Risk Assessment for Cardiovascular Disease With Nontraditional Risk Factors: US Preventive Services Task Force Recommendation Statement

• Published in: JAMA : the journal of the American Medical Association 2018-07, Vol.320 (3), p.272-280
• Main Authors: Curry, Susan J, Krist, Alex H, Owens, Douglas K, Barry, Michael J, Caughey, Aaron B, Davidson, Karina W, Doubeni, Chyke A, Epling, John W, Kemper, Alex R, Kubik, Martha, Landefeld, C. Seth, Mangione, Carol M, Silverstein, Michael, Simon, Melissa A, Tseng, Chien-Wen, Wong, John B
• Format: Article
• Language: English
• Subjects: Adults; Ankle; Ankle Brachial Index; Arteriosclerosis; Biomarkers - blood; C-reactive protein; C-Reactive Protein - analysis; Calcification (ectopic); Calcium; Calibration; Cardiovascular disease; Cardiovascular Diseases; Coronary artery; Coronary artery disease; Coronary Artery Disease - diagnosis; Disease prevention; Health risks; Heart diseases; Humans; Mathematical models; Medical treatment; Proteins; Reclassification; Risk analysis; Risk assessment; Risk Assessment - methods; Risk Factors; Sensitivity analysis; Vascular Calcification - diagnosis
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2018.8359

IMPORTANCE: Cardiovascular disease (CVD) is the most common cause of death among adults in the United States. Treatment to prevent CVD events by modifying risk factors is currently informed by the Framingham Risk Score, the Pooled Cohort Equations, or similar CVD risk assessment models. If current CVD risk assessment models could be improved by adding more risk factors, treatment might be better targeted, thereby maximizing the benefits and minimizing the harms. OBJECTIVE: To update the 2009 US Preventive Services Task Force (USPSTF) recommendation on using nontraditional risk factors in coronary heart disease risk assessment. EVIDENCE REVIEW: The USPSTF reviewed the evidence on using nontraditional risk factors in CVD risk assessment, focusing on the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) level, and coronary artery calcium (CAC) score; the health benefits and harms of CVD risk assessment and treatment guided by nontraditional risk factors combined with the Framingham Risk Score or Pooled Cohort Equations compared with using either risk assessment model alone; and whether adding nontraditional risk factors to existing CVD risk assessment models improves measures of calibration, discrimination, and risk reclassification. FINDINGS: The USPSTF found adequate evidence that adding the ABI, hsCRP level, and CAC score to existing CVD risk assessment models results in small improvements in discrimination and risk reclassification; however, the clinical meaning of these changes is largely unknown. Evidence on adding the ABI, hsCRP level, and CAC score to the Pooled Cohort Equations is limited. The USPSTF found inadequate evidence to assess whether treatment decisions guided by the ABI, hsCRP level, or CAC score, in addition to risk factors in existing CVD risk assessment models, leads to reduced incidence of CVD events or mortality. The USPSTF found adequate evidence to conceptually bound the harms of early detection and interventions as small. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the ABI, hsCRP level, or CAC score in risk assessment for CVD in asymptomatic adults to prevent CVD events. CONCLUSIONS AND RECOMMENDATION: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adding the ABI, hsCRP level, or CAC score to traditional risk assessment for CVD in asymptomatic adults to prevent CVD events. (I s