What are the ACCF-AHA recommendations coronary artery disease (CAD) risk assessment in asymptomatic adults?

Updated: Mar 30, 2020
  • Author: F Brian Boudi, MD, FACP; Chief Editor: Yasmine S Ali, MD, MSCI, FACC, FACP  more...
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The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have produced guidelines for the procedures of detection, management, or prevention of cardiovascular disease. One set of recommendations focuses on cardiovascular risk in asymptomatic results, and these recommendations are discussed below. [16]

For all asymptomatic adults, global risk scoring should be performed and a family history of cardiovascular disease should be obtained for cardiovascular risk assessment.

Other tests and measures for cardiovascular risk assessment in asymptomatic adults are recommended as reasonable, might be reasonable, or may be considered for specific patient populations and risk levels, such as the following:

  • Measurement of lipid parameters beyond a standard fasting lipid profile (A standard fasting lipid profile is recommended as part of global risk scoring.)

  • Brachial/peripheral arterial flow-mediated dilation studies

  • Specific measures of arterial stiffness

  • Coronary computed tomography angiography

  • MRI for detection of vascular plaque

Note the following:

  • A resting electrocardiogram (ECG) is reasonable for asymptomatic adults with hypertension or diabetes and may be considered in asymptomatic adults without hypertension or diabetes.

  • An exercise ECG may be considered in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity.

  • Transthoracic echocardiography to detect left ventricular hypertrophy may be considered for asymptomatic adults with hypertension but is not recommended in asymptomatic adults without hypertension.

  • Stress echocardiography is not indicated for low- or intermediate-risk asymptomatic adults.

  • Coronary artery calcium (CAC) measurement is reasonable for asymptomatic intermediate-risk adults, [10] but it should not be performed for persons at low risk; it may be reasonable when the patient’s risk falls between low and intermediate.

  • For cardiovascular risk assessment in asymptomatic adults with diabetes mellitus, measurement of CAC is reasonable in patients older than 40 years. [17] Measurement of hemoglobin A1C and stress myocardial perfusion imaging (MPI) may be considered.

  • MRI among asymptomatic individuals with regional myocardial dysfunction (RMD) is an independent predictor beyond traditional risk factors and global left ventricle (LV) assessment for incident heart failure and atherosclerotic cardiovascular events. [18]

  • The Heart and Estrogen/progestin Replacement Study evaluated the effects of hormone replacement therapy on cardiovascular events among 2763 postmenopausal women with CAD. Sudden cardiac death comprised most cardiac deaths among these postmenopausal women. Independent predictors of sudden cardiac death included myocardial infarction, congestive heart failure, an estimated glomerular filtration rate of less than 40 mL/min/1.73 m2, atrial fibrillation, physical inactivity, and diabetes. These risk factors should be considered when left ventricular ejection fraction (LVEF) is present. [19]

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