2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults

56 Pages·2010·0.98 MB·English

by  P. Greenland

2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in
Asymptomatic Adults
American College of Cardiology Foundation, American Heart Association Task
Force on Practice Guidelines, American Society of Echocardiography, American
Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention,
Society for Cardiovascular Angiography and Interventions, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic
Resonance, Philip Greenland, Joseph S. Alpert, George A. Beller, Emelia J.
Benjamin, Matthew J. Budoff, Zahi A. Fayad, Elyse Foster, Mark.A. Hlatky, John
McB. Hodgson, Frederick G. Kushner, Michael S. Lauer, Leslee J. Shaw, Sidney C.
Smith, Jr, Allen J. Taylor, William S. Weintraub, and Nanette K. Wenger
J. Am. Coll. Cardiol. published online Nov 15, 2010;
doi:10.1016/j.jacc.2010.09.001
This information is current as of November 15, 2010
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.09.001v1
Downloaded from content.onlinejacc.org by on November 15, 2010
JournaloftheAmericanCollegeofCardiology Vol.56,No.25,2010
©2010bytheAmericanCollegeofCardiologyFoundationandtheAmericanHeartAssociation,Inc. ISSN0735-1097/$36.00
PublishedbyElsevierInc. doi:10.1016/j.jacc.2010.09.001
PRACTICE GUIDELINES
2010 ACCF/AHA Guideline for Assessment
of Cardiovascular Risk in Asymptomatic Adults
A Report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines
Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology,
Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions,
Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance
Writing Philip Greenland, MD, FACC, FAHA, Chair Sidney C. Smith, JR, MD, FACC, FAHA(cid:1)(cid:1)¶¶
Committee
Allen J. Taylor, MD, FACC, FAHA##
Members
Joseph S. Alpert, MD, FACC, FAHA William S. Weintraub, MD, FACC, FAHA
George A. Beller, MD, MACC, FAHA Nanette K. Wenger, MD, MACC, FAHA
EmeliaJ.Benjamin,MD,SCM,FACC,FAHA*†
Matthew J. Budoff, MD, FACC, FAHA‡§(cid:1) *ACCF/AHATaskForceonPerformanceMeasuresLiaison;†Recused
fromvotingonSection2.4.5,Lipoprotein-AssociatedPhospholipaseA2;
Zahi A. Fayad, PHD, FACC, FAHA¶
‡RecusedfromvotingonSection2.5.11,CoronaryComputedTomogra-
Elyse Foster, MD, FACC, FAHA# phy Angiography; §Recused from voting on Section 2.6.1, Diabetes
Mark. A. Hlatky, MD, FACC, FAHA§** Mellitus;(cid:1)SAIPRepresentative;¶SCMRRepresentative;#ASERepre-
sentative;**RecusedfromvotingonSection2.5.10,ComputedTomogra-
John McB. Hodgson, MD, FACC, FAHA,
phy for Coronary Calcium; ††SCAI Representative; ‡‡Recused from
FSCAI‡§**†† voting on Section 2.3, Lipoprotein and Apolipoprotein Assessments;
Frederick G. Kushner, MD, FACC, FAHA†‡‡ §§ASNCRepresentative;(cid:1)(cid:1)ACCF/AHATaskForceonPracticeGuide-
linesLiaison;¶¶RecusedfromvotingonSection2.4.2,Recommendations
Michael S. Lauer, MD, FACC, FAHA
forMeasurementofC-ReactiveProtein;##SCCTRepresentative.
Leslee J. Shaw, PHD, FACC, FAHA§§
ACCF/AHA Alice K. Jacobs, MD, FACC, FAHA, Chair, Jonathan L. Halperin, MD, FACC, FAHA
TaskForce
2009–2011 Judith S. Hochman, MD, FACC, FAHA
Members
Sidney C. Smith, JR, MD, FACC, FAHA, Frederick G. Kushner, MD, FACC, FAHA
Immediate Past Chair, 2006–2008*** Rick Nishimura, MD, FACC, FAHA***
Jeffrey L. Anderson, MD, FACC, FAHA, E. Magnus Ohman, MD, FACC
Chair-Elect Richard L. Page, MD, FACC, FAHA***
William G. Stevenson, MD, FACC, FAHA
Nancy Albert, PHD, CCNS, CCRN Lynn G. Tarkington, RN***
Christopher E. Buller, MD, FACC*** Clyde W. Yancy, MD, FACC, FAHA
Mark A. Creager, MD, FACC, FAHA
Steven M. Ettinger, MD, FACC ***FormerACCF/AHATaskForcememberduringthiswritingeffort.
Robert A. Guyton, MD, FACC
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyFoundationBoard ThisarticleiscopublishedinCirculationandtheJournalofCardiovascularComputed
of Trustees, the American Heart Association Science Advisory and Coordinating Tomography.
CommitteeandallcosponsoringorganizationsinSeptember2010. Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmerican
TheAmericanCollegeofCardiologyFoundationrequeststhatthisdocumentbecited CollegeofCardiologyFoundation(www.cardiosource.org)andtheAmericanHeart
asfollows:GreenlandP,AlpertJS,BellerGA,BenjaminEJ,BudoffMJ,FayadZA, Association (my.americanheart.org). For copies of this document, please contact
FosterE,HlatkyMA,HodgsonJMcB,KushnerFG,LauerMS,ShawLJ,SmithSC,Jr., ElsevierInc.ReprintDepartment,fax[phone],[email protected].
TaylorAJ,WeintraubWS,WengerNK.2010ACCF/AHAguidelineforassessmentof Permissions: Modification, alteration, enhancement, and/or distribution of this
cardiovascular risk in asymptomatic adults: a report of the American College of documentarenotpermittedwithouttheexpresspermissionoftheAmericanCollege
CardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines. of Cardiology Foundation. Please contact Elsevier’s permission department at
JAmCollCardiol2010;56:xxx–xxx. [email protected].
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2.4.3.3. ASSOCIATIONWITHCARDIOVASCULARRISK
TABLE OF CONTENTS
INPERSONSWITHOUTDIABETES..........XXXX
2.4.4. UrinaryAlbuminExcretion................XXXX
Preamble...................................................XXXX 2.4.4.1. RECOMMENDATIONSFORTESTING
FORMICROALBUMINURIA................XXXX
2.4.4.2. GENERALDESCRIPTION.................XXXX
1. Introduction ...........................................XXXX 2.4.4.3. ASSOCIATIONWITH
CARDIOVASCULARRISK.................XXXX
1.1. MethodologyandEvidenceReview............XXXX 2.4.4.4. USEFULNESSINMOTIVATINGPATIENTSOR
1.2. OrganizationoftheWritingCommittee .......XXXX GUIDINGTHERAPY.....................XXXX
1.3. DocumentReviewandApproval................XXXX 2.4.5. L2i.p4o.5p.1r.otReEinC-OAMMssEoNcDiaAtTeIOdNPFhORosLpIPhOoPlRipOaTsEeINA-AS2SO.C.I.AXTXEDXX
1.4. MagnitudeoftheProblemofCardiovascular PHOSPHOLIPASEA2....................XXXX
RiskinAsymptomaticAdults...................XXXX 2.4.5.2. GENERALDESCRIPTION.................XXXX
1.5. AssessingthePrognosticValueofRisk 2.4.5.3. ASSOCIATIONWITHCARDIOVASCULARRISK.XXXX
FactorsandRiskMarkers.......................XXXX 2.4.5.4. USEFULNESSINMOTIVATINGPATIENTSORGUIDING
1.6. UsefulnessinMotivatingPatientsor THERAPY.............................XXXX
GuidingTherapy..................................XXXX 2.5. CardiacandVascularTestsforRisk
1.7. EconomicEvaluationofNovelRiskMarkers....XXXX AssessmentinAsymptomaticAdults..........XXXX
2.5.1. RestingElectrocardiogram.................XXXX
2. ApproachestoRiskStratification .................XXXX 2.5.1.1. RECOMMENDATIONSFOR
RESTINGELECTROCARDIOGRAM...........XXXX
2.1. GeneralApproachtoRiskStratification.......XXXX 2.5.1.2. GENERALDESCRIPTION.................XXXX
2.1.1. RecommendationforGlobalRiskScoring ...XXXX 2.5.1.3. ASSOCIATIONWITHINCREASEDRISKAND
2.1.1.1. GENERALDESCRIPTION.................XXXX INCREMENTALRISK....................XXXX
2.1.2. AssociationWithIncreasedRiskand 2.5.1.4. USEFULNESSINMOTIVATINGPATIENTS,GUIDING
IncrementalRiskofAdditionalRiskFactors...XXXX THERAPY,ANDIMPROVINGOUTCOMES......XXXX
2.2. FamilyHistoryandGenomics...................XXXX 2.5.2. Resting Echocardiography for Left
2.2.1. RecommendationforFamilyHistory.......XXXX Ventricular Structure and Function
2.2.1.1. ASSOCIATIONWITHINCREASEDCARDIOVASCULAR and Left Ventricular Hypertrophy:
RISKANDINCREMENTALRISK..............XXXX TransthoracicEchocardiography..........XXXX
2.2.1.2. USEFULNESSINMOTIVATINGPATIENTSOR 2.5.2.1. RECOMMENDATIONSFORTRANSTHORACIC
GUIDINGTHERAPY.....................XXXX ECHOCARDIOGRAPHY...................XXXX
2.2.2. Genotypes:CommonGeneticVariantsfor 2.5.2.2. LEFTVENTRICULARFUNCTION............XXXX
CoronaryHeartDisease....................XXXX 2.5.2.3. LEFTVENTRICULARHYPERTROPHY ........XXXX
2.2.2.1. RECOMMENDATIONFORGENOMICTESTING...XXXX 2.5.2.4. USEFULNESSINMOTIVATINGPATIENTSOR
2.2.2.2. ASSOCIATIONWITHINCREASEDCARDIOVASCULAR GUIDINGTHERAPY.....................XXXX
RISKANDINCREMENTALRISK..............XXXX 2.5.3. CarotidIntima-MediaThickness
2.2.2.3. USEFULNESSINMOTIVATINGPATIENTSOR onUltrasound..............................XXXX
GUIDINGTHERAPY.....................XXXX 2.5.3.1. RECOMMENDATIONFORMEASUREMENTOF
2.3. LipoproteinandApolipoproteinAssessments ..XXXX CAROTIDINTIMA-MEDIATHICKNESS........XXXX
2.3.1. RecommendationforLipoproteinand 2.5.3.2. GENERALDESCRIPTION.................XXXX
2.5.3.3. INDEPENDENTRELATIONSHIPBEYOND
ApolipoproteinAssessments................XXXX
2.3.2. AssessmentofLipoproteinConcentrations, STANDARDRISKFACTORS...............XXXX
2.5.3.4. USEFULNESSINMOTIVATINGPATIENTSOR
OtherLipoproteinParameters,and
ModifiedLipids............................XXXX GUIDINGTHERAPY.....................XXXX
2.3.3. RiskPredictionRelationshipsBeyond 2.5.3.5. EVIDENCEFORIMPROVEDNET
StandardRiskFactors......................XXXX HEALTHOUTCOMES ....................XXXX
2.3.4. UsefulnessinMotivatingPatientsor 2.5.4. Brachial/PeripheralFlow-MediatedDilation....XXXX
2.5.4.1. RECOMMENDATIONFORBRACHIAL/PERIPHERAL
GuidingTherapy...........................XXXX
FLOW-MEDIATEDDILATION................XXXX
2.3.5. Evidence for Improved Net
2.5.4.2. GENERALDESCRIPTION.................XXXX
HealthOutcomes .........................XXXX
2.5.4.3. ASSOCIATIONWITHINCREASEDRISKAND
2.4. OtherCirculatingBloodMarkersand
INCREMENTALPREDICTION...............XXXX
AssociatedConditions...........................XXXX 2.5.4.4. USEFULNESSINMOTIVATINGPATIENTSOR
2.4.1. RecommendationforMeasurementof
GUIDINGTHERAPY.....................XXXX
NatriureticPeptides........................XXXX 2.5.4.5. CHANGESINPATIENTOUTCOMES .........XXXX
2.4.1.1. GENERALDESCRIPTION.................XXXX 2.5.5. PulseWaveVelocityandOtherArterial
2.4.1.2. USEFULNESSINMOTIVATINGPATIENTSOR
Abnormalities:Measuresof
GUIDINGTHERAPY.....................XXXX
2.4.2. RecommendationsforMeasurementof ArterialStiffness............................XXXX
2.5.5.1. RECOMMENDATIONFORSPECIFICMEASURES
C2-.4R.2e.1a.ctAivSeSOPCIrAoTItOeNinW.IT.H.I.N.C.R.E.A.S.E.D.C.A.R.D.I.O.V.A.S.C.U.LA.R.XXXX OFARTERIALSTIFFNESS ................XXXX
2.5.5.2. DESCRIPTIONOFSPECIFICMEASURESOF
RISKANDINCREMENTALRISKPREDICTION....XXXX
2.4.3. Metabolic:HemoglobinA1C..............XXXX ARTERIALSTIFFNESS...................XXXX
2.4.3.1. RECOMMENDATIONFORMEASUREMENTOF 2.5.5.3. EVIDENCEONTHEASSOCIATIONWITH
HEMOGLOBINA1C .....................XXXX INCREASEDCARDIOVASCULARRISKAND
2.4.3.2. GENERALDESCRIPTION.................XXXX INCREMENTALRISK....................XXXX
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2.5.5.4. USEFULNESSINMOTIVATINGPATIENTSOR 2.6.1.4. NONINVASIVESTRESSIMAGINGFORDETECTION
GUIDINGTHERAPY.....................XXXX OFISCHEMIAANDRISKSTRATIFICATION.....XXXX
2.5.6. RecommendationforMeasurementof 2.6.1.5. USEFULNESSINMOTIVATINGPATIENTS.....XXXX
Ankle-BrachialIndex ......................XXXX 2.6.1.6. EVIDENCEOFVALUEFORRISKASSESSMENTFOR
2.5.6.1. GENERALDESCRIPTION.................XXXX CORONARYATHEROSCLEROSISORISCHEMIA
2.5.6.2. ASSOCIATIONWITHINCREASEDRISK ......XXXX ORBOTHTOGUIDETHERAPYORCHANGE
2.5.6.3. USEFULNESSINMOTIVATINGPATIENTSOR PATIENTOUTCOMES.....................XXXX
GUIDINGTHERAPY.....................XXXX 2.6.1.7. DIABETESANDHEMOGLOBINA1C.........XXXX
2.5.7. Recommendation for 2.6.1.8. ASSOCIATIONWITHCARDIOVASCULARRISK....XXXX
ExerciseElectrocardiography .............XXXX 2.6.1.9. USEFULNESSINMOTIVATINGPATIENTS,GUIDING
2.5.7.1. ASSOCIATIONWITHINCREASEDRISKAND
THERAPY,ANDIMPROVINGOUTCOMES......XXXX
INCREMENTALRISK....................XXXX 2.6.2. SpecialConsiderations:Women............XXXX
2.5.7.2. USEFULNESSINMOTIVATINGPATIENTSOR 2.6.2.1. RECOMMENDATIONSFORSPECIAL
GUIDINGTHERAPY.....................XXXX CONSIDERATIONSINWOMEN.............XXXX
2.5.8. Recommendationfor 2.6.2.2. DETECTIONOFWOMENATHIGHRISKUSING
StressEchocardiography ...................XXXX TRADITIONALRISKFACTORSANDSCORES...XXXX
2.5.8.1. GENERALDESCRIPTION.................XXXX 2.6.2.3. COMPARABLEEVIDENCEBASEFORRISK
2.5.8.2. ASSOCIATIONWITHINCREASEDRISK ......XXXX STRATIFICATIONOFWOMENANDMEN.....XXXX
2.5.8.3. USEFULNESSINMOTIVATINGPATIENTSOR 2.6.3. EthnicityandRace.........................XXXX
GUIDINGTHERAPY.....................XXXX 2.6.4. OlderAdults...............................XXXX
2.5.9. MyocardialPerfusionImaging .............XXXX 2.6.5. ChronicKidneyDisease....................XXXX
2.5.9.1. RECOMMENDATIONSFORMYOCARDIAL
PERFUSIONIMAGING...................XXXX 3. FutureResearchNeeds..............................XXXX
2.5.9.2. DESCRIPTIONOFMYOCARDIAL
PERFUSIONIMAGING...................XXXX 3.1. TimingandFrequencyofFollow-UpforGeneral
2.5.9.3. EVIDENCEOFASSOCIATIONWITH RiskAssessment..................................XXXX
INCREASEDCARDIOVASCULARRISKIN
3.2. OtherTestStrategiesforWhichAdditional
ASYMPTOMATICADULTS.................XXXX ResearchIsNeeded.............................XXXX
2.5.9.4. USEFULNESSINMOTIVATINGPATIENTSOR
3.2.1. MagneticResonanceImaging..............XXXX
GUIDINGTHERAPY.....................XXXX 3.2.2. GeneticTestingandGenomics ............XXXX
2.5.9.5. CHANGESINPATIENTOUTCOMES .........XXXX 3.2.3. GeographicandEnvironmentalor
2.5.10. ComputedTomographyfor
NeighborhoodRisks .......................XXXX
CoronaryCalcium..........................XXXX 3.2.4. RoleofRiskAssessmentStrategiesin
2.5.10.1. RECOMMENDATIONSFORCALCIUM
SCORINGMETHODS....................XXXX ModifyingPatientOutcomes...............XXXX
2.5.10.2. CALCIUMSCORINGMETHODS.............XXXX 3.3. ClinicalImplicationsofRiskAssessment:
2.5.10.3. DATAONINDEPENDENTRELATIONSHIPTO ConcludingComments...........................XXXX
CARDIOVASCULAREVENTS...............XXXX Appendix1.AuthorRelationshipsWithIndustry
22..55..1100..45.. UUSSEEFAUSLNAESRSEPINEAMTOMTEIVAASTUINRGETPOATMIEONNTISTO.R....XXXX andOtherEntities........................................XXXX
EFFECTSOFTHERAPYIN
ASYMPTOMATICPERSONS ..............XXXX Appendix2.ReviewerRelationshipsWithIndustry
2.5.10.6. USEFULNESSOFCORONARYCALCIUM andOtherEntities........................................XXXX
SCORINGINGUIDINGTHERAPY...........XXXX
2.5.10.7. EVIDENCEFORIMPROVEDNET
HEALTHOUTCOMES ....................XXXX Appendix3.AbbreviationsList.........................XXXX
2.5.10.8. SPECIALCONSIDERATIONS...............XXXX
2.5.11. CoronaryComputed References................................................XXXX
TomographyAngiography.................XXXX
2.5.11.1. RECOMMENDATIONFORCORONARYCOMPUTED
TOMOGRAPHYANGIOGRAPHY .............XXXX
2.5.11.2. GENERALDESCRIPTION.................XXXX Preamble
2.5.11.3. ASSOCIATIONWITHINCREASEDRISKAND
INCREMENTALPREDICTIONIN
ASYMPTOMATICPERSONS...............XXXX Itisessentialthatthemedicalprofessionplayacentralrole
2.5.11.4. CHANGESINPATIENTOUTCOMES .........XXXX incriticallyevaluatingtheevidencerelatedtodrugs,devices,
2.5.12. MagneticResonanceImagingofPlaque....XXXX and procedures for the detection, management, or preven-
2.5.12.1. RECOMMENDATIONFORMAGNETIC
tionofdisease.Properlyapplied,rigorous,expertanalysisof
RESONANCEIMAGINGOFPLAQUE.........XXXX
2.5.12.2. GENERALDESCRIPTION.................XXXX the available data documenting absolute and relative bene-
fitsandrisksofthesetherapiesandprocedurescanimprove
2.6. SpecialCircumstancesand
OtherConsiderations............................XXXX the effectiveness of care, optimize patient outcomes, and
2.6.1. DiabetesMellitus ..........................XXXX favorablyaffectthecostofcarebyfocusingresourcesonthe
2.6.1.1. RECOMMENDATIONSFORPATIENTS most effective strategies. One important use of such data is
WITHDIABETES........................XXXX
the production of clinical practice guidelines that, in turn,
2.6.1.2. GENERALDESCRIPTIONANDBACKGROUND...XXXX
canprovideafoundationforavarietyofotherapplications,
2.6.1.3. ELECTROCARDIOGRAPHICSTRESSTESTING
FORSILENTMYOCARDIALISCHEMIA.......XXXX such as performance measures, appropriate use criteria,
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clinical decision support tools, and quality improvement illustrates how the grading system provides an estimate of
tools. the size as well as the certainty of the treatment effect. A
The American College of Cardiology Foundation new addition to the ACCF/AHA methodology is a sepa-
(ACCF)andtheAmericanHeartAssociation(AHA)have ration of the Class III recommendations to delineate
jointlyengagedintheproductionofguidelinesintheareaof whether the recommendation is determined to be of “no
cardiovascular disease since 1980. The ACCF/AHA Task benefit” or associated with “harm” to the patient. In addi-
Force on Practice Guidelines (Task Force) is charged with tion, in view of the increasing number of comparative
developing, updating, and revising practice guidelines for effectiveness studies, comparator verbs and suggested
cardiovascular diseases and procedures, and the Task Force phrases for writing recommendations for the comparative
directs and oversees this effort. Writing committees are effectiveness of one treatment/strategy with respect to an-
charged with assessing the evidence as an independent other for COR I and IIa, LOE A or B only, have been
group of authors to develop, update, or revise recommen- added.
dations for clinical practice. TheTaskForceonPracticeGuidelinesmakeseveryeffort
Experts in the subject under consideration have been to avoid actual, potential, or perceived conflicts of interest
selectedfrombothorganizationstoexaminesubject-specific that may arise as a result of industry relationships or
dataandwriteguidelinesinpartnershipwithrepresentatives personal interests among the writing committee. Specifi-
fromothermedicalpractitionerandspecialtygroups.Writ- cally,allmembersofthewritingcommittee,aswellaspeer
ingcommitteesarespecificallychargedtoperformaformal reviewers of the document, are asked to disclose ALL
literature review; weigh the strength of evidence for or relevant relationships and those existing 24 months before
against particular tests, treatments, or procedures; and initiation of the writing effort. All guideline recommenda-
include estimates of expected health outcomes where data tions require a confidential vote by the writing committee
exist.Patient-specificmodifiers,comorbidities,andissuesof and must be approved by a consensus of the members
patient preference that may influence the choice of tests or voting. Members who were recused from voting are noted
therapiesareconsidered.Whenavailable,informationfrom on the title page of this document and in Appendix 1.
studiesoncostisconsidered,butdataonefficacyandclinical Members must recuse themselves from voting on any
outcomesconstitutetheprimarybasisforrecommendations recommendation to which their relationship with industry
in these guidelines. and other entities (RWI) applies. Any writing committee
In analyzing the data and developing recommendations memberwhodevelopsanewRWIduringhisorhertenure
and supporting text, the writing committee used evidence- is required to notify guideline staff in writing. These
based methodologies developed by the Task Force that are statements are reviewed by the Task Force on Practice
described elsewhere (1). The committee reviewed and Guidelinesandallmembersduringeachconferencecalland
rankedevidencesupportingcurrentrecommendations,with meeting of the writing committee and are updated as
the weight of evidence ranked as Level A if the data were changes occur. For detailed information about guideline
derived from multiple randomized clinical trials or meta- policies and procedures, please refer to the ACCF/AHA
analyses.ThecommitteerankedavailableevidenceasLevel methodology and policies manual (1). Authors’ and peer
Bwhendatawerederivedfromasinglerandomizedtrialor reviewers’ RWI pertinent to this guideline are disclosed in
nonrandomized studies. Evidence was ranked as Level C Appendixes 1 and 2, respectively. In addition, to ensure
when the primary source of the recommendation was complete transparency, writing committee members’ com-
consensus opinion, case studies, or standard of care. In the prehensive disclosure information—including RWI not perti-
narrative portions of these guidelines, evidence is generally nent to this document—is available online as a supplement
presented in chronological order of development. Studies to this document. Disclosure information for the ACCF/
areidentifiedasobservational,retrospective,prospective,or AHATaskForceonPracticeGuidelinesisavailableonline
randomized when appropriate. For certain conditions for at www.cardiosource.org/ACC/About-ACC/Leadership/
which inadequate data are available, recommendations are Guidelines-and-Documents-Task-Forces.aspx. The work
based on expert consensus and clinical experience and of the writing committee was supported exclusively by the
ranked as Level C. An example is the use of penicillin for ACCF and AHA without commercial support. Writing
pneumococcal pneumonia, where there are no randomized group members volunteered their time for this effort.
trials and treatment is based on clinical experience. When The ACCF/AHA practice guidelines address patient
recommendations at Level C are supported by historical populations (and health care providers) residing in North
clinical data, appropriate references (including clinical re- America. As such, drugs that are not currently available in
views)arecitedifavailable.Forissueswheresparsedataare North America are discussed in the text without a specific
available, a survey of current practice among the clinicians class of recommendation. For studies performed in large
on the writing committee was the basis for Level C numbersofsubjectsoutsideofNorthAmerica,eachwriting
recommendations and no references are cited. The schema committeereviewsthepotentialimpactofdifferentpractice
forClassificationofRecommendations(COR)andLevelof patternsandpatientpopulationsonthetreatmenteffectand
Evidence (LOE) is summarized in Table 1, which also the relevance to the ACCF/AHA target population to
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Table1. ApplyingClassificationofRecommendationsandLevelofEvidence
■
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchasgender,age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheart
failure,andprioraspirinuse.ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonot
lendthemselvestoclinicaltrials.Eventhoughrandomizedtrialsarenotavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.
†Forcomparativeeffectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisonsofthe
treatmentsorstrategiesbeingevaluated.
determine whether the findings should inform a specific and patient in light of all the circumstances presented by
recommendation. that patient. Thus, there are circumstances in which devi-
The ACCF/AHA practice guidelines are intended to ations from these guidelines may be appropriate. Clinical
assist healthcare providers in clinical decision making by decisionmakingshouldconsiderthequalityandavailability
describingarangeofgenerallyacceptableapproachestothe ofexpertiseintheareawherecareisprovided.Whenthese
diagnosis, management, and prevention of specific diseases guidelines are used as the basis for regulatory or payer
orconditions.Thesepracticeguidelinesrepresentaconsen- decisions,thegoalshouldbeimprovementinqualityofcare.
susofexpertopinionafterathoroughandsystematicreview The Task Force recognizes that situations arise in which
of the available current scientific evidence and are intended additional data are needed to better inform patient care;
to improve patient care. The guidelines attempt to define these areas will be identified within each respective guide-
practices that meet the needs of most patients in most line when appropriate.
situations. The ultimate judgment regarding care of a Prescribed courses of treatment in accordance with these
particular patient must be made by the healthcare provider recommendations are effective only if they are followed.
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Because lack of patient understanding and adherence may harm; data related to the relative treatment effects will also
adversely affect outcomes, physicians and other healthcare be provided, such as odds ratio (OR), relative risk (RR),
providers should make every effort to engage the patient’s hazardratio(HR),orincidencerateratio(IRR),alongwith
active participation in prescribed medical regimens and confidence interval (CI) when available.
lifestyles. Thefocusofthisguidelineistheinitialassessmentofthe
The guidelines will be reviewed annually by the Task apparentlyhealthyadultforriskofdevelopingcardiovascu-
Forceandconsideredcurrentuntiltheyareupdated,revised, lar events associated with atherosclerotic vascular disease.
or withdrawn from distribution. The executive summary Thegoalofthisearlyassessmentofcardiovascularriskinan
and recommendations are published in the Journal of the asymptomatic individual is to provide the foundation for
AmericanCollegeofCardiology,Circulation,andtheJournalof targeted preventive efforts based on that individual’s pre-
Cardiovascular Computed Tomography. dicted risk. It is based on the long-standing concept of
targeting the intensity of drug treatment interventions to
Alice K. Jacobs, MD, FACC, FAHA
the severity of the patient’s risk (2). This clinical approach
Chair, ACCF/AHA Task Force on Practice Guidelines
serves as a complement to the population approach to
prevention of cardiovascular disease (CVD), in which
1. Introduction
population-widestrategiesareusedregardlessofanindivid-
ual’s risk.
1.1. Methodology and Evidence Review
Thisguidelinepertainstoinitialassessmentofcardiovas-
The recommendations listed in this document are, when- cular risk in the asymptomatic adult. Although there is no
everpossible,evidence based. Anextensiveevidencereview clear age cut point for defining the onset of risk for CVD,
was conducted for the period beginning March 2008 elevated risk factor levels and subclinical abnormalities can
through April 2010. Searches were limited to studies, be detected in adolescents as well as young adults. To
reviews, and other evidence conducted in human subjects maximizethebenefitsofprevention-orientedinterventions,
and published in English. Key search words included, but especially those involving lifestyle changes, the writing
were not limited to, African Americans, Asian Americans, committee advises that these guidelines be applied in
albuminuria, asymptomatic, asymptomatic screening and bra- asymptomatic persons beginning at age 20. The writing
chial artery reactivity, atherosclerosis imaging, atrial fibrilla- committee recognizes that the decision about a starting
tion, brachial artery testing for atherosclerosis, calibration, point is an arbitrary one.
cardiactomography,compliance,carotidintima-mediathickness This document specifically excludes from consideration
(IMT), coronary calcium, coronary computed tomography an- patients with a diagnosis of CVD or a coronary event, for
giography (CCTA), C-reactive protein (CRP), detection of example,anginaoranginalequivalent,myocardialinfarction
subclinical atherosclerosis, discrimination, endothelial function, (MI), or revascularization with percutaneous coronary in-
family history, flow-mediated dilation, genetics, genetic screen- tervention or coronary artery bypass graft surgery. It also
ing, guidelines, Hispanic Americans, hemoglobin A, glycosy- excludes testing for patients with known peripheral artery
lated,meta-analysis,MexicanAmericans,myocardialperfusion disease(PAD)andcerebralvasculardisease.Thisguideline
imaging (MPI), noninvasive testing, noninvasive testing and is not intended to replace other sources of information on
type2diabetes,outcomes,patientcompliance,peripheralarterial cardiovascular risk assessment in specific disease groups or
tonometry (PAT), peripheral tonometry and atherosclerosis, higher-risk groups such as those with known hypertension
lipoprotein-associated phospholipase A2, primary prevention of or diabetes who are receiving treatment.
coronaryarterydisease(CAD),proteinuria,cardiovascularrisk,
1.2. Organization of the Writing Committee
risk scoring, receiver operating characteristics (ROC) curve,
screening for brachial artery reactivity, stress echocardiography, The committee was composed of physicians and others
subclinical atherosclerosis, subclinical and Framingham, sub- expert in the field of cardiology. The committee included
clinical and Multi-Ethnic Study of Atherosclerosis (MESA), representativesfromtheAmericanSocietyofEchocardiog-
and type 2 diabetes. Additionally, the writing committee raphy (ASE), American Society of Nuclear Cardiology
revieweddocumentsrelatedtothesubjectmatterpreviously (ASNC), Society of Atherosclerosis Imaging and Preven-
published by the ACCF and AHA, American Diabetes tion (SAIP), Society for Cardiovascular Angiography and
Association (ADA), European Society of Cardiology, and Interventions(SCAI),SocietyofCardiovascularComputed
the Joint National Committee on Prevention, Detection, Tomography (SCCT), and Society for Cardiovascular
Evaluation, and Treatment of High Blood Pressure (JNC) Magnetic Resonance (SCMR).
7. References selected and published in this document are
1.3. Document Review and Approval
representative and not all-inclusive.
To provide clinicians with a comprehensive set of data, This document was reviewed by 2 outside reviewers nomi-
whenever deemed appropriate or when published in the nated by the ACCF and 2 outside reviewers nominated by
article, data from the clinical trial will be used to calculate the AHA, as well as 2 reviewers each from ASE, ASNC,
the absolute risk difference and number needed to treat or SAIP, SCAI, SCCT, and SCMR, and 23 individual con-
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tent reviewers (including members from the Appropriate problem is immense, but the preventive opportunity is also
Use Criteria Task Force, ACCF Cardiac Catheterization great.
Committee, ACCF Imaging Council, and ACCF Preven-
1.5. Assessing the Prognostic Value of Risk
tion of Cardiovascular Disease Committee). All reviewer
Factors and Risk Markers
RWI information was collected and distributed to the
writing committee and is published in this document ManyriskfactorshavebeenproposedaspredictorsofCHD
(Appendix 2). (13,14). New risk factors or markers are frequently identi-
This document was approved for publication by the fied and evaluated as potential additions to standard risk
governingbodiesoftheACCFandAHAandendorsedby assessment strategies. The AHA has published a scientific
ASE, ASNC, SAIP, SCCT, and SCMR. statement on appropriate methods for evaluating the pre-
dictive value of new risk factors or risk markers (15). The
1.4. Magnitude of the Problem of Cardiovascular scientific statement endorsed previously published guide-
Risk in Asymptomatic Adults lines for proper reporting of observational studies in epide-
miology (16) but also went beyond those guidelines to
AtheroscleroticCVDistheleadingcauseofdeathforboth
specificallyaddresscriteriaforevaluationofestablishedand
men and women in the United States (3). Risk factors for
new risk markers. The current writing committee endorses
thedevelopmentofatheroscleroticdiseasearewidespreadin
this scientific statement and incorporated these principles
theU.S.population.In2003,approximately37%ofAmer-
intotheassessmentsforthisguideline.Thegeneralconcepts
icanadultsreportedhaving(cid:1)2riskfactorsforCVD.Ninety
and requirements for new risk marker validation and eval-
percentofpatientswithcoronaryheartdisease(CHD)have
uation are briefly reviewed to provide a basis for the
at least 1 atherosclerotic risk factor (4). Approximately half
assessments in this document.
ofallcoronarydeathsarenotprecededbycardiacsymptoms
For any new risk marker to be considered useful for risk
ordiagnoses(5).Oneaimofthisguidelineistoprovidean
prediction, it must, at the very least, have an independent
evidence-based approach to risk assessment in an effort to
statistical association with risk after accounting for estab-
lowerthishighburdenofcoronarydeathsinasymptomatic
lished readily available and inexpensive risk markers. This
adults.
independentstatisticalassociationshouldbebasedonstud-
CVD was mentioned on the death certificates of 56% of
ies that include large numbers of outcome events. Tradi-
decedents in 2005. It was listed as the underlying cause of
tionally, reports of novel risk markers have only gone this
death in 35.3% (864,480) of all deaths (2,448,017) in 2005
far, reporting adjusted HRs with CIs and p values (17).
or 1 of every 2.8 deaths in the U.S. (6). In every year since
Although this level of basic statistical association is often
1900 (except 1918), CVD accounted for more deaths than
regarded by researchers as meaningful in prediction of a
any other major cause of death in the United States (6). It
particularoutcomeofinterest,theAHAscientificstatement
isestimatedthatifallformsofmajorCVDwereeliminated,
called for considerably more rigorous assessments that
life expectancy would rise by almost 7 years (6). Analyses
include analysis of the calibration, discrimination, and
suggest that the decrease in U.S. deaths due to CHD from
reclassification of the predictive model. Many of the tests
1980to2000waspartlyattributable(approximately47%)to
reviewed in this guideline fail to provide these more com-
evidence-based medical therapies, and about 44% of the
prehensive measures of test evaluation, and for this reason,
reduction has been attributed to changes in risk factors in many tests that are statistically associated with clinical
thepopulation(7).Theestimateddirectandindirectcostof outcomes cannot be judged to be useful beyond a standard
CVD for 2009 is $475.3 billion (6). risk assessment profile. In the absence of this evidence of
CHD has a long asymptomatic latent period, which “additive predictive information,” the writing committee
provides an opportunity for early preventive interventions. generallyconcludedthatanewriskmarkerwasnotreadyfor
Atherosclerosis begins in childhood and progresses into routine use in risk assessment.
adulthood due to multiple coronary risk factors such as Calibration and discrimination are 2 separate concepts
unfavorable levels of blood lipids, blood pressure, body that do not necessarily track with each other. Calibration
weightandbodyfat,smoking,diabetes,andgeneticpredis- refers to the ability to correctly predict the proportion of
position (8–10). The lifetime risk of CHD and its various subjectswithinanygivengroupwhowillexperiencedisease
manifestations has been calculated for the Framingham events.Amongpatientspredictedtobeathigherrisk,there
Heart Study population at different ages. In nearly 8000 will be a higher number of events, whereas among patients
persons initially free of clinical evidence of CHD, the identified as being at lower risk, there will be fewer events.
lifetimeriskofdevelopingclinicallymanifestCHD(angina For example, if a diagnostic test or a multivariable model
pectoris,MI,coronaryinsufficiency,ordeathfromCHD)at splitspatientsinto3groupswithpredictedrisksof5%,10%,
age 40 was 48.6% for men and 31.7% for women (11). At and15%withineachgroup,calibrationwouldbeconsidered
age70,thelifetimeriskofdevelopingCHDwas34.9%for goodifinaseparategroupofcohortswithsimilarpredicted
men and 24.2% for women. The lifetime risk for all CVD risks, the actual rates of events were close to 5%, 10%, and
combined is nearly 2 of every 3 Americans (12). Thus, the 15%. Calibration is best presented by displaying observed
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8 Greenlandetal. JACCVol.56,No.25,2010
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versusexpectedeventratesacrossquantilesofpredictedrisk 1.6. Usefulness in Motivating Patients or
formodelsthatdoanddonotincludethenewriskmarker. Guiding Therapy
Discrimination is a different concept that refers to the In 1996 the American College of Cardiology Bethesda
probability of a diagnostic test or a risk prediction instru- Conference reviewed the concept of risk stratification, an
ment to distinguish between patients who are at higher approachthatisnowstandardforidentifyingtheappropri-
compared with lower risk. For example, a clinician sees 2 ate degree of therapeutic or preventive interventions (2).
random patients, 1 of whom is ultimately destined to Patients deemed to be at low risk for clinical events are
experience a clinical event. A diagnostic test or risk model unlikely to gain substantial benefits from pharmaceutical
discriminateswellifitusuallycorrectlypredictswhichofthe interventions and therefore might best be managed with
2subjectsisathigherriskforanevent.Mathematicallythis lifestylemodifications.Conversely,patientsdeemedtobeat
is described by calculating a C index or C statistic, param- high risk for events are more likely to benefit from phar-
eters that are analogous to the area under the ROC curve. macologic interventions and therefore are appropriate can-
These statistics define the probability that a randomly didatesforintensiveriskfactormodificationefforts.Among
selectedpersonfromthe“affectedgroup”willhaveahigher patients at intermediate risk, further testing may be indi-
test score than a randomly selected person from the “non- cated to refine risks and assess the need for treatment.
affectedgroup.”Atestwithnodiscriminationwouldhavea Althoughthismodelisattractiveandhasbeenshowntobe
Cstatisticof0.50andaperfecttestwouldhaveaCstatistic appropriate in certain situations, there is no definitive
of1.0.Throughoutthisdocument,Cstatisticinformationis evidencethatitdirectlyleadstoimprovedpatientoutcomes.
cited where available. Further research is clearly needed, and it is appropriate to
point out that the risk stratification paradigm has not been
As an example of a risk marker that improves discrimi-
subjected to rigorous evaluation by randomized trials. In-
nation, MESA investigators found that the addition of
deed, the impact of various risk assessment modalities on
coronary artery calcium (CAC) scores to standard risk
patientoutcomesisrarelystudiedandnotwelldocumented
factors improved the area under the ROC curve from 0.77
to0.82(p(cid:1)0.001)(18).Incontrast,ascorebasedon9genes in the few studies that have been conducted (24).
that code for cholesterol levels added no predictive value
1.7. Economic Evaluation of Novel Risk Markers
over established risk factors and family history (19). Simi-
larly, a study comparing the predictive capacity of conven- Theprogressivelyrisingcostsofmedicalcarehaveincreased
tionalandnewerbiomarkersforpredictionofcardiovascular interest in documenting the economic effects of new tests
events derived a C statistic of 0.760 for coronary events for and therapies. The most basic goal is to estimate the
economic consequences of a decision to order a new test.
the conventional risk factor model. Adding a number of
The ultimate goal is to determine whether performing the
newer biomarkers changed the C statistic by only 0.009
(p(cid:2)0.08)(20).SmallchangessuchastheseintheCstatistic test provides sufficient value to justify its use.
A complete economic evaluation of the test has to
suggest limited or rather modest improvement in risk
accountforallthesubsequentcostsinducedbyorderingthe
discrimination with additional risk markers.
test,notjustthecostofthetestitself.Theresultsofthetest
Someinvestigatorshavecalledforevaluatingthenum-
should change subsequent clinical management, which
berofsubjectsreclassifiedintootherriskcategoriesbased
mightincludeorderingfollow-uptests,startingorstopping
on models that include the new risk marker (21). For
drug therapy, or using a device or procedure. The costs of
example, in a model of cardiovascular risk in a large
these subsequent clinical management choices must be
cohort of healthy women, the addition of CRP resulted
included in an “intention-to-test” analysis of the economic
in reclassification of a large proportion of subjects who
consequences of the initial decision to use the test. Ideally,
werethoughttobeatintermediateriskbasedonstandard
theanalysisshouldbeextendedtoaccountforclinicalevents
risk markers alone (22). One problem with this approach
that are either averted or caused as a result of the strategy
is that not all reclassification is necessarily clinically
based on performing the test.
useful. If a patient is deemed to be at intermediate risk
Anexampleoftheeconomicconsequencesoftestingwill
and is then reclassified as being at high or low risk, the
illustrate the importance of these principles. Suppose a
clinician might find that information helpful. It may not
patient with diabetes who has no cardiac symptoms under-
beknown,however,whetherornotthesereclassifications goes a computed tomography (CT) coronary angiogram,
arecorrectforindividualsubjects.Pencinaandcolleagues which reveals obstructive CAD but also leads to contrast-
introduced2newapproaches,namely“netreclassification induced nephropathy. Further suppose this patient has a
improvement” and “integrated with classification im- follow-upinvasivecoronaryangiogram,undergoesinsertion
provement,” which provide quantitative estimates of cor- ofacoronarystent,andistreatedforrenalinsufficiency.The
rect reclassifications (23). Correct reclassifications are costsofallthese“downstreamevents”shouldbeincludedin
associatedwithhigherpredictedrisksforcasesandlower anyeconomicassessmentoftheuseofCCTAbecausethey
predicted risks for noncases. all resulted from the initial decision to perform the test.
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Note that the total costs of a “test strategy” may greatly “classic risk factors,” namely, cigarette smoking, cholesterol
exceed the cost of the initial test itself. levels, blood pressure levels, and diabetes. Data obtained
The cost of any medical intervention has to be placed in from the Framingham Heart Study and other population-
the context of the clinical benefits that the intervention based cohorts have demonstrated that age, sex, cigarette
provides. In the example of the patient with diabetes, smoking,leveloflow-densitylipoprotein(LDL)cholesterol
perhaps the aggressive use of coronary revascularization or total cholesterol, diabetes, and levels of blood pressure
actuallyextendedlifeexpectancy.Cost-effectivenessanalysis can be combined in predictive models to estimate risk of
provides a formal framework with which to compare the fatal and nonfatal CHD events (26). Beginning in the
clinical effectiveness of an intervention (measured in 1990s, a number of global risk prediction instruments were
patient-centeredoutcomessuchaslengthoflifeorqualityof introduced,basedonmultivariablemodelsthatincorporated
life) with the cost of that intervention. Cost-effectiveness risk factor data and clinical events (25–28). These instru-
analysishasbeenmostcommonlyapplied to theevaluation ments go beyond simple demographics by taking into
of new medical therapies that directly improve clinical account modifiable risk markers that are also appropriate
outcomes (e.g., use of bypass surgery to treat CAD). evidence-basedtargetsforpreventiveinterventions.Table2
Diagnostic tests do not improve clinical outcomes directly, summarizes a sample of published global risk score
however, and do so only indirectly by changing clinical instruments.
management decisions, which in turn may improve clinical Globalriskassessmentinstruments,suchastheFRS,are
outcomes. Thus, determining the cost-effectiveness of a considered valuable in medical practice because clinicians
diagnostictestdependsonhoweffectivelytheinformationis and patients may not otherwise accurately assess risk. In
used and can be evaluated only in the context of available some survey studies, clinicians presented with scenarios
treatments and how effective those treatments are. A test werefoundtooverestimatethelikelihoodofafuturemajor
thatprovidesaccurateriskinformationaboutanuntreatable clinical cardiovascular event (29). Other studies have sug-
diseaseisunlikelytobecost-effectivesimplybecauseclinical gestedthatphysiciansmayalsounderestimaterisk(30–32).
outcomes cannot be improved by its use. Failuretouseglobalquantitativeriskinstrumentsmayresult
Ingeneral,testingstrategiessuchasthoseassessedinthis in physicians inappropriately informing patients that they
document have not included evaluations of the cost and are at high risk and inappropriately promoting therapeutic
cost-effectiveness of the tests. Therefore, although this interventions of modest or questionable benefit or, alterna-
general guidance is offered to the reader as a caveat, the tively, inadequately emphasizing risk when risk is actually
writing committee was generally unable to find evidence to present.
supportthecost-effectivenessofanyofthetestsandtesting Global risk scores, although designed to estimate risk
approaches discussed here. Where exceptions were identi- across a continuous range from 0% to 100%, have most
fied, cost-related information is included. In addition, for commonly been advocated as a method by which patients
the uncommon examples for which clinical outcomes of can be categorized in broad terms as “low risk,” “interme-
testing strategies were assessed, the writing committee diate risk,”and“highrisk.”Ingeneral,patients aredeemed
includedthatevidenceintheassessmentofthevalueofthe to be high risk if they are found to have a global risk
risk assessment test. estimateforhardCHDeventsofatleast20%over10years.
Thethresholdfordividinglowriskfromintermediateriskis
2. Approaches to Risk Stratification notuniform,withsomeproposingalowercutoffvalueof6%
riskover10years,whereasothersuseavalueof10%over10
2.1. General Approach to Risk Stratification years (27,33,34). This document, unless otherwise noted,
usesalowercutoffvalueofatleast10%andahighercutoff
2.1.1. Recommendation for Global Risk Scoring of (cid:1)20% to designate intermediate risk.
CLASSI The evidence with regard to global risk scores is most
1. Globalriskscores(suchastheFraminghamRiskScore[FRS])that appropriateforindividuals(cid:1)40yearsofage.Itisimportant
use multiple traditional cardiovascular risk factors should be ob- to note that there are limited data from Framingham and
tained for risk assessment in all asymptomatic adults without a
other long-term observational studies on 10-year risk in
clinical history of CHD. These scores are useful for combining
youngadults;consequently,itisdifficulttoestimate10-year
individualriskfactormeasurementsintoasinglequantitativeesti-
riskinyoungadults.Thisisduetothefactthat10-yearrisk
mateofriskthatcanbeusedtotargetpreventiveinterventions(25).
in young adults is very rarely impressively elevated, even in
(LevelofEvidence:B)
the face of significant risk factors, and thus there are a
2.1.1.1. GENERALDESCRIPTION limited number of coronary events for calculating risk. As
Prospective epidemological studies have established, pri- noted earlier in this document, the long-term or lifetime
marily in studies of people (cid:1)40 years of age, that readily risk may be substantially raised by the presence of risk
measured and often modifiable risk factors are associated factors in young adults. Although the earliest age at which
with the development of clinical CHD in asymptomatic these risk scores should be used has not been rigorously
individuals.Therearerobustprognosticdataforeachofthe established, the application of a particular risk score or test
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