Editor-In-Chief: C. Michael Gibson, M.S., M.D. 
Risk stratification among patients with and at risk for coronary artery disease is critical so that the level of aggressiveness of management can match the risk of future events. The magnitude of risk is often clearer in the patient who has had a vascular event than in the assessment of primary risk assessment (who will have a future event who does not yet have evidence of CHD). Patients at low to intermediate risk by history and physical examination account for 75% of cardiovascular events. There is therefore the need for improved risk stratification tools to reclassify those patients deemed to be at low risk on history and physical examination into a higher risk category. In select populations, coronary artery calcium scoring,
carotid intima-media thickness ( CIMT) assessment and C reactive protein ( CRP) assessment may offer addition improvements in risk stratification.
Risk Equivalents in Primary Prevention
You are essentially considered to have the equivalent of coronary heart disease if you have any of the following:
CV Risk Factors in the Setting of Primary Prevention
Cigarette smoking Family history of premature
coronary artery disease ( CAD) High
LDL (defined as LDL > 130 mg /dl)
Hypertension ( defined as a BP ≥140/90 mm Hg or if the patient is on antihypertensive drugs) Low
HDL (defined as HDL < 40 mg/dL males, < 50 mg/dL in females) Older Age (men ≥45 years old; women ≥55 years old)
The Framingham Risk Score is used to estimate the 10-year cardiovascular risk of an individual. The Framingham Risk Score is based on data obtained from the Framingham Heart Study. There are two Framingham Risk Scores, one for men and one for women.
- Low Risk is less than 10%
- Intermediate Risk is 10 - 20%
- High Risk is more than 20%
Stress EKG: Duke Treadmill Score
Duke treadmill score (DTS) = Treadmill time (Bruce) - 5 x ST deviation (no. mm) - 4 x Angina index (0,1,2)
Low Risk Score
10 to 4
High Risk Score
Stress imaging is induction of reversible ischemia in a patient using drugs which can can cause increased contraction of heart muscle like
dobutamine or drugs which cause vasodilatation and decrease blood supply to heart. Both these mechanisms cause stress on heart.
ACC/AHA guidelines for Stress Imaging
" 1. Symptomatic, able to exercise, uninterpretable ECG."
" 2. Symptomatic, unable to exercise."
" 3. Symptomatic prior coronary revascularization."
" 4. Functionally significant lesion."
" 5. Intermediate risk on Duke Treadmill Score."
Stress Imaging Results
Low risk findings
It has normal or near normal MPI
Normal stress echo
The annual mortality rate in these patients will be < 1%
Intermediate risk findings
Mild to moderate dysfunction of left ventricle. (resting ejection fraction of 35- 49%)
Moderate stress induced perfusion defect without LV dilatation or increased uptake into pulmonary vessels.
Mild to moderate stress induced regional wall motion abnormalities in echocardiogram seen in upto 4 segments.
The annual mortality rate of these patients will be 1 - 3%.
High risk findings
Significant LV dysfuntion. (resting ejection fraction of <40%%)
Abnormal left ventricular end systolic volume.
Extensive ischemic regional wall motion abnormality in more than 5 segments.
Low ischemic threshold during stress echo.
Multi-vessel regional wall motion abnormality.
The annual mortality rate in these patients will be > 3%.
2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults (DO NOT EDIT) 
Global Risk Scoring (DO NOT EDIT) 
" 1. Global risk scores (such as the Framingham Risk Score) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD. These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to target preventive interventions.  ("
Level of Evidence: B)
Family History (DO NOT EDIT) 
Genomic Testing (DO NOT EDIT) 
Lipoprotein and Apolipoprotein Assessments (DO NOT EDIT) 
Measurement of Natriuretic Peptides (DO NOT EDIT) 
Measurement of C-Reactive Protein (DO NOT EDIT) 
" 1. In men 50 years of age or older or women 60 years of age or older with low-density lipoprotein cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy.  ("
Level of Evidence: B)
" 1. In asymptomatic intermediate-risk men 50 years of age or younger or women 60 years of age or younger, measurement of CRP may be reasonable for cardiovascular risk assessment.   ("
Level of Evidence: B)
Measurement of Hemoglobin A1C (DO NOT EDIT) 
Testing for Microalbuminuria (DO NOT EDIT) 
Lipoprotein-Associated Phospholipase A2 (DO NOT EDIT) 
Resting Electrocardiogram (DO NOT EDIT) 
Transthoracic Echocardiography (DO NOT EDIT) 
Measurement of Carotid Intima-Media Thickness (DO NOT EDIT) 
" 1. Measurement of carotid artery intima-media thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk.  Published recommendations on required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high-quality results.   ("
Level of Evidence: B)
Brachial/Peripheral Flow-Mediated Dilation (DO NOT EDIT) 
Specific Measures of Arterial Stiffness (DO NOT EDIT) 
Measurement of Ankle-Brachial Index (DO NOT EDIT) 
Exercise Electrocardiography (DO NOT EDIT) 
" 1. An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity.   ("
Level of Evidence: B)
Stress Echocardiography (DO NOT EDIT) 
Class III: No Benefit
" 1. Stress echocardiography is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress echocardiography is primarily used for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known coronary artery disease or the assessment of patients with known or suspected valvular heart disease.) ("
Level of Evidence: C)
Myocardial Perfusion Imaging (DO NOT EDIT) 
Class III: No Benefit
1. Stress MPI is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress MPI is primarily used and studied for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known CAD.).  ("
Level of Evidence: C)
" 1. Stress myocardial perfusion imaging (MPI) may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or asymptomatic adults with a strong family history of CHD or when previous risk assessment testing suggests a high risk of CHD, such as a coronary artery calcium (CAC) score of 400 or greater. ("
Level of Evidence: C)
Calcium Scoring Methods (DO NOT EDIT) 
Coronary Computed Tomography Angiography (DO NOT EDIT) 
Magnetic Resonance Imaging of Plaque (DO NOT EDIT) 
Patients With Diabetes (DO NOT EDIT) 
" 1. Measurement of hemoglobin A1C may be considered for cardiovascular risk assessment in asymptomatic adults with diabetes.  ("
Level of Evidence: B)
" 1. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests a high risk of CHD, such as a CAC score of 400 or greater. ("
Level of Evidence: C)
Women (DO NOT EDIT) 
↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23
Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA; et al. (2010). "2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 122 (25): e584–636. doi: 10.1161/CIR.0b013e3182051b4c. PMID 21098428.
D'Agostino RB, Grundy S, Sullivan LM, Wilson P, CHD Risk Prediction Group (2001). "Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation". JAMA. 286 (2): 180–7. PMID 11448281. Review in: ACP J Club. 2002 Jan-Feb;136(1):36
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Ridker PM, Buring JE, Rifai N, Cook NR (2007). "Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score". JAMA. 297 (6): 611–9. doi: 10.1001/jama.297.6.611. PMID 17299196.
↑ 4.0 4.1
Assmann G, Cullen P, Schulte H (2002). "Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Münster (PROCAM) study". Circulation. 105 (3): 310–5. PMID 11804985.
Paynter NP, Chasman DI, Buring JE, Shiffman D, Cook NR, Ridker PM (2009). "Cardiovascular disease risk prediction with and without knowledge of genetic variation at chromosome 9p21.3". Ann Intern Med. 150 (2): 65–72. PMC . 2629586 PMID 19153409.
Scheuner MT, Sieverding P, Shekelle PG (2008). "Delivery of genomic medicine for common chronic adult diseases: a systematic review". JAMA. 299 (11): 1320–34. doi: 10.1001/jama.299.11.1320. PMID 18349093.
Ip S, Lichtenstein AH, Chung M, Lau J, Balk EM (2009). "Systematic review: association of low-density lipoprotein subfractions with cardiovascular outcomes". Ann Intern Med. 150 (7): 474–84. PMID 19349632.
Di Angelantonio E, Chowdhury R, Sarwar N, Ray KK, Gobin R, Saleheen D; et al. (2009). "B-type natriuretic peptides and cardiovascular risk: systematic review and meta-analysis of 40 prospective studies". Circulation. 120 (22): 2177–87. doi: 10.1161/CIRCULATIONAHA.109.884866. PMID 19917883.
Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C; et al. (2005). "Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins". Lancet. 366 (9493): 1267–78. doi: 10.1016/S0140-6736(05)67394-1. PMID 16214597. Review in: ACP J Club. 2006 May-Jun;144(3):62
↑ 10.0 10.1
Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook NR (2008). "C-reactive protein and parental history improve global cardiovascular risk prediction: the Reynolds Risk Score for men". Circulation. 118 (22): 2243–51, 4p following 2251. doi: 10.1161/CIRCULATIONAHA.108.814251. PMC . 2752381 PMID 18997194. Review in: Ann Intern Med. 2009 Mar 17;150(6):JC3-14
Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AM, Kastelein JJ; et al. (2008). "Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein". N Engl J Med. 359 (21): 2195–207. doi: 10.1056/NEJMoa0807646. PMID 18997196. Review in: Evid Based Med. 2009 Apr;14(2):48 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-4
Khaw KT, Wareham N, Bingham S, Luben R, Welch A, Day N (2004). "Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk". Ann Intern Med. 141 (6): 413–20. PMID 15381514. Review in: ACP J Club. 2005 Mar-Apr;142(2):52
Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J; et al. (2010). "Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults". N Engl J Med. 362 (9): 800–11. doi: 10.1056/NEJMoa0908359. PMC . 2872990 PMID 20200384. Review in: Ann Intern Med. 2010 Jul 20;153(2):JC1-13
Ibsen H, Olsen MH, Wachtell K, Borch-Johnsen K, Lindholm LH, Mogensen CE; et al. (2005). "Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients: losartan intervention for endpoint reduction in hypertension study". Hypertension. 45 (2): 198–202. doi: 10.1161/01.HYP.0000154082.72286.2a. PMID 15655123.
Wachtell K, Ibsen H, Olsen MH, Borch-Johnsen K, Lindholm LH, Mogensen CE; et al. (2003). "Albuminuria and cardiovascular risk in hypertensive patients with left ventricular hypertrophy: the LIFE study". Ann Intern Med. 139 (11): 901–6. PMID 14644892.
Arnlöv J, Evans JC, Meigs JB, Wang TJ, Fox CS, Levy D; et al. (2005). "Low-grade albuminuria and incidence of cardiovascular disease events in nonhypertensive and nondiabetic individuals: the Framingham Heart Study". Circulation. 112 (7): 969–75. doi: 10.1161/CIRCULATIONAHA.105.538132. PMID 16087792.
Lp-PLA2 Studies Collaboration. Ballantyne C, Cushman M, Psaty B, Furberg C, Khaw KT; et al. (2007). "Collaborative meta-analysis of individual participant data from observational studies of Lp-PLA2 and cardiovascular diseases". Eur J Cardiovasc Prev Rehabil. 14 (1): 3–11. doi: 10.1097/01.hjr.0000239464.18509.f1. PMID 17301621.
Koenig W, Khuseyinova N, Löwel H, Trischler G, Meisinger C (2004). "Lipoprotein-associated phospholipase A2 adds to risk prediction of incident coronary events by C-reactive protein in apparently healthy middle-aged men from the general population: results from the 14-year follow-up of a large cohort from southern Germany". Circulation. 110 (14): 1903–8. doi: 10.1161/01.CIR.0000143377.53389.C8. PMID 15451783.
De Bacquer D, De Backer G (2002). "Electrocardiographic findings and global coronary risk assessment". Eur Heart J. 23 (4): 268–70. doi: 10.1053/euhj.2001.2849. PMID 11812060.
Okin PM, Roman MJ, Lee ET, Galloway JM, Howard BV, Devereux RB (2004). "Combined echocardiographic left ventricular hypertrophy and electrocardiographic ST depression improve prediction of mortality in American Indians: the Strong Heart Study". Hypertension. 43 (4): 769–74. doi: 10.1161/01.HYP.0000118585.73688.c6. PMID 14769809.
Ashley EA, Raxwal V, Froelicher V (2001). "An evidence-based review of the resting electrocardiogram as a screening technique for heart disease". Prog Cardiovasc Dis. 44 (1): 55–67. doi: 10.1053/pcad.2001.24683. PMID 11533927.
U.S. Preventive Services Task Force (2004). "Screening for coronary heart disease: recommendation statement". Ann Intern Med. 140 (7): 569–72. PMID 15068986.
Verdecchia P, Carini G, Circo A, Dovellini E, Giovannini E, Lombardo M; et al. (2001). "Left ventricular mass and cardiovascular morbidity in essential hypertension: the MAVI study". J Am Coll Cardiol. 38 (7): 1829–35. PMID 11738281.
Rodriguez CJ, Lin F, Sacco RL, Jin Z, Boden-Albala B, Homma S; et al. (2006). "Prognostic implications of left ventricular mass among Hispanics: the Northern Manhattan Study". Hypertension. 48 (1): 87–92. doi: 10.1161/01.HYP.0000223330.03088.58. PMID 16651457.
Nambi V, Chambless L, Folsom AR, He M, Hu Y, Mosley T; et al. (2010). "Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: the ARIC (Atherosclerosis Risk In Communities) study". J Am Coll Cardiol. 55 (15): 1600–7. doi: 10.1016/j.jacc.2009.11.075. PMC . 2862308 PMID 20378078.
↑ 26.0 26.1
Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER; et al. (2008). "Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force. Endorsed by the Society for Vascular Medicine". J Am Soc Echocardiogr. 21 (2): 93–111, quiz 189-90. doi: 10.1016/j.echo.2007.11.011. PMID 18261694.
Kuvin JT, Mammen A, Mooney P, Alsheikh-Ali AA, Karas RH (2007). "Assessment of peripheral vascular endothelial function in the ambulatory setting". Vasc Med. 12 (1): 13–6. PMID 17451088.
Takase B, Uehata A, Akima T, Nagai T, Nishioka T, Hamabe A; et al. (1998). "Endothelium-dependent flow-mediated vasodilation in coronary and brachial arteries in suspected coronary artery disease". Am J Cardiol. 82 (12): 1535–9, A7–8. PMID 9874063.
Ankle Brachial Index Collaboration. Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ; et al. (2008). "Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis". JAMA. 300 (2): 197–208. doi: 10.1001/jama.300.2.197. PMC . 2932628 PMID 18612117.
Gulati M, Pandey DK, Arnsdorf MF, Lauderdale DS, Thisted RA, Wicklund RH; et al. (2003). "Exercise capacity and the risk of death in women: the St James Women Take Heart Project". Circulation. 108 (13): 1554–9. doi: 10.1161/01.CIR.0000091080.57509.E9. PMID 12975254.
Wei M, Kampert JB, Barlow CE, Nichaman MZ, Gibbons LW, Paffenbarger RS; et al. (1999). "Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men". JAMA. 282 (16): 1547–53. PMID 10546694.
Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS; et al. (2003). "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina)". J Am Coll Cardiol. 41 (1): 159–68. PMID 12570960.
↑ 33.0 33.1
Detrano R, Guerci AD, Carr JJ, Bild DE, Burke G, Folsom AR; et al. (2008). "Coronary calcium as a predictor of coronary events in four racial or ethnic groups". N Engl J Med. 358 (13): 1336–45. doi: 10.1056/NEJMoa072100. PMID 18367736.
↑ 34.0 34.1 34.2
Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC (2004). "Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals". JAMA. 291 (2): 210–5. doi: 10.1001/jama.291.2.210. PMID 14722147.
Budoff MJ, Nasir K, McClelland RL, Detrano R, Wong N, Blumenthal RS; et al. (2009). "Coronary calcium predicts events better with absolute calcium scores than age-sex-race/ethnicity percentiles: MESA (Multi-Ethnic Study of Atherosclerosis)". J Am Coll Cardiol. 53 (4): 345–52. doi: 10.1016/j.jacc.2008.07.072. PMC . 2652569 PMID 19161884.
Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O'Malley PG (2005). "Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project". J Am Coll Cardiol. 46 (5): 807–14. doi: 10.1016/j.jacc.2005.05.049. PMID 16139129.
Choi EK, Choi SI, Rivera JJ, Nasir K, Chang SA, Chun EJ; et al. (2008). "Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals". J Am Coll Cardiol. 52 (5): 357–65. doi: 10.1016/j.jacc.2008.02.086. PMID 18652943.
Anand DV, Lim E, Hopkins D, Corder R, Shaw LJ, Sharp P; et al. (2006). "Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy". Eur Heart J. 27 (6): 713–21. doi: 10.1093/eurheartj/ehi808. PMID 16497686.
Becker A, Leber AW, Becker C, von Ziegler F, Tittus J, Schroeder I; et al. (2008). "Predictive value of coronary calcifications for future cardiac events in asymptomatic patients with diabetes mellitus: a prospective study in 716 patients over 8 years". BMC Cardiovasc Disord. 8: 27. doi: 10.1186/1471-2261-8-27. PMC . 2569906 PMID 18847481.
Scholte AJ, Schuijf JD, Kharagjitsingh AV, Jukema JW, Pundziute G, van der Wall EE; et al. (2008). "Prevalence of coronary artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in asymptomatic patients with type 2 diabetes". Heart. 94 (3): 290–5. doi: 10.1136/hrt.2007.121921. PMID 17646190.
Becker A, Leber A, Becker C, Knez A (2008). "Predictive value of coronary calcifications for future cardiac events in asymptomatic individuals". Am Heart J. 155 (1): 154–60. doi: 10.1016/j.ahj.2007.08.024. PMID 18082507.
Pilote L, Dasgupta K, Guru V, Humphries KH, McGrath J, Norris C; et al. (2007). "A comprehensive view of sex-specific issues related to cardiovascular disease". CMAJ. 176 (6): S1–44. doi: 10.1503/cmaj.051455. PMC . 1817670 PMID 17353516.