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
Tóm tắt
Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current US prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general US 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. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient–clinician discussion with consideration of risk enhancing factors (eg, family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. 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.
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Tài liệu tham khảo
Fuster, V, Pearson, TA. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. J Am Coll Cardiol. 1996;27:957–1047.
Piepoli, MF, Hoes, AW, Agewall, S, et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR). Eur Heart. 2016;37:2315–81.
Karmali, KN, Persell, SD, Perel, P, et al. Risk scoring for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2017;3:CD006887.
Chia, YC, Lim, HM, Ching, SM. Validation of the pooled cohort risk score in an Asian population - a retrospective cohort study. BMC Cardiovasc Disord. 2014;14:163.
DeFilippis, AP, Young, R, McEvoy, JW, et al. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort. Eur Heart. 2017;38:598–608.
Mortensen, MB, Nordestgaard, BG, Afzal, S, et al. ACC/AHA guidelines superior to ESC/EAS guidelines for primary prevention with statins in non-diabetic Europeans: the Copenhagen General Population Study. Eur Heart. 2017;38:586–94.
American College of Cardiology. ASCVD Risk Estimator Plus. Available at: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Accessed October 16 2018.
American Heart Association. ASCVD Risk Calculator. Available at: https://professional.heart.org/professional/GuidelinesStatements/ASCVDRiskCalculator/UCM_457698_ASCVD-Risk-Calculator.jsp. Accessed October 16 2018.
American College of Cardiology. ASCVD Risk Estimator Plus. Available at: https://www.acc.org/ASCVDApp. Accessed October 16 2018.
Mayo Clinic Shared Decision Making National Resource Center. Available at: https://shareddecisions.mayoclinic.org/decision-aid-information/decision-aids-for-chronic-disease/cardiovascular-prevention/. Accessed October 16 2018.
How Much Does a CT Scan Cost? Available at: https://health.costhelper.com/ct-scan.html. Accessed August 13 2018.
The Multi-Ethnic Study of Atherosclerosis. CAC Score Reference Values. Available at: https://www.mesa-nhlbi.org/Calcium/input.aspx. Accessed October 16 2018.
Lloyd-Jones, DM, Huffman, MD, Karmali, KN, et al. Estimating longitudinal risks and benefits from cardiovascular preventive therapies among Medicare patients: the Million Hearts Longitudinal ASCVD Risk Assessment Tool: a special report from the American Heart Association and American College of Cardiology [published correction appears in Circulation. 2017;135:e824–e825]. Circulation. 2016;135:e793–813.