Risk Stratification in CVD Prevention

How to Identify Cardiovascular Risk in the Office

Dr. Thomas G. Allison

Cardiovascular Diseases and Internal Medicine
Mayo Clinic
Rochester, MN
 Clinically-Based CVD Prevention

1. Risk assessment for all patients

2. Set evidence- and guideline-based goals
for specific risk factors
3. Lifestyle management
4. Pharmacologic intervention for selected
risk factors in appropriate patients
Levels of Risk in Primary Prevention
1. Highest: the patient has evidence of CVD
2. High: the patient has high immediate risk (a
probability of > 20% in the next 10 years) for
having a CVD event
• 2 or more major risk factors
BP > 160/100
Diabetes
Cigarette smoking
LDL cholesterol > 160 mg/dL
HDL cholesterol < 35 mg/dL men, < 45 mg/dL women
Family history of premature CVD
Levels of Risk in Primary Prevention
3. Intermediate: the patient will not likely have
a CVD event in the next 10 years, but has a
high lifetime risk
• 1 major risk factor or
• > 2 minor risk factors
BP 140-159/90-99 mmHg
Blood glucose 100-129 mg/dL
LDL cholesterol 130-159 mg/dL
HDL cholesterol 35-39 mg/dL men, 45-49 mg/dL women
Levels of Risk in Primary Prevention
4. Low: the patient may develop CVD at
older ages without lifestyle adjustment
• 1 or 2 minor risk factors
• Minor risk factors are generally correctable
with lifestyle change
• Diet change, exercise, weight loss
5. Very low: the patient will not likely
develop CVD during his or her lifetime
• No major or minor risk factors
 What Do We Do with Risk?
1. Highest risk patient
– Use secondary prevention guidelines to
manage risk factors
– Further evaluation: exercise test ± imaging or
angiography
2. High risk patient
– Treat all major risk factors pharmacologically
– Provide appropriate lifestyle counseling
– Exercise test
 What Do We Do with Risk?
3. Intermediate risk patient
– Lifestyle counseling
– Pharmacologic treatment of any major risk
factors
– Initial follow-up in 3-6 months, annually
thereafter
– Consider exercise test
 Stress Testing for Risk Stratification
in Primary Prevention
• Look for clinical disease
• Evaluate symptoms
• Establish prognosis

• Prior to prescribing exercise

• Intermediate-high risk patients
• High threshold of disease
 What Do We Do with Risk?
4. Low risk patient
• Recommend appropriate lifestyle change
• Re-evaluate in 3-12 months
5. Very low risk patient
• Reassure
• Suggest additional evaluation in 3-5 years
 Prediction of Lifetime Risk for
Cardiovascular Disease by Risk
Factor Burden at 50 Years of Age
Donald M. Lloyd-Jones et al

Circulation 2006;113:791-798
High

Intermediate

Low

Very Low
 Identifying Risk in the Office
Step 1

• Symptoms: Angina, TIA, claudication

• Physical exam: bruits, AAA, diminished
peripheral pulses, reduced ABI (0.90 for men
and 0.85 for women), xanthomas
• ECG: Q-waves, ST-T wave abnormalities, LVH
Angina has 3 characteristics
1. Feels like tightness, pressure, squeezing, or
burning (not generally a sharp pain)
2. Starts in the center of the chest, behind or
underneath the sternum (breast bone) – may
radiate to the neck and jaw, around the back,
down the arms (left more common than right)
3. Increased by physical activity, relieved by rest
(or nitroglycerine)
 Rose Angina Questionnaire
• 1. Do you get pain or discomfort in your chest
when walking up hills, stairs or hurrying on level
ground? (Yes or no) Positive = “yes”
• 2. If you get pain or discomfort in the chest when
walking, do you usually stop? Slow down? Carry
on at the same pace? (Mark the alternative best
fitting) Positive = “stop” or “slow down”
• 3. If you stop or slow down, does the pain
disappear after less than 10 minutes? Or after 10
minutes or more? (Mark the alternative best
fitting) Positive = “after less than 10 minutes”
• Other symptoms that might represent
coronary heart disease include
– Fatigue
– Reduced exercise tolerance
– Shortness of breath
• Symptoms suggesting other vascular
disease
– TIA
– Claudication
 Assessing CVD Risk in the Office
Step 2
• Measure height, weight, waist circumference,
calculate BMI
• Measure blood pressure and pulse
• Discuss family history of premature CVD
• Review lifestyle: smoking, physical activity,
diet (servings of fruits/vegetables per day)
Non-Fasting Blood Sugar, Lipids
• Physicians in developing countries (or in
low income populations in developed
countries) may not have the luxury of
scheduled visits for measurement of fasting
blood sugar and lipids
• Inexpensive, fingertip, glucometer
• Opportunities for measuring these factors in
non-fasting states will present
 Non-Fasting Blood Sugar
• In routine cases where patient is not fasting
but not acutely ill, FBG > 150 mg/dL may
serve to identify patients with diabetes or
impaired fasting glucose
• Consider measuring hemoglobin A1C
– Reflects status prior to acute illness
– May underestimate prevalence of diabetes
– Elevated A1c indicates need to begin therapy
 When to Add a Lipid Profile
Step 3
• Positive family history of CVD
• BMI > 28 kg/m2 or prominent waist
circumference (> 102 cm men, 89 cm women)
• High non-fasting glucose
• Improper dietary habits
• Elevated blood pressure
• Cigarette smoking
• Consider for all patients if resources available
 Honduras versus US Statistics
• Total expenditure on health per capita
– Honduras: $241 US: $6,714
• Gross national income per capita
– Honduras: $3,240 US: $44,070
• Total expenditure on health as % of GDP
– Honduras: 7.4% US: 15.3%

World Health Statistics 2008

Financial data from 2006
 Fasting Lipid Profile?
Non-HDL Cholesterol
• Easy to calculate: Total-C – HDL-C
• Predicts CVD risk as well as LDL-C
• Goals = LDL-C goals + 30 mg/dL
• Not much affected by non-fasting samples
• Can be used opportunistically
 More Tools for Assessing CHD Risk
in Asymptomatic Adults
• Novel risk factors (CRP, Lp(a), Lp-PLA2, etc.)
• Advanced lipid testing
– LDL particle concentrations, apolipoproteins
• Non-invasive imaging
– EBCT, CIMT, CTA, MRI
• Arterial function studies
– Brachial reactivity, ENDO-PAT, arterial stiffness
Framingham Risk Score
 Framingham Risk Score
• Very age dependent
• Short-term (10-year) risk projections
• Ignores many factors that likely contribute to
cardiovascular risk
• Developed in USA with people of (western)
European descent
– Does it have to be modified for developing nations
or different racial or ethnic groups?
 Framingham 10-year risk by age for a male
or female
● smokes 1 ppd
● TC = 212 (5.5), HDL-C = 42 (1.1)
● No DM, normal BP
35%
30% Male
Female
25%
10-Year Risk

20%
15%
10%
5%
0%
30 40 50 60 70
Age (years)
 Three Options for Preventing CVD
in Asymptomatic Individuals
1. Wait until the patient has had a CVD event
2. Wait until the patient has signs of
atherosclerosis
• Requires expensive imaging procedures
3. Treat factors that lead to an increased
lifetime risk of CV disease
• How do we know when it is time to start?
• Likely 10-20 years earlier than current practice
Rochester, MN early fall
• Comments?

• Questions?