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Top Ten Things to Know:
Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease

  1. Quantitative absolute risk assessment in clinical practice has assumed a prominent role in U.S. and international guidelines to facilitate decision-making in primary prevention of atherosclerotic cardiovascular disease (ASCVD).
     
  2. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.
     
  3. ACC/AHA clinical practice guideline recommends the use of the PCE (pooled cohort equation) as an important starting point, not as the final arbiter, for decision-making in primary prevention of ASCVD. The features of the currently available US based cardiovascular risk assessment tools (PCE, Framingham General CVD Risk Profile, Reynolds Risk Score) that include ASCVD as least part of their outcome is presented in this report.
     
  4. PCE have been widely validated and are broadly useful for the general U.S. clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services.
     
  5. Because the PCE and most other risk scores apply only to adults 40 to 75 years of age, there are limited data on the performance and use of quantitative 10-year risk scores among adults <40 years of age and it is reasonable to consider 30-year or lifetime risk estimation in these younger adults to inform the intensity of prevention efforts.
     
  6. This special report provides a conceptual approach to risk assessment and its role in decision-making regarding the intensity of prevention efforts and use of pharmacotherapy in primary prevention of ASCVD, particularly in the context of decision making for use of statin medications.
     
  7. A clinical workflow for implementing risk assessment in adults for primary prevention of ASCVD is described in this special report.
     
  8. An algorithm of clinical approach to incorporate CAC measurements in risk assessments for borderline and intermediate risk patients is provided. 
     
  9. Quantitative ASCVD risk scores will likely be improved in the future by advances in epidemiology, development of additional large and representative cohorts (especially among Hispanics, East Asians, South Asians and patients >75 years of age), consideration of novel risk markers, and advances in data analysis.
     
  10. Of even greater impact than marginal improvements in risk estimation would be improvements in health systems approaches to implementing ASCVD risk assessment and prevention in practice and developing better tools to facilitate clinician-patient discussions and shared clinical decision-making around prevention.

Citation

Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC Jr, Sperling LS, Virani SS, Blumenthal RS. Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology [published online ahead of print November 10, 2018]. Circulation. DOI: 10.1161/CIR.0000000000000638.