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Cardiac Risk

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Cardiac Risk, Cardiac Risk Factor, Coronary Risk Factor, Cardiac Risk Assessment, Cardiovascular Risk Factor, Cardiovascular Risk

  • See Also
  1. Cardiac Risk Management
  2. Framingham Score
  • Background
  1. Majority of patients with coronary events have a low Framingham risk
    1. High Framingham risk does predict more events
    2. However, low Framingham risk does not eliminate coronary risk
    3. Ajani (2006) JACC 48:1177-82 [PubMed]
  2. Cardiac Risks are multiplied by one another (not additive)
  3. Example of multplied risks (Odds Ratio)
    1. Relative Risk of Tobacco Abuse, diabetes, Hypertension: 13 fold increased risk
    2. Add Hyperlipidemia (4 risks): 42 fold increased risk
    3. Add Obesity (5 risks): 68 fold increased risk
    4. Add Stress (6 risks): 182 fold increased risk
  4. References
    1. Yusuf (2004) Lancet 364: 937-52 [PubMed]
  • Grading
  • Cardiac Risk
  1. Precautions
    1. Risk calculators (Framingham, Pooled cohort) overestimate Cardiovascular Risks by as much as double
    2. Ko (2020) CMAJ 192(17):E442-49 [PubMed]
  2. Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator
    1. https://www.mdcalc.com/calc/10491/predicting-risk-cardiovascular-disease-events-prevent
    2. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
    3. Expanded Test Sensitivity to include younger patients with cardiovascular, renal or metabolic risk factors
    4. May replace ASCVD Risk Estimator (less over-estimation of Cardiac Risk)
  3. Framingham Risk Score
    1. https://www.mdcalc.com/framingham-risk-score-hard-coronary-heart-disease
  4. ACC ASCVD Risk Estimator Plus
    1. https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
  5. ACC/AHA 2013 Cardiovascular Risk Calculator
    1. https://www.cvriskcalculator.com/
  6. QRISK Calculator
    1. https://qrisk.org
    2. Expanded Test Sensitivity to include ethnicities (e.g. southeast asian) at higher risk of cardiovascular events
  7. Diabetes-Related Cardiovascular Risk Calculator
    1. http://www.dtu.ox.ac.uk/index.php?maindoc=/ukpds/
  8. Reynold's Risk Score
    1. http://www.reynoldsriskscore.org/
  9. Interpretation of Framingham Cardiac Risk
    1. Low: <10% CAD 10 year risk (<0.6% per year)
    2. Moderate: 10-20% CAD 10 year risk (0.6-2.0% per year)
    3. High:>20% CAD 10 year risk (>2% per year)
  • Risk Factors
  • Common/Conventional Risks
  1. Age
    1. Men over age 45
    2. Women
      1. Over 55: Normal onset Menopause
      2. Over 45: Early Menopause (no Estrogen Replacement)
  2. Family History premature CAD
    1. Definite Myocardial Infarction or sudden death
    2. Father or first-degree male relative under age 55
    3. Mother or first-degree female relative under age 65
    4. Premature Coronary Artery DiseaseFamily History confers 2 fold increased risk
      1. Lloyd-Jones (2004) JAMA 291(18):2204-11 [PubMed]
  3. Sibling CAD history confers up to a 5 fold increased risk (higher than parent)
    1. Nasir (2004) Circulation 110:2150-6 [PubMed]
    2. Murabito (2005) JAMA 294: 3117-23 [PubMed]
  4. Tobacco Abuse
    1. Current Tobacco use or within the last 5 years
    2. Especially more than 40 pack years
  5. Hypertension
    1. Blood Pressure exceeding 140/90 mmHg
    2. Antihypertensive medication use
  6. Hyperlipidemia
    1. LDL Cholesterol over 130 mg/dl
    2. HDL Cholesterol less than 40 mg/dl (ATP III guideline)
  7. Diabetes Mellitus
    1. More than doubles risks of Coronary Artery Disease
    2. Considered Coronary Artery Disease equivalent
      1. Used in determining Hyperlipidemia Management
  8. Ethnicity and Race associated with significantly increased Cardiovascular Risk
    1. Black adults
      1. Relative Risk 2 for CV mortality compared with white patients
      2. Higher risk for undertreated comorbidities (e.g. Hypertension, Obesity)
    2. American Indian
      1. Relative Risk 1.5 for Coronary Artery Disease than white patients
    3. South Asian (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Maldives, or Bhutan)
      1. Higher risk of premature cardiovascular disease with higher hospitalization and mortality rates
      2. Shajahan (2024) Am Fam Physician 110(1):16-17 [PubMed]
  9. Other Lifestyle Risk Factors (not typically included in calculators)
    1. Obesity
    2. Sedentary lifestyle
    3. Type A Personality (especially hostility prone)
    4. Lack of supportive primary relationship
  10. Comorbidity with Substantial Risks (but not typically included in calculators or Hyperlipidemia protocols)
    1. HIV Positive status (especially if CD4 Count has ever been <500)
      1. HIV alone increases risk (Atherosclerosis and Platelet activation)
        1. Increased risk with medication non-compliance
        2. Increased risk with comorbid Hepatitis C infection
      2. Antiretrovirals (esp. increased lipids)
        1. Protease Inhibitors
        2. Abacavir
    2. Systemic inflammatory states (e.g. Systemic Lupus Erythematosus)
    3. Chronic Kidney Disease
    4. Chemotherapy
    5. Chronic Alcohol Abuse
      1. Whitman (2017) J Am Coll Cardiol 69(1):13-24 [PubMed]
  • Risk Factors
  • Workplace Chemical Exposures
  1. Carbon Monoxide
  2. Lead Exposure
  3. Methylene Chloride (paint removers)
  4. Nitrate esters (explosives)
  5. Carbon Disulfide (Viscose rayon fibers)
  6. Tobacco smoke (passive exposure)
  • Risk Factors
  • Emerging (and those not used in calculators)
  1. EKG abnormalities at rest
    1. See EKG Markers of Underlying Coronary Artery Disease
  2. Increased C-Reactive Protein
    1. See C-Reactive Protein as Cardiac Risk Factor
    2. Not recommended for routine screening currently
    3. High-Sensitivity CRP may be used in high-risk patient
      1. hs-CRP >3 mg/L predicts more ischemic episodes
    4. Comparatively weak predictor of heart disease
      1. Odds RatioC-RP: 1.45
    5. References
      1. Ridker (2004) Circulation 109:1955-9 [PubMed]
  3. Coronary Calcium Score
    1. Baseline coronary calcifications predict CAD events
    2. Can raise Relative Risk of CAD event for men to 10.5 (in coronary Calcium >1000)
      1. Contrast with diabetes CAD Relative Risk of 1.98
      2. Contrast with tobacco Relative Risk of 1.4
    3. Kondos (2003) Circulation 107:2571-6 [PubMed]
  4. Increased apolipoprotein B (LDL core)
    1. Better measure of coronary risk than LDL Cholesterol
    2. Associated with risk of fatal acute MI
    3. Sniderman (2002) Am J Cardiol 90:48i-54i [PubMed]
  5. Decreased apolipoprotein A-1 (HDL core)
    1. Apo B to A1 ratio may be better than TC to HDL ratio
  6. ACE DD Genotype
  7. Infections (e.g. Coxsackie Virus)
  8. Increased Fibrinogen
  9. Low birth weight
  10. Triglycerides
  11. Insulin Resistance Syndrome (Metabolic Syndrome)
  • Management
  • Disproven preventive factors (not beneficial after evaluation)
  1. Vitamin E (increases Cardiovascular Risk )
  2. Beta Carotene (increases cardiovacular risk)
  3. Increased Homocysteine levels or low Serum Folate
    1. Folate supplementation does not appear to lower arterial Cardiovascular Risk
  • References
  1. Orman and Mattu in Herbert (2017) EM:Rap 17(9): 8-9
  2. (2001) JAMA 285:2486-97 [PubMed]
  3. (1988) Arch Intern Med 148:36-69 [PubMed]
  4. Grundy (1997) Circulation 95:2329-31 [PubMed]