GRUNDY
ET AL., Assessment of Cardiovascular Risk
J Am Coll Cardiol 1999;34:1348--59
AHA/ACC
Scientific Statement: Assessment of Cardiovascular Risk
by Use of Multiple-Risk-Factor Assessment Equations
A
Statement for Healthcare Professionals From the American
Heart Association and the American College of Cardiology
XV.
Implications for Clinical Risk Reduction
Identification
of risk factors lies at the heart of clinical efforts
to reduce risk for CVD and/or CHD. Every major risk factor
predisposes to CHD and other cardiovascular events, particularly
if left unattended for long periods. In addition, when
multiple risk factors occur in a single individual, risk
is compounded, which justifies efforts to estimate global
risk. The summation of contributions of individual risk
factors can be a valuable first step in planning a risk-reduction
strategy for individual patients. This first step should
be divided into 2 phases. First, absolute risk should
be estimated from the major risk factors (listed in Table
1). Framingham risk scoring provides an acceptable
tool for most non-Hispanic white, Hispanic, and black
Americans. People of South Asian origin appear to have
about twice the absolute risk for any set of risk factors
as whites. In contrast, East Asian Americans may have
a lower absolute risk than other ethnic groups in the
United States. Second, when absolute risk has been estimated
from the major risk factors, consideration can be given
to modifying the estimate in the presence of other risk
factors (Table 2). Clinical
judgment is required to estimate incremental risk incurred
by these latter factors. Risk estimates are useful both
for short-term, high-risk primary prevention and for long-term
(or lifetime) primary prevention. Implications for global
risk assessment can be considered for each.
Short-Term
Prevention
Recent clinical trials demonstrate that significant
risk reduction can be achieved by aggressive reduction
of risk factors in high-risk patients. Clinical trials
have shown that excess risk can be reduced by ≈33%
to ≈50% in ≈5 years. This is particularly the
case when risk-reduction strategies use smoking cessation,
blood pressure–lowering agents, cholesterol-lowering
drugs, and aspirin. Clinical trials strongly suggest
that glucose control reduces the incidence of various
cardiovascular end points in patients with either type
1 diabetes112
or type 2 diabetes.113
Other clinical trials 114,115
strongly suggest that aggressive LDL-lowering therapy
reduces risk for CHD in patients with type 2 diabetes.
For this reason, detection of patients at high risk,
with the aid of global risk assessment, should be an
important aim of routine medical evaluation of all patients.
Specific therapies for risk reduction in high-risk patients
are described in the NCEP ATP II report for cholesterol
management,6
the JNC VI report for treatment of hypertension,7
and by the ADA's guidelines for treatment of diabetes
mellitus.8
Once appropriate therapies are selected, global risk
scores can also be used to help instruct patients and
to improve compliance with preventive interventions.
Long-Term
Prevention
Global risk assessment is particularly useful in young
and middle-aged adults for assessing relative risk and
absolute long-term risk (Figures
1 and 2). Even though short-term
risk may not be high in younger patients who have multiple
risk factors of only moderate severity, long-term risk
can be unacceptably high. Risk assessment in these patients
will highlight the need for early and prolonged intervention
on risk factors. In young adults, relative risk ratios
help to reveal long-term risk for CHD. Although long-term
prevention may not call for the use of risk-reducing
drugs, it definitely will require the introduction of
lifestyle modification (ie, smoking cessation in smokers,
weight control, increased physical activity, and a diet
low in cholesterol and cholesterol-raising fats). The
AHA provides guidelines to assist healthcare professionals
in the implementation of life-habit modifications.30
There is a common misconception that most of the excess
risk accumulated over many years can be erased by aggressive
short-term prevention introduced later in life. Although
the use of risk-reducing drugs can significantly lower
risk when begun in later years, there is no evidence
that it can return a patient to the low-risk status
of a younger person. This reduction can only be accomplished
by decreasing the magnitude of coronary plaque burden
through long-term control of risk factors. Therefore,
appropriate intervention, guided by risk assessment
that is performed periodically in early adulthood and
early middle age, has the potential to bring about a
significant reduction in long-term risk.
Copyright
© 2000 by The American Heart Association, Inc.
and
The American College of Cardiology
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