CVD Risk Assessment Guidelines and InstinctsDena Wilson, MD, FACCMay 23, 2017

Objectives• Describe cardiovascular risk factors and

cardiovascular equivalents. • Outline key elements of CVD risk assessment which

should be considered in clinical decision making. • Explain what tests should be ordered in evaluating

CVD.• Describe test results warranting referral to a higher

level of care.

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Classification of Recommendations and Levels of Evidence

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Icons Representing the Classification and Evidence Levels for Recommendations

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Case 1• 37-year-old female with DMII and HTN presents for

routine medication refill visit• She feels well but asks to have her heartburn pill

renewed because she has been having more heartburn in the past few weeks

• BP 123/72 PU 67 HgA1C 6.3 LDL 100 HDL 60• An ECG is performed….

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ECG Findings

• NSR• Non-specific ST-T waves• Should ECG have been performed?

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Does this Patient (Case 1) Need Further Testing?

• YES• NO• Need more INFO

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HPI• She denies any chest pain or pressure. She denies

any SOB. She states that her heartburn is mostly in the evenings after she eats.

• She describes heartburn as a burning in her chest and feels like she has something in her throat. She belches and feels better.

• She denies any pain or pressure when she cleans or walks but then states that at times she feels a “twinge” in her chest.

• She is unable to give more details. “It’s just a twinge”

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Past Medical History

• DMII diagnosed age 30• HTN diagnosed age 30

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Social History/Family History• Patient is married and has three children ages 12, 9,

and 7. She is a non-smoker. She owns a house-cleaning company but does most of the cleaning alone. She walks two miles in approximately 30 minutes every morning.

• Her father (70) has “heart problems,” and her mother had a heart valve surgery last year (67).

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Does this Patient (Case 1) Need Further Testing?

• YES• NO• Need more INFO

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Does the Patient (Case 1) Need Further Testing? (cont.)• NO• Patient has good functional capacity and is

asymptomatic• 10-year CVD risk is low.

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Pre-test Probability• Based on

• clinical history• age and sex• risk factors for CAD

• Global Risk Scoring (Class I indication)• Framingham Risk Score (FRS)• Strong Heart Risk Calculator• CVD Risk Calculator*

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Pre-Test Probability (2)Diamond and Forrester Pre-Test Probability of Coronary Artery Disease by Age, Sex, and Symptoms∗

High: >90% pre-test probability. Intermediate: between 10% and 90% pre-test probability. Low: between 5% and 10% pre-test probability. Very low: <5% pre-test probability. 14

Asymptomatic

From: ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons.

Copyright © The American College of Cardiology. All rights reserved. 15

Learning Points for Abnormal ECG

• History is extremely important in clinical decision making

• Assessing functional status is a priority• Use multiple tools to assess functional status• ECG changes must be in context• Risk calculators are helpful

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Risk Assessment

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Case 2

• 62-year-old male with DMII and Morbid Obesity presents for pre-operative risk assessment prior to hip replacement.

• Patient is asymptomatic. He denies any chest pain or pressure. He is short of breath but states that this is normal for him.

• Patient is unable to walk more than 100 feet due to hip pain but feels confident that he could walk one mile if he didn’t have hip pain.

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PMHX (Case 2)

• Osteoarthritis• DMII-dx 1999• OSA on CPAP• HTN• Hypothyroid

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Case 2 Family History/Social History

• Lives with wife and one son • On disability• No TOB, No ETOH, No drugs• Wheels around the yard and picks up trash• His whole family has heart problems

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PE (Case 2)

• BP 143/82, PU 101 BMI 52• Distant heart sounds• Lungs are clear• 2+ LE edema bilaterally• Repeat BP was 133/78 pulse 91

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Does this Patient (Case 2) Need Further Testing?

• YES• NO• Need more INFO

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Cardiac Risk Factors

• Diabetes • Tobacco use• Hypertension• Hyperlipidemia• PAD• Family History of premature CAD

• Father <55, Mother <65

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Functional Capacity

• Excellent (>10 METs)• Good (7 METs to 10 METs)• Moderate (4 METs to 6 METs) • Poor (<4 METs)• Unknown

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Duke Activity Status Index

Reproduced with permission from Hlatky et al.25

Duke Activity Status Index 2

• (DASI x 0.43) + 9.6 =_______/3.5 = _______METS• 58 x 0.43 + 9.6 = 35/3.5 = 10 METS• 4.5 x 0.43 + 9.6 = 12/3.5 = 3.4 METS

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What Further Testing Is Needed?

• EKG?• Echo?• Stress Test?

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12-Lead ECG

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Assessment of LV Function

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Noninvasive Pharmacological Stress Testing Before Non-cardiac Surgery

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CV Risk Tools

• Revised Cardiac Risk Index (RCRI)• American College of Surgeons National Surgical

Quality Improvement Program(NSQIP) Myocardial Infarction and Cardiac Arrest(MICA)

• American College of Surgeons NSQIP Surgical Risk Calculator

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Pearls/Pitfalls

Advice: Used to judge the benefits and risks of surgery. Decision to have surgery should be based on the total risk judged against the benefit of surgery over the next best option.

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Procedure Risk Assessment

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Patient Risk Factors

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Summary of Recommendations for Supplemental Preoperative Evaluation

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Learning Points for Pre-Op

• Assess for symptoms• Assess functional status METS• Use DASI if unable to assess METS based on

activity• Ask if testing will really change management• Use risk calculators

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Case 3

• 37-year-old female with DMII and HTN being seen for routine medication refill

• She feels well but asks to have her heartburn pill renewed because she has been having more heartburn recently

• BP 152/92 PU 67 HgA1C 9.7• An ECG is performed….

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Does this Patient (Case 3) Need Further Testing? • YES• NO• Need more INFO

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HPI (Case 3)

• She describes heartburn as a burning in her chest. She is not sure when she gets the heartburn. Sometimes after eating but also before she eats.

• She denies any chest pain or pressure but then states that at times she feels a “twinge” in her chest.

• She is unable to give more details.

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Past Medical History (Case 3)

• DMII diagnosed age 33• HTN diagnosed age 33• No surgeries

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Social History (Case 3)

• Patient is married and has 3 children ages 12, 9, 7. She is a non-smoker. She owns a house-cleaning company. She used to do the cleaning on her own but stopped 3 years ago after an injury. She doesn’t do much around the house and leaves most household chores to her husband and children.

• Her father (70) has “heart problems” and her mother had a heart valve surgery last year.

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Pretest Probability

• Based on • Clinical History• Age and Sex• Risk Factors for CAD

• Global Risk Scoring (Class I Indication)• Framingham Risk Score (FRS)• Strong Heart Risk Calculator• CVD Risk Calculator*

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Pretest Probability 2Diamond and Forrester Pre-Test Probability of Coronary Artery Disease by Age, Sex, and Symptoms∗

High: >90% pre-test probability. Intermediate: between 10% and 90% pre-test probability. Low: between 5% and 10% pre-test probability. Very low: <5% pre-test probability. 43

Angina

• Typical Angina (Definite)• 1) Substernal chest pain or discomfort that is 2) provoked by

exertion or emotional stress and 3) relieved by rest and/or SLNTG

• Atypical Angina (Probable)• Chest pain or discomfort that lacks one of the characteristics

of typical angina• Non-anginal Chest Pain

• Chest pain or discomfort that meets one or none of the the typical angina characteristics

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Symptomatic

From: ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

Copyright © The American College of Cardiology. All rights reserved.

J Am Coll Cardiol. 2014;63(4):380-406. doi:10.1016/j.jacc.2013.11.00945

Diabetes Mellitus:Impact of Glycemic Control on CV Risk

United Kingdom Prospective Diabetes Study (UKPDS) 35

The risk of CV disease increases with increasing HbA1CCV=Cardiovascular, HbA1C=Glycosylated hemoglobin. Stratton IM et al. BMJ 2000;321:405-412 46

Diabetes Mellitus:Impact of Glycemic Control on CV Risk

Prospective observational study of 10,232 patients with DM aged 45-79 years

The risk of CV disease increases with increasing HbA1C.Khaw KT et al. Ann Intern Med 2004;141:413-420

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Case 4• 73-year-old obese female with DMII and HTN

presents in same day clinic with complaints of palpitations. Symptoms have been present for about a year but in the past few month have gotten worse. She is now having symptoms daily. She denies any dizziness or syncope but she is worried and can’t sleep. Of note, her CPAP machine broke a few months ago.

• Patient had a stress test six months ago that was normal.

• ECG showed NSR, LVH and two PACs. 48

Does this Patient (Case 4) Need Further Testing?• YES• NO• Need more INFO

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Case 4 (Cont.)

• 48-hour Holter monitor showed atrial fibrillation with the longest episode lasting four minutes. Symptoms corresponded to atrial fibrillation.

• Echocardiogram showed normal LVEF with moderate LVH and LAE

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Mechanisms of AF

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Atrial Fibrillation

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Case 5• 55-year-old male is being seen for routine

evaluation. He was diagnosed with DMII five years ago but was not started on medical therapy. He was lost to follow up. He returns today because he figured “it was time”.

• Patient denies symptoms but states that he feels different than he did before but thinks it might be because he sobered up.

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PMHX/PSHX (Case 5)

• DMII diagnosed 5 years ago• Surgery on his shoulder 5 years ago after he got hit

with a crow bar• Ankle surgery 8 years ago• Stomach surgery after getting stabbed

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Social History (Case 5)

• Lives with his sister. No tobacco for one year. No ETOH x 1 years. No drugs but has used marijuana in the past.

• Works “odds and ends”—usually manual labor. • Walks daily to the bus stop and back but no routine

exercise.

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PE (Case 5)

• PE: BP 176/82, Pu 89 BMI 27 • NO JVD or bruits• CTA b• RRR I/VI SEM• 1+ LE edema• Labs: HgA1C 14, Creat 1.6, LDL 78, HDL 90, TG 390• Echocardiogram: Normal LVEF, aortic sclerosis

without stenosis, grade II diastolic dysfunction56

What Next?

• Tell the patient that he has a highly abnormal ECG and may die. Place a referral to cardiology and schedule follow up in three months.

• Tell the patient it is his fault that he is in this situation and prescribe metformin, glyburide, statin, ASA, ACE-I, BB and tell him the medications are needed, and that he will end up on dialysis if he doesn’t take them.

• Discuss HTN, DMII. Discuss medical therapy and lifestyle modification. After prescribing appropriate medical therapy place a referral to cardiologist explaining that there are some abnormalities that may be due to underlying cardiac disease and that the initial treatment is medical therapy and lifestyle modification.

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Thank you!

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