Global risk assessment best for predicting heart failure in asymptomatic patients, panel finds

A global risk assessment rather than extensive testing is the best way to predict heart disease in most asymptomatic patients, according to a new practice guideline from the American College of Cardiology Foundation/American Heart Association.

An expert panel reviewed over 400 studies to arrive at their recommendations, which were released online this week and will appear in the Dec. 14/21 Journal of the American College of Cardiology and the Dec. 21 Circulation: Journal of the American Heart Association. The guideline looked at which diagnostic tests are most helpful in assessing cardiovascular risk in adults 20 years of age and older without obvious signs of heart disease. Tests were evaluated based on whether they added new information that could improve health outcomes by changing physicians' treatment or patients' behavior. High risk was defined as a global risk for "hard" coronary heart disease (CHD) events of 20% or higher over 10 years, while intermediate risk was distinguished from low risk by using a lower cutoff value of at least 10% and a higher cutoff value of less than 20%.

The guideline recommended that global risk scoring including factors such as cholesterol, blood pressure, age, sex, diabetes and smoking (e.g., the Framingham Score) should be used to assess cardiovascular risk in all adults, and that family history should always be examined. The expert panel concluded that the following tests are reasonable and may be considered in certain subgroups of asymptomatic patients:

• C-reactive protein for cardiac risk assessment in intermediate-risk men age 50 and younger and women age 60 and younger, and for determining the appropriateness of statin therapy in certain older people;coronary artery calcium scoring in people with diabetes who are over 40 years old, in intermediate-risk people and possibly in patients at low to intermediate risk;resting electrocardiogram (ECG), especially for patients with high blood pressure or diabetes;ankle-brachial index in those at intermediate risk;carotid intima-media thickness in those at intermediate risk;urinalysis to detect microalbuminuria in patients at intermediate risk or with high blood pressure or diabetes;conventional echocardiography in hypertensive patients;nuclear stress testing in patients who have diabetes or a strong family history of heart disease, if previous tests suggest a high heart disease risk;exercise ECG stress test in those at intermediate risk, for example, previously sedentary adults who are about to start a vigorous exercise program;hemoglobin A_1c, regardless of patients' diabetes status, to assess average blood glucose levels over time; andlipoprotein-associated phospholipase A2 in those at intermediate risk.

The expert panel also concluded that the following lack benefit in asymptomatic patients:

• genetic testing;lipid parameters besides a standard profile, including lipoproteins, apolipoproteins, particle size and density;natriuretic peptide levels;coronary computed tomography angiography;magnetic resonance imaging for detection of vascular plaque;stress echocardiography;flow-mediated dilation; andmeasures of arterial stiffness, such as pulse wave velocity.

Research is lacking on the optimal timing and frequency of cardiovascular risk assessment in asymptomatic patients, the panel members noted. More research is also needed on MRIs, genetic testing, environmental risks, and the effect of risk management strategies on outcomes, they wrote.