The following question refers to Section 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Mayo Clinic Fellow Dr. Teodora Donisan, and then by expert faculty Dr. Eugene Yang.

Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and chair of the ACC Prevention of CVD Section.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

Question #25

Please choose the CORRECT statement from the ones below.

A

CAC scoring can be considered to improve ASCVD risk classification around treatment decision thresholds.

B

Patients with type 1 or type 2 diabetes are considered very high CV risk, regardless of comorbidities and other risk factors.

C

CKD does not increase the cardiovascular risk in the absence of other risk factors.

D

Men and women older than 65 years old are at high cardiovascular risk.

Answer #25

Explanation

Option A is correct. Coronary artery calcium (CAC) scoring can reclassify CVD risk upwards and downwards in addition to conventional risk factors and may thus be considered in men and women with calculated risks around decision thresholds (Class IIb, Level B). If CAC is detected, its extent should be compared with what would be expected for a patient of the same sex and age. CAC scoring does not provide direct information on total plaque burden or stenosis severity and can be low or even zero in middle-aged patients with soft non-calcified plaque.

Option B is false. Not all patients with diabetes are very high risk by default.

·       Moderate risk: well controlled diabetes, <10 years duration, without evidence of target organ damage and no additional ASCVD risk factors.

·       High risk: patients not fulfilling the criteria above, without ASCVD and/or severe target organ damage.

·       Very high risk: diabetic patients with established ASCVD and/or severe target organ damage.

Severe target organ damage is defined by:

·       eGFR <45 mL/min/1.73 m²

·       eGFR 45-59 mL/min/1.73 m2 and microalbuminuria (albumin-to-creatinine ratio, ACR 30 -300 mg/g)

·       Proteinuria (ACR >300 mg/g)

·       Presence of microvascular disease in at least 3 different sites (e.g., microalbuminuria + retinopathy + neuropathy

Option C is false. CKD carries at least a high CVD risk even in the absence of diabetes or ASCVD.

·       Moderate CKD carries a high CVD risk:

o   eGFR 30−44 mL/min/1.73 m² and ACR <30

o   eGFR 45−59 mL/min/1.73 m² and ACR 30−300

o   eGFR ≥60 mL/min/1.73 m² and ACR >300

·       Severe CKD carries a very high CVD risk:

o   eGFR<30 mL/min/1.73 m²

o   eGFR 30−44 mL/min/1.73 m² and ACR >30

Option D is false. There is an age difference between men and women with regards to cardiovascular risk. Age is a major CVD risk driver, but age cutoffs should be used with flexibility.

·       Women < 50 years-old and men < 40 years old are usually at low 10-year CVD risk. It is still important to be aware of unfavorable modifiable risk factors that can sharply increase their lifetime CVD risk.

·       Women > 75 years-old and men > 65 years-old are usually at high 10-year CVD risk.

·       Only between the ages of 55 – 75 years in women and 40 – 65 years in men does the 10-year CVD risk vary around commonly used thresholds for intervention.

Of note:

·       In younger, apparently healthy patients, we also discuss lifetime CVD risk estimates since 10-year risk assessments often underestimate risk.

·       In an aging population, treatment decisions should take competing non-CVD risk into account.

·       In patients with established ASCVD we can discuss about residual CVD – defined as the risk estimated after initial lifestyle changes and risk factor treatment.

Main Takeaway

Estimating CVD risk is not only important in apparently healthy patients, but also in patients with diabetes, renal disease, established ASCVD, or older patients. This can provide information to allow shared decision making and personalized approach for our patients.

Guideline Loc.

Table 3, page 3237; Section 3.2.3., page 3243; Table 4, page 3244

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