Author + information
- Published online June 17, 2019.
- Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA,
- Lynne T. Braun, PhD, CNP, FAHA,
- Chiadi E. Ndumele, MD, PD, FAHA,
- Sidney C. Smith Jr., MD, MACC, FAHA,
- Laurence S. Sperling, MD, FACC, FAHA,
- Salim S. Virani, MD, PhD, FACC, FAHA and
- Roger S. Blumenthal, MD, FACC, FAHA
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 U.S. 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 U.S. 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 (e.g., 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.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee and the American Heart Association Science Advisory and Coordinating Committee in October 2018, and the American Heart Association Executive Committee in October 2018.
The American College of Cardiology requests that this document be cited as follows: Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC Jr, Sperling LS, Virani SS, Blumenthal RS. 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. J Am Coll Cardiol 2019;73:3153–67.
This article has been copublished in Circulation.
Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department via fax (212-633-3820) or e-mail ( ).
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- 2019 American Heart Association, Inc., and the American College of Cardiology Foundation
- Quantitative Risk Assessment in Primary Prevention
- Existing U.S.-Derived Risk Scores for CVD Risk Prediction
- Refining Risk Assessment for Individual Patients: The Clinician-Patient Discussion
- CAC Measurement to Reclassify Risk
- Practical Approach to Risk Assessment and Clinical Decision-Making
- Future Directions
- Author Relationships With Industry and Other Entities (Comprehensive)—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 the American College of Cardiology (August 2018)
- Reviewer Relationships With Industry and Other Entities (Comprehensive)—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 the American College of Cardiology