Assessing prognosis using risk scores the cardiology advisor

Consider a typical scenario of a year-old white man who takes no medications and does not smoke. His systolic blood pressure is mm Hg, and his total cholesterol is mg per dL 5. The MESA score is the only cardiovascular risk calculator that provides a score with, and without, coronary artery calcium values that has been validated in a large prospective sample.

In addition to counseling the patient on lifestyle changes, the clinician engages him in shared decision-making about initiating statin therapy. The patient remains undecided about starting a statin because of concerns related to taking medicine in general and the inconvenience and cost of taking a daily pill for the rest of his life. The most likely outcome of coronary artery calcium testing for this patient is a coronary artery calcium score greater than 0, and his absolute risk of having an ASCVD event would not be significantly altered.

assessing prognosis using risk scores the cardiology advisor

However, this patient could still benefit from statin therapy with an approximate NNT of Therefore, it is unclear if knowing the coronary artery calcium score would improve decision quality or adherence to statin therapy.

The tenets of behavioral psychology would suggest no improvement. Although supporters of using the coronary artery calcium score presume that knowledge of elevated coronary artery calcium or a score of 0 would facilitate the initiation of and long-term adherence to statins if the patient is at high risk or deferral if he is at low risk, the guideline recommendations to incorporate coronary artery calcium testing are not based on any data of hard clinical outcomes.

Proponents also argue that the coronary artery calcium score helps reclassify patients up or down in the risk of cardiovascular disease relative to the pooled cohort equation e.

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Data from the MESA cohort of 5, people were used to conclude that adding the coronary artery calcium score to the risk estimator resulted in a better prediction of ASCVD events. The problem is that many more people do not have events.

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In absolute terms, the number of people reclassified incorrectly is much higher than the number reclassified correctly. Therefore, if a person is reclassified to a higher risk group with coronary artery calcium vs.

Although experts do not recommend that coronary artery calcium tests should start a cascade of downstream testing, we routinely see asymptomatic people referred for stress testing, which often leads to coronary angiography and interventions. Percutaneous revascularization does not improve outcomes over optimal medical therapy 12 ; therefore, it is likely that most interventions that result from coronary artery calcium testing represent overtreatment and incur potential harm.

Coronary artery calcium testing for cardiovascular disease risk assessment also goes much farther than an LDL cholesterol test or a risk calculator.

For some patients, knowing they have calcium in their coronary arteries makes them believe they have heart disease, which can be life changing. Let's return to the year-old white man undergoing a coronary artery calcium test who is hoping for a score of 0 to avoid taking a statin. Instead, the coronary artery calcium score was less than but showed a focal area of calcium in a proximal coronary artery.

The patient started a statin to reduce his cardiovascular disease risk, but now every palpitation or period of dyspnea during exercise raises thoughts about angina and death. Although coronary artery calcium testing may slightly improve future risk prediction, this theoretical benefit is outweighed by its potential harms. Atherosclerosis is a complex lifelong disease, and wrongly simplifying it with coronary artery calcium testing helps the testers more than the tested.

Already a member or subscriber? Log in. Address correspondence to John Mandrola, MD, at john. Reprints are not available from the authors. J Am Coll Cardiol. Patient-accessible tool for shared decision making in cardiovascular primary prevention. Statin use for the primary prevention of cardiovascular disease in adults. Affect, risk, and decision making.

Health Psychol.Perspective: As a preventive cardiologist, I find this summary and guide to risk assessment for decision-making in primary prevention for ASCVD outstanding and a must-read for all health care providers responsible for primary prevention. However, it is important that clinicians realize the tools that recommend specific therapies based on risk estimates are vulnerable to the ever-changing recommendations based on new studies e. The following are key points to remember from this Special Report on the Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease ASCVD : This Special Report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk score tools, 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.

How and why to use risk estimates for events when deciding treatment options? Clinicians are often influenced by the term "relative risk" when making decisions regarding treatment options. Placebo-controlled studies generally describe comparative benefits of an active treatment lifestyle or pharmacologic using relative risk estimates for future events or incidence rates.

But these have little clinical usefulness even if relative risk is to fold when the risk in the reference group is low. In contrast, absolute risk estimation allows direct understanding of prognosis and identification of patients with certain risk factors and at sufficient risk to merit treatment with higher likelihood of net benefit to the individual or society.

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There is substantial observational evidence to support this approach in terms of patient selection for medical therapy maximizing net benefit and minimizing number-needed-to-treat to prevent one event in years for both statins and antihypertensive therapy. Health care providers can readily obtain estimates of absolute risk in patients without known heart or vascular disease using internet-based applications, and similar tools are often available within electronic health records, each of which can provide advice regarding long-term utility of treatment usually event rate over 10 years.

It provides therapy impact with expected change in risk with statins, blood pressure therapy, aspirin, and cigarette smoking. It also provides the rationale and advice with actual treatment suggestions e. While useful for the general US population and specific for ethnic groups, PCE is less accurate in certain groups known as a miscalibration or a mismatch between predicted and observed events.

In contrast, it may underestimate risk in persons with a family history of premature vascular disease, varying degrees of chronic kidney disease, and chronic inflammatory diseases. The latter require statin therapy regardless of age, gender, and other risk factors.

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While most diabetics require statin therapy, the PCE risk calculator provides additional data for deciding blood pressure treatment and targets and intensity of statin dosing. PCE applies to adults ages years. It is reasonable to consider year or lifetime risk estimation in younger adults to inform intensity of prevention efforts see ASVD Risk Estimator Plus. Adding these variables and selective use of coronary artery calcium scoring CAC scorecan help to overcome most issues of miscalibration for each of the many risk prediction equations.

The Reynolds Risk Score performs better than the PCE in some higher socioeconomic and lower risk cohorts and includes coronary revascularization as an endpoint. Recognizing the imprecision of multivariable CVD risk prediction scores, as well as the uncertainty clinicians and patients may encounter regarding the potential benefits of drug therapy for an individual patient at borderline or intermediate year ASCVD risk, additional testing for assessment of the presence of subclinical atherosclerosis with CAC score patient pay is reasonable and preferable to serum biomarkers and other modalities to detect subclinical atherosclerosis, which are weaker predictors of ASCVD events than the CAC score.

Consider avoiding or postponing drug therapy with exceptions being diabetes, heavy current smokers, or strong family history of premature ASCVD. Repeat discussion with patient regarding new information. Above threshold for statin benefit. Recommend statin therapy. Share via:. Media Center ACC. All rights reserved.This includes eating a heart-healthy diet, regular aerobic exercises, maintenance of desirable body weight and avoidance of tobacco products.

The results and recommendations provided by this application are intended to inform but do not replace clinical judgment. Therapeutic options should be individualized and determined after discussion between the patient and their care provider.

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assessing prognosis using risk scores the cardiology advisor

The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status. Estimates of year risk for ASCVD are based on data from multiple community-based populations and are applicable to African-American and non-Hispanic white men and women 40 through 79 years of age.

The estimates of lifetime risk are most directly applicable to non-Hispanic whites. Because the primary use of these lifetime risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

In rare cases, year risks may exceed lifetime risks given that the estimates come from different approaches.

assessing prognosis using risk scores the cardiology advisor

The reported estimate of lifetime risk is based on assigning each person into one of 5 mutually exclusive sex-specific groups, as per Lloyd-Jones et al. Within each of the 5 groups, each person receives the same lifetime risk estimate.

In other words, using this approach, there are only 5 possible lifetime risk estimates reported for men and only 5 possible lifetime risk estimates reported for women.

This feature of lifetime risk estimation will result in the estimated lifetime risk being less than the estimated year risk. In these cases, the year risk should be the primary focus for the risk discussion and risk reduction efforts.

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Nguyen, MD. By using this application and its content, you accept and agree to be bound by the following terms and conditions. This Application was produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of publication.

The results and recommendations provided by this application are not intended to, and should not, replace clinical judgment of the care provider. Further, the material is not intended to present the only, or necessarily the best, methods or procedures for the medical situation, but rather is intended to represent an approach, view, statement, or opinion.

The content in this product is presented as an educational service intended for licensed healthcare professionals. Therapeutic options should be determined after discussion between the patient and their care provider.

All Rights Reserved.

assessing prognosis using risk scores the cardiology advisor

The content of this app has been published for personal and educational use only. No commercial use is authorized. Comments: Heterogeneity in risk according to ethnic groups and within ethnic groups. An increased prevalence of high TGs was seen in all Asian American subgroups.

Comments: All ethnic groups appear to be at greater risk for dyslipidemia, but important to identify those with more sedentary behavior and less favorable diet. Type 2 diabetes DM develops at a lower lean body mass and at earlier age Majority of risk in South Asians explained by known risk factors, especially those related to insulin resistance. Comments: Increased prevalence of DM.

Features of MetS vary by ethnicity.

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Waist circumference, not weight, should be used to determine abdominal adiposity when possible. PCE may overestimate risk in East Asians. Comments: Country specific ethnicity, along with socio-economic status, may affect estimation of risk of PCE.

Asian-Americans: Utilize lifestyle counseling to recommend a heart healthy diet consistent with ethnic preferences to avoid weight gain, address BP and lipids. African-Americans: Utilize lifestyle counseling to recommend a heart healthy diet consistent with ethnic preferences to avoid weight gain, address BP and lipids.

Challenge is to avoid increased sodium, sugar and calories as groups acculturate. Asian-Americans: Japanese patients may be sensitive to statin dosing. In an open-label, randomized primary prevention trial, Japanese participants had a reduction in CVD events with low-intensity doses of pravastatin as compared to placebo.

In a secondary prevention trial, Japanese participants with CAD benefitted from a moderate-intensity doses of pitavastatin.This calculator assumes that you have not had a prior heart attack or stroke.

If you have, generally it is recommended that you discuss with your doctor about starting aspirin and a statin. Furthermore, if you have an LDL-cholesterol bad cholesterol greater thanit is also generally recommended that you discuss with your doctor about starting aspirin and a statin. Unfortunately, there is insufficient data to reliably predict risk for those less than 40 years of age or greater than 79 years of age and for those with total cholesterol greater than This will be a significant change from JNC Please let us know if you would like us to incorporate the new guidelines into cvriskcalculator.

An excel spreadsheet is also available for download. If you are an investigator interested in implementing an app for your own risk calculator, please submit an inquiry about our platform. Age years. Gender Male. Race African American.

Systolic blood pressure mmHg. Diastolic blood pressure mmHg. Treated for high blood pressure No.

Use of Risk Assessment Tools to Guide Decision-Making in ASCVD Prevention

Diabetes No. Smoker No.In the heart failure population, risk prediction is more challenging, with the severity of the heart failure having much more impact on expected survival than simple patient status as younger versus older.

Multivariate risk scores are generated by combining a selection of these individual markers, generally using a logistic regression or Cox proportional hazard model.

Overall, they provide a powerful means of predicting the likelihood of outcomes in heart failure patients, making them quite valuable in selecting patients for advanced therapies and in helping patients and their families plan for the future.

This chapter will focus on a selection of the more commonly used risk models and their clinical applications. Many of the individual risk factors that predict patient outcomes are intuitive. Ejection fraction has not, however, been as predictive of outcomes in hospitalized cohorts. Abnormalities of many biomarkers predict worsened outcomes.

High-sensitivity troponins have shown predictive power, as have newer markers such as ST2 or gal The most widely validated lab marker is B-type natriuretic peptide BNPwith a doubling of mortality risk seen for normal versus abnormal range BNP.

BNP also correlates with other important clinical outcomes, such as increased risk of hospitalization with progressively more abnormal values. Some clinical data points show a reverse epidemiology, with lower body mass index BMI and cholesterol levels serving as favorable prognostic markers in the general population, but as unfavorable prognostic markers in the heart failure population.

The SHFM was developed as a predictor of life expectancy and 1- 2- and 5- year mortality in heart failure patients.

There is also a downloadable application that is available for Windows, Macintosh, and several portable platforms. The risk score was developed via Cox proportional hazards modeling.

FFR wires passé? Rethinking the physiological assessment of coronary artery disease

It is scored as a continuous variable that can be converted to a percentage chance of survival at various time points. A screenshot of the Windows version of the web calculator is shown in Figure 1. Assessing prognosis can be quite challenging. Some patients are clearly floridly decompensated, barely ambulatory, and in need of inpatient management for acute exacerbation of their heart failure. Others have minimal functional decline or evidence of laboratory or hemodynamic dysfunction and have a much better prognosis.

The ASCVD Risk Estimator Is Not Fully Supported For Your Browser Version

Multiple studies have shown that neither patients nor providers are particularly good at providing accurate assessments of expected mortality. The value of the SHFM is in allowing more accurate risk stratification than allowed by holistic clinician assessment.

The value of the SHFM in lower risk patients is both in providing more knowledge for patients and providers about likely prognosis, and in allowing a more clear understanding of the survival changes that can occur with starting new heart failure medications or placing life-saving devices, such as implantable cardiac defibrillators or cardiac resynchronization therapy.

Peak consumption of oxygen with maximal exertion has long been used as a criterion for listing for heart transplantation. The HFSS was developed to integrate additional clinical information and provide more accurate risk stratification. It divides patients into high- intermediate- and low-risk strata.

The HFSS is calculated using seven clinical variables. The score is calculated as 0. Scores less than 7. Use of the HFSS is limited by the requirement for peak consumption of oxygen with maximal exertion to calculate the score.

Patients in the medium- and high-risk category are appropriate for consideration of listing for heart transplantation or placement of ventricular assist device, while low-risk patients are appropriately deferred for consideration of these advanced heart failure therapies.

Approximately 4, patients hospitalized with acute decompensation of heart failure in Ontario, Canada, were used to derive and validate a model for predicting day and 1-year all-cause mortality for hospitalized inpatients. It has been prospectively validated in other cohorts. Clinicians have the same pitfalls in predicting mortality in hospitalized patients as in ambulatory patients.

Identifying a high-risk cohort of patients allows more quantitative decision-making on discharge from the emergency department versus admission to the floor versus admission to the intensive care unit.Survival after out-of-hospital cardiac arrest OHCA remains disappointingly low. Among patients admitted alive, early prognostication remains challenging. This study aims to establish a stratification score for patients admitted in intensive care unit ICU after OHCA, according to their neurological outcome.

The primary outcome was poor neurological outcome defined as Cerebral Performance Category 3, 4, or 5 at hospital discharge. Independent prognostic factors were identified using logistic regression analysis and thresholds defined to stratify low- moderate- and high-risk groups.

The developmental data set included patients admitted from May to December After multivariate analysis, seven variables were independently associated with poor neurological outcome and subsequently included in the CAHP score age, non-shockable rhythm, time from collapse to basic life support, time from basic life support to return of spontaneous circulation, location of cardiac arrest, epinephrine dose, and arterial pH.

A high-risk category of patients with very poor prognosis can be easily identified. See page for the editorial comment on this article doi Worldwide, between and patients experience an out-of-hospital cardiac arrest OHCA every year.

Moreover, the post-cardiac arrest period requires outstanding life supports, providing lengthily, expensive, and often difficulties for families and caregivers. Accurate assessment of prognosis is necessary to identify patients who will most benefit from intensive care.

Coronary Calcium Score and Cardiovascular Risk

Early identification of patients with poor neurological outcome would help in stratifying patients for randomized studies and in epidemiological studies. As there is no specific clinical sign that can predict outcome in the first few hours after ROSC, a reliable prognostication tool could be very useful. Currently, no single tool can provide neurological prognostication after OHCA, which should be based on multiple predictors EEG, biomarkers, and imaging depending on locally available tests and expertise.

The previously reported OHCA score, 10 that used variables readily available at admission to the ICU, studied a small-sample size and selected cohort and deserves to be replicated.

To address this need, we undertook a population-based database from the Paris Sudden Death Expertise Center 11 to generate a valuable scoring system in order to early discriminate patients according to their neurological outcome. In Paris and its inner suburbs, management of OHCA involves mobile emergency units and fire departments, covering a population of 6.

Out-of-hospital resuscitation is delivered by an emergency team including at least one trained physician in emergency medicine according to the international guidelines. Percutaneous coronary intervention is attempted if necessary. After the procedure, patients are admitted to the ICU for supportive treatments, which can include therapeutic hypothermia if indicated. Those consecutive to circumstantial causes such as trauma, hanging, drowning, intoxication, or asphyxia were excluded.

For validation, we used two separate samples.This review discusses the cardiac risks associated with aortic stenosis AS during noncardiac surgery. The following are 10 points to consider: Based on studies published in the s through the s, AS was thought to be associated with a high risk of cardiac complications during noncardiac surgery.

Published reports addressing the perioperative risk associated with AS include substantial ambiguity in terms of assessment of AS severity mean gradient vs. Among patients with AS, adverse outcomes during noncardiac surgery can be attributed to the following interactions between AS, anesthesia, and surgical stress: Anesthesia can result in a decrease in systemic vascular resistance; because of the fixed obstruction of AS, there is an inadequate compensatory increase in cardiac output, leading to hypotension.

Hypotension in turn can lead to reduced myocardial perfusion and myocardial ischemia, with resulting decreased LV contractility. Anesthesia can result in reduced sinus node automaticity, arrhythmias, and direct myocardial depression.

The cardiac risk during noncardiac surgery in patients with AS appears to have decreased compared to historical reports, perhaps due to an increased awareness of hemodynamic concerns and advances in anesthetic and surgical approaches.

A study is cited that associated increase in gradients during exercise with outcomes among patients with AS who were not undergoing noncardiac surgery.

The authors note that there are little data that address risk during noncardiac surgery among patients with low-flow, low-gradient severe AS with normal LV ejection fraction; and that there are no data that address the efficacy of transcatheter aortic valve replacement among patients undergoing noncardiac surgery. Share via:. Media Center ACC. All rights reserved.


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