Cardiovascular disease screening: Clinical sciences

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. 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. 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.

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.