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Risk Enhancing Factors and Coronary Artery Calcium Strengthen Atherosclerotic Cardiovascular Disease Risk Estimation

  • Danish Saleh
    Correspondence
    Corresponding author: Tel: 312-695-0070; fax: (312) 695-1903
    Affiliations
    Division of Cardiology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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  • Scott M. Grundy
    Affiliations
    Center for Human Nutrition, Departments of Internal Medicine, Applied Clinical Research, University of Texas Southwestern Medical Center and The Veterans Administration North Texas Healthcare System, Dallas, Texas
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  • Neil J. Stone
    Affiliations
    Division of Cardiology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois

    Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Published:December 07, 2022DOI:https://doi.org/10.1016/j.amjcard.2022.11.004
      Quantification of risk for atherosclerotic cardiovascular disease (ASCVD) is important. Traditional risk assessment begins with numerical estimation. The pooled-cohort equation (PCE), as described in the 2018 American Hospital Association/American College of Cardiology/MultiSociety guidelines, serves as the basis for 10-year ASCVD-risk estimation.
      • Grundy SM
      • Stone NJ
      • Bailey AL
      • Beam C
      • Birtcher KK
      • Blumenthal RS
      • Braun LT
      • de Ferranti S
      • Faiella-Tommasino J
      • Forman DE
      • Goldberg R
      • Heidenreich PA
      • Hlatky MA
      • Jones DW
      • Lloyd-Jones DM
      • Lopez-Pajares N
      • Ndumele CE
      • Orringer CE
      • Peralta CA
      • Saseen JJ
      • Smith Jr, SC
      • Sperling L
      • Virani SS
      • Yeboah J
      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.
      ,
      • Muntner P
      • Colantonio LD
      • Cushman M
      • Goff Jr, DC
      • Howard G
      • Howard VJ
      • Kissela B
      • Levitan EB
      • Lloyd-Jones DM
      • Safford MM
      Validation of the atherosclerotic cardiovascular disease pooled cohort risk equations.
      Although the PCE has been verified in a natural history cohort, the reliability of the equation in contemporary US subpopulations has been debated for those in the intermediate range of risk.
      • Muntner P
      • Colantonio LD
      • Cushman M
      • Goff Jr, DC
      • Howard G
      • Howard VJ
      • Kissela B
      • Levitan EB
      • Lloyd-Jones DM
      • Safford MM
      Validation of the atherosclerotic cardiovascular disease pooled cohort risk equations.
      The guidelines thereby recommend a patient-oriented risk discussion and clinical risk assessment precede the prescription of statin therapy because patient-specific insights can inform treatment decisions.
      • Grundy SM
      • Stone NJ
      • Bailey AL
      • Beam C
      • Birtcher KK
      • Blumenthal RS
      • Braun LT
      • de Ferranti S
      • Faiella-Tommasino J
      • Forman DE
      • Goldberg R
      • Heidenreich PA
      • Hlatky MA
      • Jones DW
      • Lloyd-Jones DM
      • Lopez-Pajares N
      • Ndumele CE
      • Orringer CE
      • Peralta CA
      • Saseen JJ
      • Smith Jr, SC
      • Sperling L
      • Virani SS
      • Yeboah J
      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.
      ,
      • Greenland P
      • Lloyd-Jones DM
      Role of coronary artery calcium testing for risk assessment in primary prevention of atherosclerotic cardiovascular disease: a review.
      Moreover, to refine individual risk, the guidelines propose evaluation of a panel of risk-enhancing factors (REFs) (Figure 1). Coronary artery calcium (CAC) scoring has also been proposed as a tool to stratify risk in the setting of clinical uncertainty. Nevertheless, the approach to incorporating REFs and CAC scoring in patient-oriented risk discussions and clinical decision-making remains unclear.
      • Greenland P
      • Lloyd-Jones DM
      Role of coronary artery calcium testing for risk assessment in primary prevention of atherosclerotic cardiovascular disease: a review.
      ,
      • Agarwala A
      • Liu J
      • Ballantyne CM
      • Virani SS
      The use of risk enhancing factors to personalize ASCVD risk assessment: evidence and recommendations from the 2018 AHA/ACC multi-society cholesterol guidelines.
      Here, we aim to highlight the utility of incorporating REFs in patient-oriented risk discussions that are grounded in a risk score, introduce studies demonstrating quantitative value in cataloging REF burden, and illustrate utility in CAC scoring.
      Figure 1
      Figure 1REFs in the clinician-patient risk discussion for those at risk of atherosclerotic cardiovascular disease. The content presented is adapted from Figure 2 of the 2018 AHA/ACC/MultiSociety Guideline on the management of blood cholesterol to illustrate the usefulness of risk enhancing factors and is not intended to replace said figure as a practice guideline.
      ACC = American College of Cardiology; AHA = American Heart Association; LDL-C = low-density lipoprotein cholesterol.
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