Risk Prediction Tools in Cardiovascular Disease Prevention: How to Incorporate ACC/AHA Guidelines into Practice Care

Educational Objectives

The goal of this program is to improve prevention of cardiovascular disease (CVD). After hearing and assimilating this program, the clinician will be better able to:

1. Implement risk prediction tools to prevent CVD.

Summary

Pooled cohort equations (PCEs): incorporated into electronic health records (EHRs) and automated risk calculators; application is limited to persons without atherosclerotic cardiovascular disease (ASCVD), diabetes mellitus, or very high low-density lipoprotein (LDL) levels; use of risk-enhancing factors is recommended for patients with borderline or intermediate risk; the derivative cohort for PCEs was mostly comprised of White and Black patients and excluded patients with congestive heart failure and atrial fibrillation; do not perform well in contemporary cohorts and Hispanic or Asian patients (in whom risk is overestimated or underestimated, especially with population disaggregation); do not apply to persons <40 yr of age and do not incorporate key factors (eg, prediabetes)

Other risk estimation tools: Systemic Coronary Risk Estimation 2 — developed in Europe and only applicable there; calibrates risk based on country of origin, local prevalence, and populations; QRISK3 — overcomes some limitations of PCEs; derived from a diverse cohort (particularly Asian patients) in the United Kingdom; the incorporated age range is more inclusive, compared with PCEs; offers greater opportunity to discuss risk with patients; disaggregates ethnic categories, especially Asian and Black patients; directly includes autoimmune diseases and body mass index in the risk estimator

Risk factors absent from current guidelines: despite having the greatest risk for obesity or being overweight, formal estimation for cardiometabolic risk is often missed in young adults; nonalcoholic fatty liver disease is an underappreciated risk factor for ASCVD; lipoprotein A — considered a risk-enhancing factor; useful for patients with borderline or intermediate risk, as well as with family or personal history of premature unexplained CAD, history of severe hyperlipidemia, or patient interest; coronary artery calcium score — the Multi-Ethnic Study of Atherosclerosis (MESA) risk score can quantify 10-yr risk for myocardial infarction; familial hypercholesterolemia(FH) — highly underdiagnosed (10% of patients), confers 20-fold risk for ASCVD, and affects 1 in 220 patients; personal or family history of LDL >190 mg/dL is suggestive; refer patients to preventive cardiology for treatment

Machine learning (ML): can help inform personalized risk; in studies, ML embedded in EHRs had increased applicability to more patients and provided similar or better risk stratification than PCEs; can diagnose previously-missed FH based on information within the EHR

Risk prediction in clinic: apply PCEs for risk determination with patient eligibility; MESA and QRISK3 scores are alternatives, especially for patients of younger age or South Asian descent (at highest risk for ASCVD in the United States); assess previous imaging for evidence of vascular calcification

Readings

Blaha M, Cainzos-Achirica M, Greenland P, et al. Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2016;133(9):849-858. doi:10.1161/CIRCULATIONAHA.115.018524. View article; Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625. View article; Visseren F, Mach F, Smulders Y, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice: developed by the task force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies with the special contribution of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2021;42(34):3227-3337. doi:10.1093/eurheartj/ehab484. View article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Sarraju was recorded at the Cardiovascular Update for the Primary Care Provider, held October 20-21, 2022, in Cleveland, OH, and presented by Cleveland Clinic. For information about upcoming CME activities from this presenter, please visit https://www.clevelandclinicmeded.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

FP711001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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