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On Nov. 12, 2013, the American Heart Association (AHA) and the American College of Cardiology (ACC) released four new sets of clinical practice guidelines to assist primary care clinicians in identifying adults who may be at high risk for developing atherosclerotic cardiovascular disease (ASCVD) and who may benefit from lifestyle changes or drug therapy for prevention.
The new guidelines differ in content and approach from the earlier 2004 recommendations, issued by the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP).1
The authors state, “As opposed to an extensive compendium of clinical information,” the new guidelines are “significantly more limited in scope and focus on the critical questions in each topic, based on the highest quality evidence available.” The text accompanying each recommendation is “succinct” and provides brief summary of the evidence.2
This four-part series, published in MPR, will summarize the new guidelines, and will also discuss how they differ from the earlier guidelines.
Part One of a Special Four-Part Series.
This first article focuses on the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk.2 The second article covers the Guideline on Lifestyle Management to Reduce Cardiovascular Risk.
The third article, which looks at the Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, will include an interview with Robert Eckel, MD, one of the Guideline authors. He will address some of the controversy surrounding the new recommendations, and explain the rationale behind them.
The fourth article will discuss the Guideline for the Management of Overweight and Obesity in Adults.
A New Approach
The new Guideline has broadened assessment of ASCVD risk to include both stroke and myocardial infarction (MI) and offers new gender- and ethnicity-specific formulas for predicting risk in African-American and white women and men.
The recommendations also help clinicians and patients look beyond traditional short-term (10-year) risk estimates to predict an individual’s lifetime risk of developing heart disease and having a stroke.
The authors state that their Work Group used “the best available data from community-based cohorts of adults, with adjudicated endpoints for CHD health, nonfatal myocardial infarction (MI), and fatal or nonfatal stroke.”2 Data were taken from cohorts that include African-American or white participants with at least 12 years of follow-up.
Recommendations for Assessment of 10-Year Risk for a First Hard ASCVD Event
Recommendation 1
The race- and sex-specific Pooled Cohort Equations should be used in non-Hispanic whites and African Americans, ages 40 to 79 years. (Grade B, Moderate)
Recommendation 2
The sex-specific Pooled Cohort Equations for non-Hispanic whites may be considered when estimating risk in patients from populations other than African Americans or non-Hispanic whites. (Grade E, Expert Opinion) However, the authors add, “It is important to remember that the estimated risks may be overestimates, especially for Hispanic- and Asian-Americans.”
A downloadable spreadsheet enabling estimation of 10-year risk for ASCVD and a web-based calculator are available at: My.AmericanHeart.org/CVRiskCalculator and at CardioSource.org.
The authors note that 10-year risk is defined as “the risk of developing a first ASCVD event, defined as nonfatal MI or CHD death, or fatal or nonfatal stroke, over a 10-year period among people free from ASCVD at the beginning of the period.”
Use of Newer Risk Markers After Quantitative Risk Assessment
Recommendation 1
This recommendation is to be implemented in cases in which, following a quantitative risk assessment, treatment decisions still remain uncertain. The authors recommend including “assessment of one or more of the following—family history, high-sensitivity C-reactive protein (hs-CRP), coronary artery calcium (CAC) score, or ankle-brachial index (ABI). (Grade E, Expert Opinion)
Recommendation 2
The use of other factors, such as apolipoprotein B (ApoB), chronic kidney disease, albuminuria, or cardiorespiratory fitness is “uncertain at present.” (Grade N, No Recommendation For or Against)
To look at any of the articles in this series, click below.
