Cardiovascular disease screening: Clinical sciences

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Introduction0:00–0:56

Cardiovascular disease screening plays a significant role in preventive healthcare and early intervention for patients with atherosclerotic cardiovascular disease, or ASCVD for short.
ASCVD is associated with plaque build-up within arterial walls that can eventually rupture and result in blood clot formation.
These blood clots can partially or completely obstruct the blood flow to downstream tissues, eventually causing tissue ischemia or infarction.
Because the plaque develops over time, there is an opportunity to intervene before symptoms appear or a major adverse event occurs, such as myocardial infarction or stroke.
The ASCVD screening helps determine the risk in adult individuals with no symptoms or history of ASCVD to determine their risk of future cardiovascular events.Alright, when your patient presents for cardiovascular disease screening, first, assess your patient’s risk factors.

Assess Risk Factors0:56–2:41

The first risk factor to consider is age. While there is no specific age cutoff that defines an increase in ASCVD risk, it is accepted that the older the patient, the higher the risk.
Race also has a significant impact on ASCVD risk. For example, Black individuals carry more than double the risk of death from cardiovascular events compared to white individuals.
Next, biologically male individuals have a higher risk than biologically female individuals due to the protective effects of estrogen.
This protection lasts until biologically female individuals reach menopause, at which point, their risk is higher than males.
Individuals with a history of tobacco use or who are currently using tobacco are also at greater risk of ASCVD due to the chemicals in cigarettes that damage arterial vessel lining.
Other conditions that carry an increased risk for ASCVD include hypertension, diabetes mellitus, and dyslipidemia. Now, here’s a clinical pearl!
Don’t forget other risk factors like family history of premature cardiovascular disease, obesity, and a sedentary lifestyle.
Non-traditional risk-enhancing factors include metabolic syndrome, premature menopause, and kidney disease. There are also other tools that may help in clinical decision-making, including obtaining a high sensitivity C-reactive protein level and measuring the ankle-brachial index.
Now, if no risk factors are present, no intervention is needed, so re-screen your patient every four to six years.On the other hand, if risk factors are present, assess your patient’s age again.

No risk factors2:41–2:50

Age 40 - 75 years2:50–4:05

Let’s start with individuals who are 40 to 75 years old. In this case, use the ASCVD Risk Estimator which is a validated metric tool used to calculate the risk of having a major cardiovascular event in the next 10 years.
Here’s a clinical pearl to keep in mind! In general, you should evaluate all individuals aged 40 to 75 using the 10-year ASCVD Risk Estimator and reevaluate every 4 to 6 years.
But, there are two exceptions. The first exception includes patients with an LDL cholesterol level of 190 mg/dL or more, as they should begin high-intensity statin immediately.
The second exception covers those with known type 2 diabetes, as they should begin, at minimum, moderate-intensity statin therapy.
The reason is that these two groups already have compelling indications for statin therapy, so further risk stratification will not change their management.

Low risk4:05–4:28

Now, individuals with a 10-year ASCVD risk score less than 5% are deemed low risk. In this case, encourage lifestyle modifications, such as a healthy diet, adequate physical activity, and smoking cessation; and don’t forget to manage any modifiable risk factors that are present.
On the other hand, patients with a 10-year ASCVD risk score between 5% and 7.4% are considered to be at borderline risk.

Borderline risk4:28–5:37

For these patients, again, encourage lifestyle modifications and manage any modifiable risk factors. Additionally, if your patient has risk-enhancing factors like metabolic syndrome or premature menopause, consider starting a moderate-intensity statin.
Next, if the clinical picture is unclear, obtain a coronary artery calcium, or CAC score, which is calculated based on the results of a non-contrast CT of the heart to look for calcified plaque in the coronary arteries.
A score of zero means that no coronary artery calcification is seen, which lowers the chance of future cardiovascular events.
However, when coronary artery calcification is present, the risk of future cardiovascular events increases. Finally, schedule a follow-up examination and screening in four to 12 weeks to assess the efficacy of any medication changes.Next, if your patient has a 10-year ASCVD risk score ranging from 7.5% to 19.9%, they have an intermediate risk of ASCVD.

Intermediate risk5:37–6:18

For these patients, again, encourage lifestyle modifications and don’t forget the management of their modifiable risk factors.
Next, start a moderate-intensity statin, and if your patient has risk-enhancing factors, consider a high-intensity statin.
Also, obtain a CAC score to guide this decision. Don’t forget to schedule follow-up in four to 12 weeks to reassess after introducing medical therapy.Finally, if the ASCVD risk score is 20% or greater, your patient is at high risk for ASCVD.

High-risk6:18–6:48

Like before, encourage lifestyle modifications and management of their modifiable risk factors. But, in this case, you should immediately start your patient on high-intensity statin therapy regardless of the presence of risk-enhancing factors, and schedule a follow-up in four to 12 weeks.

Age 20 to 396:48–7:14

Okay, now, let’s go back and look at individuals who are 20 to 39 years old. In this group, the ASCVD Risk Estimator has not been validated, so you shouldn’t use it.
Instead, you should perform a general assessment of their risk factors, manage any modifiable risk factors, and reassess their risk every four to six years.

Age Over 757:14–7:43

Finally, let’s cover individuals over 75 years of age. Just like with the younger age group, you shouldn’t use the ASCVD Risk Estimator since it has not been validated for this group.
Instead, you should assess and manage modifiable risk factors, and reassess based on the patient’s other comorbidities, functional status, and life expectancy.
Alright, as a quick recap… Cardiovascular disease screening starts with the assessment of important risk factors, which include age, race, sex, and tobacco use, as well as chronic conditions, like hypertension, diabetes mellitus, and dyslipidemia.

Review7:43–8:43

In all individuals, you should encourage lifestyle modifications and manage their modifiable risk factors. If your patient has risk factors and they are between 40 and 75 years of age, use the ASCVD Risk Estimator to calculate their 10-year ASCVD risk score.
As estimated risk goes up, add moderate to high-intensity statin therapy, especially in individuals that have risk-enhancing factors.
For patients with risk factors aged 20 to 39, and in those older than 75, the ASCVD Risk Estimator has not been validated, but you should still manage any modifiable risk factors that