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1.2 CV Risk

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17 views9 pages

1.2 CV Risk

Uploaded by

lilyhaileab9
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Cardiovascular Disease (CVD)

 Includes all heart & vascular diseases


 #1 cause of U.S. death affecting ~ 82 million Americans
 2 Types = ATHEROSCLEROTIC vs. NON-ATHEROSCLEROTIC

MI and Ischemic CVA often referred to as “Major ASCVD events”


1 Circulation. 2014; 129: e28-e292
Clinical Manifestations of ASCVD
Coronary Artery Disease (CAD)
 AKA Ischemic Heart Disease (IHD)
 AKA called Coronary Heart Disease (CHD)
 Chronic Stable Angina
 Myocardial Infarction (MI)
 Acute Coronary Syndrome (ACS) / unstable angina
 Surgical revascularization of Coronary Artery
- e.g., Coronary Artery Bypass Graft (CABG) – “bypass surgery”
- e.g., Percutaneous Coronary Intervention (PCI) - coronary stent “angioplasty”

Non-Coronary Vessel Disease


 Ischemic stroke - “Cerebrovascular Accident” (CVA)
 Transient Ischemic Attack (TIA) – “mini–stroke”
 Renal artery stenosis
 Mesenteric artery disease -” bowel infarction”
 Abdominal Aortic Aneurysm (AAA) - “triple A”
 Peripheral Vascular Disease (PVD)
- e.g., Peripheral Artery Disease (PAD) “intermittent claudication”
 Surgical revascularization of non-coronary artery (E.g., AAA repair)
2
Strategies for ASCVD Prevention
Primary Secondary
Prevention Prevention
Identification No Clinical manifestations Clinical manifestation(s)
of ASCVD exist of ASCVD exist
Clinical Goals Prevent ASCVD Prevent ASCVD
diagnosis & related progression & related
morbidity/mortality morbidity/mortality
Therapeutic Interventions to Interventions to
Targets reduce ASCVD risk reduce ASCVD risk

Risk Can be estimated Already known (high risk)


Estimation  Pooled Cohort Equation*  INVALID to use Pooled
-10yr risk score estimates risk to guide Cohort Equation
-30 yr risk score  Decisions on
-Risk enhancing factors
decisions on preventative
-Coronary calcium score interventions interventions are clear
*Pooled Cohort Equation is guideline recommended
risk estimate tool (other ASCVD risk assessment tools for
3
ASCVD Risk Assessment
Primary Prevention
 Assess traditional CV risk factors
 20-39 YO: Assess Q4-6 years
 40-75 YO: Assess “routinely”
 Estimate 10-year ASCVD risk score routinely between 40-75 YO
 If 10yr ASCVD risk 5% to 19.9%
 Consider Risk Enhancing Factors (REF)
 May consider Coronary Artery Calcium (CAC) score if risk-
based decisions remain uncertain after discussing above factors
 May consider 30-yr ASCVD risk score if 40-59 YO & 10-yr risk < 7.5%
 Recommend risk modification with lifestyle + drug therapy if indicated

Secondary Prevention
 Routinely assess traditional CV risk factors
 Recommend aggressive risk modification with lifestyle + drug therapy
 Invalid to use any ASCVD risk score, REF, or CAC

4 Circulation. 2019;139:e1162–e11
Traditional Cardiovascular
Risk Factors
1. Age ≥55 YO for males / ≥ 65 YO for females
2. *Hypercholesterolemia (Dyslipidemia)
3. *Hypertension (HTN) - High Blood Pressure (BP)
4. *Diabetes mellitus (DM) - Type 1 or Type 2
5. Current cigarette (tobacco) use (only count if any in last 30 days)
6. *Obesity
7. *Physical Inactivity

• Involves assessing health behaviors (smoking, diet, exercise) and


physiological risk factors (e.g., BP, cholesterol, diabetes)
• Non-traditional factors (genetics, diet, stress) may add to risk
• Optimal control of modifiable factors reduces risk of ASCVD

5
Pooled Cohort Equation (PCE)
 Electronic score tool estimates ASCVD risk
 Estimates 10-year ASCVD risk score for men and women
 Estimates 30-year (lifetime) risk score for men and women

 Limitations:
 Validated in primary prevention ONLY
 Validated in select age groups
 10-year risk estimate valid for ages 40-79YO (guideline: to 75 YO)
 30-year risk estimate valid for ages 40-59 YO
 Validated in Non-Hispanic White & African-American
 May underestimate ASCVD risk in patients from:
 South Asia (e.g., India, Pakistan); American Indian; Puerto Rico
 May overestimate ASCVD risk in patients from:
 East Asia (China; Japan); Mexico
6
6
http://www.cvriskcalculator.com/
 Inaccuracies (e.g., socioeconomic or preventativeCirculation.
care levels)
2019;140:e563–e5
http://tools.acc.org/ASCVD-Risk-Estimator-
ASCVD Primary Prevention Guidelines
 10 yr ASCVD risk “Short-Term”
 <5% - Low
 5% to 7.4% - Borderline
 7.5% to 19.9% - Intermediate
 ≥20% - High

 30 yr (lifetime) ASCVD risk “Long-Term ”


 Compares risk with vs. without optimal risk factor
management – e.g., 35% vs. 50%

7
7 Estimated with the Pooled Cohort Equation
Primary Prevention Guideline

CAC score: by computed tomographic (CT) scan – limited role,


often not covered by insurers (patient cost $50-350)
8 Circulation. 2019;139:e1162–e11
8 Risk Enhancing Factors (REF) for Primary Prevention of ASCVD
Family history of premature ASCVD 1st degree relative (parent, child, sibling) had
early age ASCVD (male <55YO or female <65 YO)
High-risk race/ethnicity/ancestry • South Asian, American Indian, Puerto Rican
High LDL-Cholesterol (primary) • 160–189 mg/dL
Elevated biomarker levels • Elevated TG - persistently ≥175 mg/dL
(these may ↑ ASCVD risk; cannot • Elevated CRP (FYI: risk ≥2.0 mg/L) – C reactive protein
precisely assess impact) • Elevated Lp(a) (FYI: risk ≥50 mg/dL) – Lipoprotein(a)
• Elevated ApoB (FYI: risk ≥130 mg/dL) – Apoprotein-B
• Low ABI ratio (FYI: <0.9 indicates PAD risk) - Ankle
brachial index (ankle vs. upper arm blood pressure)
Metabolic syndrome • FYI: at least 3 of 5 criteria: low HDL cholesterol;
Elevated waist circumference; high triglycerides;
high Blood Pressure; High blood glucose
Chronic Kidney Disease (CKD) (DO NOT count if dialysis or kidney transplant)
Chronic inflammatory conditions • Psoriasis
• Rheumatoid Arthritis
• Lupus
• HIV/AIDS
Premature menopause or • Menopause under age 40
pregnancy-associated conditions • Pre-eclampsia during pregnancy

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