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Risk Assessment for Cardiovascular Disease
With Nontraditional Risk Factors
The US Preventive Services Task Force (USPSTF) recently published recommendations
on risk assessment for cardiovascular disease using nontraditional risk factors.
What Is Cardiovascular Disease?
Cardiovascular disease (CVD) refers to the buildup of plaque, which
can cause blockages inside important blood vessels in the body.
These blood vessels can include the arteries of the heart (coronary
heart disease), brain (cerebrovascular disease), or legs (peripheral
arterial disease). Cardiovascular disease can cause heart attacks,
strokes, and death. Coronary heart disease is the leading cause of
death in the United States.
Traditional risk factors for CVD include older age, smoking, high
blood pressure, being overweight or obese, diabetes, high choles-
terol, and a family history of heart disease. In general, people with a
higher risk of CVD benefit more from screening and treatment. Based
on these traditional risk factors, several risk assessment tools are
available to help doctors decide who should be screened. Ex-
amples include the Framingham Risk Score and the Pooled Cohort
Equations. However, doctors are always looking to improve on their
assessment of CVD risk by adding more risk factors to the picture.
What Are Nontraditional Risk Factors for CVD?
Examples of other “nontraditional” risk factors that are sometimes
used for risk assessment include the ankle-brachial index (ABI),
high-sensitivity C-reactive protein (hsCRP) level, and the
coronary artery calcium (CAC) score. The ABI is calculated by com-
paring blood pressure values measured at the ankle and the arm
(brachial artery). High-sensitivity CRP is a protein involved in in-
flammation that is measured by its level in a person’s blood. The CAC
score measures the amount of calcium in the blood vessels of the
heart based on a computed tomographic scan of the chest.
What Is the Patient Population Under Consideration
for Using Nontraditional Risk Factors to Assess CVD Risk?
This USPSTF recommendation applies to adults who do not have any
symptoms of or a diagnosis of CVD.
What Are the Potential Benefits and Harms
of Using Nontraditional Risk Factors to Assess CVD Risk?
The potential benefit of adding nontraditional risk factors to risk as-
sessment tools that use traditional risk factors is more accurate risk
assessment, which would ultimately lead to better prevention of
heart attacks, strokes, and death in people who have no symptoms
of CVD. There is some evidence that adding the 3 nontraditional
Author: Jill Jin, MD, MPH
Source: US Preventive Services Task Force. Risk assessment for cardiovascular disease
with nontraditional risk factors: US Preventive Services Task Force recommendation
statement [published online July 10, 2018]. JAMA. doi.10.1001/jama.2018.8359
316 JAMA July 17, 2018 Volume 320, Number 3 (Reprinted)
© 2018 American Medical Association. All rights reserved.
Downloaded From: on 07/18/2018
risk factors described above may improve the accuracy of risk
assessment in certain groups of people. However, based on cur-
rent evidence, it is unclear whether this ultimately prevents CVD
events such as heart attacks, strokes, and death. The main poten-
tial harm is the low-dose radiation exposure necessary to obtain the
CAC score. Other potential harms include unnecessary diagnostic
testing for CVD, which can be invasive, as well as unnecessary life-
long treatment with medications for CVD.
How Strong Is the Recommendation to Use Nontraditional
Risk Factors to Assess CVD Risk?
Based on current evidence, it is unclear whether the potential
benefits of adding ABI, hsCRP, or CAC score measurement in risk
assessment for CVD in people with no symptoms outweighs the
potential harms.
Risk Assessment for Cardiovascular Disease (CVD)
With Added Nontraditional Risk Factors
Population
Adults who do not have symptoms or a diagnosis of CVD
Symptoms of CVD include chest pain, chest tightness,
shortness of breath, and pain in the legs, arms, neck, jaw,
throat, upper abdomen, or back.
USPSTF recommendation
There is not enough evidence to say whether adding
ankle-brachial index or high-sensitivity C-reactive protein
Statement tests or coronary artery calcium score to traditional risk
assessment tools benefits people who do not have CVD symptoms.
FOR MORE INFORMATION
US Preventive Services Task Force
www.uspreventiveservicestaskforce.org/Page/Document
/UpdateSummaryFinal/cardiovascular-disease-screening-using
-nontraditional-risk-assessment
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