- The ACC/AHA endorses the concept that the intensity of preventive intervention should be matched to the patient’s level of absolute risk. Hence, quantitative risk assessment is a critical step in efforts to prevent ASCVD.
- This guideline focuses on the large proportion of the adult population without clinical signs or symptoms of ASCVD who merit evaluation for the primary prevention of ASCVD. It does not apply to those with clinically manifest ASCVD, who require secondary prevention approaches, or to highly selected patient subgroups, such as those with symptoms suggestive of CVD, who require diagnostic strategies rather than risk assessment.
- Furthermore, these recommendations were not developed for use in specific subgroups of asymptomatic individuals at unusually high risk, such as those with genetically determined extreme values of traditional risk factors (eg, patients with familial hypercholesterolemia).
- Tools enabling estimation of 10-year and lifetime risk for ASCVD and a web-based calculator are available at http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx or http://my.americanheart.org/cvriskcalculator.
Table 1. Expert Opinion Thresholds for Use of Optional Screening Tests When Risk-Based Decisions Regarding Initiation of Pharmacological Therapy Are Uncertain Following Quantitative Risk Assessment
|Measure||Supports Revising Risk Assessment Upward||Does Not Support Revising Risk Assessment|
|Family history of|
|Male <55 years of age|
Female <65 years of age
(1st degree relative)
|Occurrences at older|
ages only (if any)
|hs-CRP||≥2 mg/L||<2 mg/L|
|CAC score||≥300 Agatston units or|
≥75th percentile for age, sex, and ethnicitya
|<300 Agatston units and|
<75th percentile for age,
sex, and ethnicitya
|aFor additional information, see http://www.mesa-nhlbi.org/CACReference.aspx.|
Table 2. Recommendations for Risk Assessment
|Recommendations||ACC/AHA COR||ACC/AHA LOE|
|The race- and sex-specific Pooled Cohort Equationsa to predict 10-year risk for a first hard ASCVD event should be used in non-Hispanic African Americans and non-Hispanic Whites, 40-79 years of age.||I||B|
|Use of the sex-specific Pooled Cohort Equations for non-Hispanic Whites may be considered when estimating risk in patients from populations other than African Americans and non-Hispanic Whites.||IIb||C|
|If, after quantitative risk assessment, a risk-based treatment decision is uncertain, assessment of 1 or more of the following— family history, hs-CRP, CAC score, or ABI—may be considered to inform treatment decision making. (See Table 2)||IIbb||B|
|The contribution of ApoB, CKD, albuminuria, and cardiorespiratory fitness to risk assessment for a first ASCVD event is uncertain at present.||N/A||N/A|
|Routine measurement of CIMT is not recommended in clinical practice for risk assessment for a first ASCVD event.||III: No Benefit b||B|
|It is reasonable to assess traditional ASCVD risk factorsc every 4-6 years in adults 20-79 years of age who are free from ASCVD and to estimate 10-year ASCVD risk every 4-6 years in adults|
40-79 years of age who are free from ASCVD.
|Assessing 30-year or lifetime ASCVD risk based on traditional risk factorsc may be considered in adults 20-59 years of age|
who are free from ASCVD and are not at high short-term risk.
a Derived from the Atherosclerosis Risk in Communities (ARIC) study, Cardiovascular Health Study (CHS), Coronary Artery Risk Development in Young Adults (CARDIA) study, Framingham original and offspring cohorts.
b Based on new evidence reviewed during ACC/AHA update of evidence.
c Age, sex, total cholesterol, high-density lipoprotein cholesterol, systolic BP, use of antihypertensive therapy, diabetes, and current smoking.
Applying Classification of Recommendations and Level of Evidence
|Estimate of Certainty (Precision) of Treatment Effect|
Procedure/ Treatment SHOULD be performed/ administered
Additional studies with focused objectives needed.
IT IS REASONABLE to perform procedure/ administer treatment
Additional studies with broad objectives needed; additional registry data would be helpful.
Procedure/ Treatment MAY BE CONSIDERED
No Benefit: procedure/test not helpful; treatment has no proven benefit
Harm: procedure/test has excess cost without benefit, or is harmful; treatment harmful to patients
Multiple populations evaluateda
Data derived from multiple randomized clinical trials or meta-analyses
Limited populations evaluateda
Data derived from a single randomized trial or nonrandomized studies
Very limited populations evaluateda
Only consensus opinion of experts, case studies, or standards of care
|Suggested phrases for writing recommendations:|
can be useful/effective/beneficial
is probably recommended or indicated
may/might be considered
may/might be reasonable
usefulness/effectiveness is unknown/unclear/uncertain or not well established
is not recommended
is not indicated
should not be performed/adminstered/other
is not useful/beneficial/effective
associated with excess morbidity/mortality
should not be performed/administered/other
|Comparative effectiveness phrasesb:|
treatment/strategy A is recommended/indicated in preference to treatment B
treatment A should be chosen over treatment B
treatment/strategy A is probably recommended/indicated in preference to treatment B
it is reasonable to choose treatment A over treatment B
A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
- Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior MI, history of HF, and prior aspirin use.
- For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
ABI, ankle-brachial index; ACC,American College of Cardiology; AHA, American Heart Association; ApoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CIMT, carotid intima-media thickness; CKD, chronic kidney disease; COR, class of recommendation; CV, cardiovascular; CVD, cardiovascular disease; ES, evidence statement; HDL-C, high-density lipoprotein cholesterol; HF, heart failure; hs-CRP, high-sensitivity C-reactive protein; LOE, Level of Evidence; MI, myocardial infarction; NHLBI, National Heart, Lung, and Blood Institute ; SBP, systolic blood pressure
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, Robinson JG, Schwartz JS, Shero ST, Smith SC Jr, Sorlie P, Stone NJ, Wilson PWF. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Published online before print November 12, 2013, J Am Coll Cardiol: doi: 10.1016/j.jacc.2013.11.005. and Circulation: 10.1161/01.cir.0000437741.48606.98.
This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care practitioners, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation.
Neither IGC, the medical associations, nor the authors endorse any product or service associated with the distributor of this clinical reference tool.