Risk stratification among patients with and at risk for coronary artery disease is critical so that the level of aggressiveness of management can match the risk of future events. The magnitude of risk is often clearer in the patient who has had a vascular event than in the assessment of primary risk assessment (who will have a future event who does not yet have evidence of CHD). Patients at low to intermediate risk by history and physical examination account for 75% of cardiovascular events. There is therefore the need for improved risk stratification tools to reclassify those patients deemed to be at low risk on history and physical examination into a higher risk category. In select populations, coronary artery calcium scoring, carotid intima-media thickness (CIMT) assessment and C reactive protein (CRP) assessment may offer addition improvements in risk stratification.
Risk Equivalents in Primary Prevention
You are essentially considered to have the equivalent of coronary heart disease if you have any of the following:
The Framingham Risk Score is used to estimate the 10-year cardiovascular risk of an individual. The Framingham Risk Score is based on data obtained from the Framingham Heart Study. There are two Framingham Risk Scores, one for men and one for women.
- Low Risk is less than 10%
- Intermediate Risk is 10 - 20%
- High Risk is more than 20%
Stress EKG: Duke Treadmill Score
Duke treadmill score (DTS) = Treadmill time (Bruce) - 5 x ST deviation (no. mm) - 4 x Angina index (0,1,2)
Low Risk Score
≥ 5
Treat medically
Intermediate Score
10 to 4
Stress Imaging
High Risk Score
≤ 11
Cath/PCI/CABG
Stress Imaging
Stress imaging is induction of reversible ischemia in a patient using drugs which can can cause increased contraction of heart muscle like dobutamine or drugs which cause vasodilatation and decrease blood supply to heart. Both these mechanisms cause stress on heart.
"1. Global risk scores (such as the Framingham Risk Score) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD. These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to target preventive interventions.[2](Level of Evidence: B)"
"1. Family history of atherothrombotic CVD should be obtained for cardiovascular risk assessment in all asymptomatic adults.[3][4](Level of Evidence: B)"
"1. In asymptomatic high-risk adults, measurement of CRP is not recommended for cardiovascular risk assessment.[9](Level of Evidence: B)"
"2. In low-risk men younger than 50 years of age or women 60 years of age or younger, measurement of CRP is not recommended for cardiovascular risk assessment.[3][10](Level of Evidence: B)"
"1. In men 50 years of age or older or women 60 years of age or older with low-density lipoprotein cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy.[11](Level of Evidence: B)"
"1. In asymptomatic intermediate-risk men 50 years of age or younger or women 60 years of age or younger, measurement of CRP may be reasonable for cardiovascular risk assessment.[3][10](Level of Evidence: B)"
"1. A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes.[21][22](Level of Evidence: C)"
"1. Measurement of carotid artery intima-media thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk.[25][26] Published recommendations on required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high-quality results.[26](Level of Evidence: B)"
Brachial/Peripheral Flow-Mediated Dilation (DO NOT EDIT)[1]
"1. Peripheral arterial flow-mediated dilation (FMD) studies are not recommended for cardiovascular risk assessment in asymptomatic adults.[27][28](Level of Evidence: B)"
Specific Measures of Arterial Stiffness (DO NOT EDIT)[1]
"1. Measures of arterial stiffness outside of research settings are not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C)"
Measurement of Ankle-Brachial Index (DO NOT EDIT)[1]
"1. An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity.[30][31](Level of Evidence: B)"
"1. Stress echocardiography is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress echocardiography is primarily used for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known coronary artery disease or the assessment of patients with known or suspected valvular heart disease.) (Level of Evidence: C)"
"1. Stress MPI is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress MPI is primarily used and studied for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known CAD.).[32](Level of Evidence: C)"
"1. Stress myocardial perfusion imaging (MPI) may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or asymptomatic adults with a strong family history of CHD or when previous risk assessment testing suggests a high risk of CHD, such as a coronary artery calcium (CAC) score of 400 or greater. (Level of Evidence: C)"
"1. Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk).[33][34](Level of Evidence: B)"
"1. Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year risk).[34][36](Level of Evidence: B)"
Coronary Computed Tomography Angiography (DO NOT EDIT)[1]
"1. In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment.[38][39][40](Level of Evidence: B)"
"1. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests a high risk of CHD, such as a CAC score of 400 or greater. (Level of Evidence: C)"