Subclinical atherosclerosis, cardiovascular health, and disease risk: is there a case for the Cardiovascular Health Index in the primary prevention population?

Sarah S Singh,Stephanie J Frisbee,Courtney S Pilkerton,Carl D Shrader

doi:10.1186/s12889-018-5263-6

Sarah S Singh, Stephanie J Frisbee + Show 2 more

Open Access

https://doi.org/10.1186/s12889-018-5263-6

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Abstract

BackgroundCurrent primary prevention guidelines for cardiovascular disease (CVD) prioritize risk identification, risk stratification using clinical and risk scores, and risk reduction with lifestyle interventions and pharmacotherapy. Subclinical atherosclerosis is an early indicator of atherosclerotic burden and its timely recognition can slow or prevent progression to CVD. Thus, individuals with subclinical atherosclerosis are a priority for primary prevention. This study takes a practical approach to answering a challenge commonly faced by primary care practitioners: in patients with no known CVD, how can individuals likely to have subclinical atherosclerosis be easily identified using existing clinical data and/or information provided by the patient?MethodsUsing NHANES (1999–2004), 6091 men and women aged ≥40 years without any CVD comprised the primary prevention population for this study. Subclinical atherosclerosis was determined via ankle-brachial index (ABI) using established cutoffs (subclinical atherosclerosis defined as ABI (0.91–0.99); normal defined as ABI (1.00–1.30)). Three common scores were calculated: the Framingham Risk Score (FRS), the Metabolic Syndrome (MetS), and the Cardiovascular Health Index (CVHI). Logistic regression analysis assessed the association between these scores and subclinical atherosclerosis. The sensitively and specificity of these scores in identifying subclinical atherosclerosis was determined.ResultsIn eligible participants, 3.8% had subclinical atherosclerosis. Optimum and average CVHI was associated with decreased odds for subclinical atherosclerosis. High, but not intermediate-risk, FRS was associated with increased odds for subclinical atherosclerosis. MetS was not associated with subclinical atherosclerosis. Of the 3 scores, CVHI was the most sensitive in identifying subclinical atherosclerosis and had the lowest number of missed cases. The FRS was the most specific but least sensitive of the 3 scores, and had almost 10-fold more missed cases vs. the CVHI. The MetS had “middle” sensitivity and specificity, and 10-fold more missed cases vs. the CVHI.ConclusionsResults from this study suggest that routine administration of the CVHI in a primary prevention population would yield the benefits of identifying patients with existing subclinical CVD not identified through traditional CVD risk factors or scores, and bring physical activity and nutrition to the forefront of provider-patient discussions about lifestyle factors critical to maintaining and prolonging cardiovascular health.

Highlights

Current primary prevention guidelines for cardiovascular disease (CVD) prioritize risk identification, risk stratification using clinical and risk scores, and risk reduction with lifestyle interventions and pharmacotherapy
Our results are consistent with a growing body of literature describing the occurrence of CVD and cardiovascular events in those without traditional CVD risk factor profiles; for example, a recent study by Fernandez-Friera et al, reported that subclinical atherosclerosis existed in almost 50% of participants free of traditional CVD risk factors [39]. Our observations extend these previous reports to a primary prevention population: that, for a portion of the CVDfree participants in this study, subclinical atherosclerosis was present in the absence of being identified as at-risk by either the Framingham Risk Score (FRS), Metabolic Syndrome (MetS), or Cardiovascular Health Index (CVHI), and without abnormal traditional CVD risk factors
Current United States of America (USA) guidelines for the assessment and treatment of traditional CVD risk factors include the calculation of the FRS (U.S Preventative Services Task Force) [9] or the Pooled Cohort Equation, derived from the FRS (American Heart Association) [5]. (Note: the Pooled Cohort Equation was not included in this study as (a) it is only applicable in non-Hispanic whites and African-Americans [5], which would have resulted in the exclusion of 30% of the study population sample from “other” races; and (b) there remain ongoing debates about the accuracy of the calibration of this score [42,43,44,45,46].) results from this study suggest a provocative question: in the primary prevention population, is the CVHI a more effective tool to identify individuals in need of prompt primary prevention?

Summary

Introduction

Current primary prevention guidelines for cardiovascular disease (CVD) prioritize risk identification, risk stratification using clinical and risk scores, and risk reduction with lifestyle interventions and pharmacotherapy. Current primary prevention guidelines prioritize risk identification, principally through traditional cardiovascular disease risk factors (obesity, blood pressure, cholesterol, glucose, and smoking), risk stratification using clinical and risk scores, and risk reduction with lifestyle interventions and pharmacotherapy [4,5,6,7,8,9]. The FRS, one of the most well-known and widely used risk scores, was originally developed in 1998 from the Framingham Heart Study cohort to predict 10-year risk of coronary heart disease (CHD) based on age, gender, smoking, cholesterol, diabetes, and blood pressure [10, 11]. For primary prevention, all components of the MetS and CVHI, but not the FRS, are modifiable through lifestyle changes alone [20]

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