In my clinical practice, one of the main areas of focus is healthspan – supporting my patients to have longevity and a higher quality of life with evidence-informed tools, personalized to their needs and goals. Given that cardiovascular disease is the number one cause of mortality, many conversations center around cardiovascular health and optimization.
For a more accurate prediction of your risk of a cardiovascular event (e.g., stroke or a heart attack) in the future and to inform your healthcare provider’s decision whether to recommend cholesterol lowering therapy, there are tools that physicians and other clinicians use in clinical practice. Based on the output of these risk assessments, as well as other clinical factors, the qualified clinician and patient should discuss risks vs benefits of treatment and make a personalized, evidence-informed decision regarding treatment.
ASVD Risk Estimator
In certain situation, we may use ASCVD risk estimator tool to determine if (and how much) a person would benefit for statin therapy according to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines.
ASCVD stands for atherosclerotic cardiovascular disease. The 10-year ASCVD risk is the 10-year risk of having a cardiovascular event, such as a heart attack, stroke, peripheral artery disease or an aortic aneurysm.
MESA Calculator
When applicable, we use MESA risk calculator. This is when coronary artery calcification score is available from a Coronary Artery Calcium scan.
When risk is determined to be low, cholesterol lowering medications are generally not recommended, and the main treatment modalities include lifestyle and nutrition to reduce this risk. The risk is periodically reassessed. In the cases of increased risk, guideline-informed decisions can be made about further testing or a multi-modality approach including not only lifestyle and nutrition, but pharmacotherapy, and supplemental support.
The risk factors include age, gender, race, lipid levels, blood pressure, presence/absence of diabetes and high blood pressure, and smoking status. Family history is also a risk factor, but it is not included in every calculation.
PREVENT
In November 2023, The American Heart Association (AHA) published a new algorithm that can aid in predicting cardiovascular risk. This algorithm differs from the prior calculations in several ways: it includes kidney function as an added prognostic indicator, it removes race and it adds an option to add a zip code as an estimate of social determinants of health (social deprivation index). When clinically indicated and available, additional metrics, such as hemoglobin A1c (3-month average of blood glucose), and urine albumin to creatinine ratio, can be entered as well.
The PREVENT equations allow for 10- and 30-year risk estimates for total CVD – cardiovascular disease (composite of atherosclerotic CVD and heart failure), in individuals with no prior history of cardiovascular disease – ie, this is used for primary prevention.
This algorithm allows individuals and their healthcare providers to enter health information here and then the risk for cardiovascular events is calculated.
Coronary Calcium Scan
When we consider cardiovascular risk assessment in my clinical practice, I may recommend doing a coronary calcium score (to assess if there is any calcified plaque formation in the arteries of the heart). This involves doing a CT scan with no contrast (i.e., no dye is injected). An ultrasound of carotid arteries may also be done (to assess for any narrowing of carotid arteries or impaired blood flow). This imaging complements our risk assessment, and if we find evidence of current plaque, we discuss more proactive forms of treatment (e.g., adding cholesterol lowering medications to nutrition and lifestyle measures). While supplements exist that may favorably impact cholesterol levels, there is no evidence that supplemental support improves cardiovascular outcomes (with the exception of some evidence for red yeast rice).
Coronary CT Angiography (CCTA)
The more precise test for visualizing and quantifying atherosclerosis, is another type of CT scan that requires a contrast to be injected. It is called a coronary CT angiogram. (CCTA). This assesses both calcified and non-calcified plaque and has a higher resolution. It is estimated that 15% of pts with no calcified plaque on coronary artery calcium scan have plaque on CCTA.
CCTA can be done with a Cleerly algorithm, which allows differentiation of non-calcified plaque into different subtypes. The low density non-calcified plaque is the most unstable plaque that leads to more heart attacks and cardiovascular events.
Cardiopulmonary exercise testing (CPET)
Functional tests such as CPET testing can assess for early endothelial dysfunction (dysfunction of the blood vessels) and exercise capacity. This test can be useful for individuals who are symptomatic as well as those who have no symptoms and would like to better understand their risk.
Note that the above algorithms and tests are discussed in the context of an asymptomatic individual who may be at risk of cardiovascular disease or is uncertain about risk for cardiovascular disease. For individuals who have symptoms of cardiovascular disease such as shortness of breath, chest pain, fatigue, palpitations, dizziness, leg swelling or other related symptoms, the work up of such symptoms and testing involved is outside of the scope of this article.
Speak to your cardiologist, internist, or primary care physician whether one of these tests may be appropriate for you. They can partner with you to determine if and when one of these tests may be appropriate, what is the optimal way to determine your risk, and if and what type of cardiovascular risk lowering strategy may be warranted to support your health.
More about ASCVD:
https://www.heart.org/en/professional/quality-improvement/ascvd
More about PREVENT:
Khan, S. S., Coresh, J., Pencina, M. J., Ndumele, C. E., Rangaswami, J., Chow, S. L., Palaniappan, L. P., Sperling, L. S., Virani, S. S., Ho, J. E., Neeland, I. J., Tuttle, K. R., Rajgopal Singh, R., Elkind, M. S. V., Lloyd-Jones, D. M., & American Heart Association (2023). Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association. Circulation, 148(24), 1982–2004. https://doi.org/10.1161/CIR.0000000000001191
More about coronary calcium scan:
More about coronary CT angiogram:
https://www.mayoclinic.org/tests-procedures/ct-coronary-angiogram/about/pac-20385117
Cleerly is an AI-based algorithm that helps to assess risk for heart attack and guide personalized recommendations.
More about early detection and Cleerly scan:
https://cleerlyhealth.com/individuals
https://cleerlyhealth.com/find-cleerly-near-you?tags=imaging%20center