Population: Adults without diagnosis or symptoms of coronary artery disease.

Organizations

ACC/AHA 2019, ESC 2012, USPSTF 2018, VA/DoD 2020

Screening Recommendations

–For adults 40–75 y, routinely assess cardiovascular risk factors and calculate 10-y risk of ASCVD using PCEs.¹

–For adults 20–39 y, assess traditional ASCVD risk factors at least every 4–6 y.

–For adults at borderline risk (5%–7.5% 10-y ASCVD risk) or intermediate risk (≥10% to <20% 10-y ASCVD risk), consider using additional risk-enhancing factors to guide decision-making about preventive interventions. If decisions remain uncertain, it is “reasonable” to measure a coronary artery calcium score to guide risk discussion.

–For adults 20–39 y or adults 40–59 y with <7.5% 10-y ASCVD risk, consider estimating lifetime or 30-y ASCVD risk (or HeartScore screening risk score in Europe).²

–Insufficient evidence to recommend for or against the addition of Ankle-Brachial Index (ABI), high-sensitivity C-reactive protein (hsCRP), and coronary artery calcium score to traditional risk assessment for CVD in asymptomatic adults with no history of CVD.

–Do not offer a cardiovascular risk assessment more frequently than every 5 y, using 10-y risk calculator.

–Do not use coronary artery calcium, high-sensitivity C-reactive protein, or ABI when assessing cardiovascular risk.

–Do not screen with resting or exercise ECG, exercise treadmill test (ETT), stress echocardiogram, or electron-beam CT for coronary artery calcium.

–Do not screen with stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of asymptomatic patients, unless high-risk markers are present.

–Do not perform annual stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients.

Sources

–J Am Coll Cardiol. 2019;74(10):e177-e232.

–Eur Heart J. 2012;33:1635-1701.

–USPSTF. JAMA. 2018;320(3):272-280.

–AAFP. Clinical Preventive Service Recommendation: Cardiovascular Disease Risk. 2018.

–USPSTF. JAMA. 2018;319(22):2308-2314.

–VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction. June 2020.

–Choosing Wisely: American College of Physicians. 2012. http://www.choosingwisely.org/societies/american-college-of-physicians/

–Choosing Wisely: American Academy of Family Physicians. 2013. http://www.choosingwisely.org/societies/american-academy-of-family-physicians/

–Choosing Wisely: American Society of Echocardiography. 2012. http://www.choosingwisely.org/societies/american-society-of-echocardiography/

–Choosing Wisely: American College of Cardiology. 2014. http://www.choosingwisely.org/societies/american-college-of-cardiology/

–Ann Intern Med. 2012;157:512-518.

–J Am Coll Cardiol. 2019;74(10):e177-e232.

Population: Women.

Organization

2011 AHA

Prevention Recommendations

–Assess CVD risk in women beginning at age 20 y, identifying women at higher risk.

–There are racial/ethnic differences in risk factors, with Black and Latina women having a higher prevalence of hypertension and diabetes. The highest CVD morbidity and mortality occurs in Black women.

–Autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis) and preeclampsia are significant risk factors for CVD in women.

–Psychological stress (anxiety, depression) and socioeconomic disadvantages are associated with a higher CVD risk in women.

–Microvascular disease with endothelial dysfunction, also known as female pattern disease, is the etiology of ischemia in more women than men.

–Women are more likely to have atypical cardiovascular symptoms such as sudden or extreme fatigue, dyspnea, sleep disturbances, anxiety, nausea, vomiting, and indigestion.

–ACC/AHA guidelines recommend a routine exercise stress test as the initial evaluation in symptomatic women who have a good exercise capacity and a normal baseline ECG. Exercise stress perfusion study (myocardial perfusion scintigraphy [MPS]) or exercise echo should be reserved for symptomatic women with higher pretest likelihood for CAD or indeterminate routine testing.

–Women often receive less medical therapy and lifestyle counseling than men.

–After PCI procedure, women experience higher rate of complications and mortality than men.

–Management of stable CAD should be the same as in men which include ASA, beta-blocker, statin, ACE inhibitor (ejection fraction [EF] < 40%), and nitrate/CCB for angina management.

–In microvascular disease, beta-blockers have shown to be superior to CCB for angina management. Statins, ACE inhibitors, ranolazine, and exercise can improve angina scores and endothelial dysfunction in female pattern disease.

Sources

–Moasca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243-1262.

–Gulati M, Shaw LJ, Bairey Merz CN. Myocardial ischemia in women: lessons from the NHLBI wise study. Clin Cardiol. 2012;35:141-148.