years if risk factors are present or lipid values approach treatment thresholds. 1, 2, 3, 4

Core Measurements Required at Each Screening Visit

Blood Pressure

• Measure blood pressure at every visit, at minimum every 2 years starting at age 40. 1, 4
• Record on at least 2 separate occasions over 1 week to several weeks before diagnosing hypertension; single-visit readings are insufficient for diagnosis. 4
• If BP is <120/80 mm Hg, recheck every 2 years; if 120–139/80–89 mm Hg, screen annually. 4

Anthropometric Measurements

• Document body mass index (BMI) and waist circumference at each visit to assess obesity as a cardiovascular risk factor. 1, 4

Pulse Assessment

• Record pulse at each visit to screen for atrial fibrillation, which substantially increases stroke risk. 1

Laboratory Tests

Fasting Lipid Panel (Primary Screening Test)

• Obtain a complete fasting lipid profile including total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, and non-HDL cholesterol. 1, 3, 4
• Screening interval: Every 5 years for adults without risk factors and with normal lipid levels. 1, 3, 4
• More frequent testing (every 1–2 years) is required when any of the following are present: ≥2 cardiovascular risk factors, lipid values near treatment thresholds, diabetes, hypertension, smoking, or the patient is on lipid-lowering therapy. 1, 3, 4
• Total cholesterol and HDL can be measured non-fasting if a fasting sample is unavailable, though fasting is preferred for complete assessment. 3, 4
• Critical practice point: Confirm all abnormal lipid results with a repeat sample on a separate occasion and use the average of both measurements for risk assessment. 3, 4

Glucose Assessment

• Measure fasting blood glucose or HbA1c at the same intervals as lipid screening (every 5 years, or every 2 years if risk factors are present). 1, 4
• HbA1c screening is specifically recommended for adults aged 40–70 years with BMI ≥25 kg/m², or age 45 and older without additional risk factors. 3, 4
• In individuals with normal results, rescreening every 3 years is reasonable. 4

Kidney Function Assessment

• Obtain serum creatinine with eGFR calculation, as eGFR <60 mL/min/1.73 m² defines chronic kidney disease and markedly elevates cardiovascular risk. 4
• Measure urine albumin-creatinine ratio (UACR) rather than dipstick, particularly in patients with diabetes or hypertension, as UACR is more sensitive for early kidney disease and vascular endothelial damage. 4

Additional Laboratory Tests

• Obtain a complete blood count with hemoglobin to detect anemia, which can modify cardiovascular risk. 4
• Consider thyroid function testing at least once in individuals with suspected chronic coronary syndrome. 4

Risk Factor Documentation

Lifestyle and Behavioral Factors

• Assess and document smoking status, physical activity level, dietary habits, and alcohol intake at every routine evaluation. 1, 4
• Update family history of premature coronary heart disease (CHD before age 55 in male relatives or before age 65 in female relatives) regularly. 1, 2, 4

10-Year Cardiovascular Risk Calculation

Risk Calculator Selection

• Use the Pooled Cohort Equations from the 2013 ACC/AHA guidelines as the primary risk assessment tool for all adults aged 40–75 years. 1, 2
• The Pooled Cohort Equations incorporate age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, antihypertensive medication use, diabetes status, and smoking status to generate sex- and race-specific 10-year ASCVD risk predictions including ischemic stroke as an outcome. 1
• Important caveat: The ACC/AHA risk calculator has been shown to overestimate actual risk in multiple external validation cohorts, particularly at the lower end of the risk spectrum, so clinical judgment is essential when calculated risk approaches treatment thresholds. 1

Risk Calculation Frequency

• Calculate 10-year ASCVD risk every 5 years, or more frequently if risk factors change, especially in adults aged 40 years or older or those with ≥2 risk factors. 1, 2

Risk Stratification and Treatment Thresholds

• ≥10% 10-year risk: Initiate statin therapy (B recommendation from USPSTF). 1, 5
• 7.5% to <10% 10-year risk: Selectively offer statin therapy based on shared decision-making (C recommendation from USPSTF). 1, 5
• ≥20% 10-year risk or diabetes: Consider these patients as CHD risk equivalents requiring aggressive preventive intervention. 1, 4

Advanced Risk Assessment When Risk Calculation Is Uncertain

Coronary Artery Calcium (CAC) Scoring

• When to use CAC: Consider CAC scoring when calculated 10-year risk is borderline (7.5%–10%) or when risk-based treatment decisions remain ambiguous despite standard assessment. 1, 2
• CAC = 0: Downgrade risk and consider withholding statin therapy, unless diabetes, family history of premature CHD, or cigarette smoking are present. 1, 2
• CAC = 1–99: Favors statin therapy, especially after age 55. 1, 2
• CAC ≥100 or ≥75th percentile for age, sex, and ethnicity: Initiate statin therapy and consider more aggressive treatment. 1, 2
• CAC >300 Agatston units: Supports aggressive lipid-lowering treatment. 2

Additional Risk-Enhancing Factors

• Measure high-sensitivity C-reactive protein (hs-CRP) when risk assessment remains uncertain; hs-CRP ≥2.0 mg/L supports more intensive preventive therapy. 1, 2
• Measure lipoprotein(a) once in a lifetime (levels are genetically determined and stable) if family history of premature CVD, unexplained early events in first-degree relatives, familial hypercholesterolemia, recurrent CVD despite optimal statin therapy, or borderline 10-year risk of 5–15% are present. 3
• Persistently elevated triglycerides ≥175 mg/dL, apoB ≥130 mg/dL, or ankle-brachial index <0.9 are additional risk-enhancing factors that may guide treatment decisions. 1

Special Populations and Age-Specific Considerations

Adults Under Age 40

• Do not routinely screen adults aged 20–39 years unless they have specific risk factors: diabetes, family history of premature CVD (CHD before age 55 in male relatives or before age 65 in female relatives), current smoking, hypertension, or obesity. 1, 3, 4
• For high-risk young adults aged 20–39 with risk factors, obtain a fasting lipid panel at initial evaluation and repeat every 5 years. 3, 4
• The USPSTF found insufficient evidence to recommend for or against screening in adults aged 21–39 years without risk factors. 1

Adults Aged 76 and Older

• The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of initiating statin therapy for primary prevention in adults ≥76 years without a history of CVD (I statement). 1, 5
• Routine lipid panel testing can be discontinued in adults over 75 years unless the patient is on statin therapy or has specific cardiovascular risk factors warranting continued monitoring. 2
• For adults over 75 already on statin therapy, continue monitoring to assess medication adherence and efficacy. 2

Common Pitfalls to Avoid

• Never rely on a single lipid measurement for diagnosis or treatment decisions; always confirm abnormal results with a repeat sample on a separate occasion and use the average of both results. 3, 4
• Do not screen all young adults indiscriminately; focus screening efforts on those aged 20–39 years who have identifiable cardiovascular risk factors. 3, 4
• Do not diagnose hypertension based on a single visit; multiple readings across at least 2 separate visits over 1 week to several weeks are required for confirmation. 4
• Recognize that age heavily influences calculated 10-year risk: 41% of men and 27% of women aged 60–69 years without CVD will have a calculated 10-year risk ≥10%, even in the absence of traditional risk factors like dyslipidemia, diabetes, hypertension, or smoking. 1
• Do not order advanced lipoprotein testing (beyond a standard fasting lipid profile) for cardiovascular risk assessment in asymptomatic adults; this is classified as Class III: No Benefit by ACC/AHA guidelines. 3
• If a non-fasting triglyceride measurement is ≥400 mg/dL, obtain a repeat fasting sample for accurate assessment. 3