If you are 30 years old or older, you may get a new kind of cardiovascular risk screening at your next check-up.
The new guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) emphasize starting long-term risk-prevention planning earlier and using more comprehensive and individualized lipid testing, among other recommendations.
To help with this assessment, this revision to the 2018 Guideline on the Management of Blood Cholesterol suggests clinicians use the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) risk estimator
PREVENT has been available since 2013, says Joohahn John Kim, MD, who is an internist and associate medical director at Dartmouth Hitchcock Clinics in Manchester.
Kim expects that internists and general practitioners will soon begin using this tool—and follow other new recommendations—in order to come up with a more personalized risk estimate to prevent and treat cardiovascular disease in their patients.
How is cardiovascular risk being evaluated differently?
This recommendation is a change from the previous guideline, which called for a cholesterol assessment starting at age 40.
If you are between 30 and 79 years old, PREVENT estimates your 10-year and 30-year cardiovascular risk of heart attack, heart failure, stroke, or congestive heart failure.
The assessment is based on your diet, physical activity, sleep, smoking-related history, body mass index, blood pressure, lipid levels, blood sugar, and other factors.
It draws on data from more than 6.5 million adults in the U.S. and is not recommended if you already have had a heart attack, stroke, or heart failure.
The guidelines also recommend that children aged 9 to 11 (who have not been previously tested) get a more straightforward cholesterol screening to identify if they might have familial hypercholesterolemia (FH) or a lipid disorder
“If a child has FH, their LDL (low-density lipoprotein) is likely going to be significantly elevated relative to other children their age and reproducible with further testing,” says Kim.
What markers for heart disease are being evaluated?
Under the new guidelines, adults are not just being screened for elevated levels of LDL, a big risk factor for atherosclerosis, which is a narrowing and hardening of the arteries.
The guidelines also acknowledge that elevated levels of other lipids can fuel the growth and development of plaque in the arteries and impact blood flow.
For example, a primary cause of a condition known as dyslipidemia (abnormally high levels of blood lipids) brings with it not just high levels of LDL, but also high triglycerides and/or low levels of high-density lipoprotein (HDL).
“Initially, we only cared about the calculated LDL, but now we know that there are other markers of atherogenicity (the ability to develop fatty plaques within artery walls),” says Kim.
Lipoprotein(a) or Lp(a)
Your doctor may consider testing your lipoprotein(a) or what is commonly abbreviated to Lp(a). Lp(a) is a type of cholesterol-carrying fat in the blood that increases your risk of heart disease and stroke when levels are high, It is genetic, meaning people tend to inherit a propensity toward a certain level.
Lp(a) should be measured at least once to identify those individuals at higher risk of atherosclerotic cardiovascular disease (ASCVD), say the guidelines.
But getting a measure of your Lp(a) is likely not a given at your next appointment.
“If I see a patient with multiple risk factors, like dyslipidemia, hypertension (a chronic condition where the force of blood against artery walls is consistently too high), and metabolic syndrome (which is a combination of conditions like high blood pressure, high blood sugar, excess waist fat, and abnormal cholesterol levels), that is enough for me to start therapy (without an Lp(a) reading),” says Kim.
Also, if you’re a healthy patient with a low PREVENT risk score and low cholesterol, along with no family history of cardiovascular disease, don’t be surprised if your doctor skips the test at your next appointment.
But if you’re a young patient with a low PREVENT risk score but have a very strong family history of premature cardiovascular disease, your doctor might test for an elevated Lp(a) in order to get a better sense of your long-term risk.
Do you have calcified plaque in your arteries?
Another recommendation for adults with intermediate or borderline risk of heart disease is for clinicians to consider getting their patients a Coronary Artery Calcium (CAC) scoring to determine if there’s calcified plaque in the arteries.
A CAC scoring through a CT (computed tomography) is most appropriate if you are:
- Without heart disease symptoms
- Aged 40 to 75
- Without a previous heart attack or stroke
- Not already on cholesterol drugs
- Have a high risk of heart disease, as indicated through an LDL score or a strong family history of premature heart disease.
“CAC scoring in men at least 40 years of age and women at least 45 years of age can improve risk assessment,” state the guidelines.
But if you’re under 40, a CAC score is usually not advised, as you likely have little calcium build-up in your heart arteries. On the other end, if you are over 75, your age means you are likely to already have calcium buildup, and a CAC score would be a less effective measure of risk.
Often, getting a scan for a CAC score is not covered by insurance and the price is often in the range of $300. Your doctor may not be as quick to recommend the scan for that reason, so if you think the scan might be appropriate for you, don’t be afraid to discuss it.
Additional tests by your cardiologist
Your cardiologist could order additional tests, depending on your risk profile.
In some instances, for example, a cardiologist might look for elevated levels of apolipoprotein B (apoB), which attaches to harmful lipoproteins like LDL.
Measuring apoB can help identify if you have a high lipoprotein-related risk that was not picked up by earlier screenings. It can prove useful in the diagnosis of some lipid and lipoprotein disorders, say the new guidelines.
Your individual profile
Kim emphasizes that most guidelines come from population studies, whereas providers see one patient at a time. Decisions on tests and treatment, therefore, come down to the clinician working directly with each patient based on their individual risk factors.
Sometimes, for example, you and your doctor may decide diet, exercise and lifestyle modifications are the best way to try to lower your cholesterol score, based on your levels of LDL, triglycerides, and HDL and on the fact that you don’t have other significant risk factors.
But assessing those factors is important, and a comprehensive health risk profile that considers them can help your doctor and you determine how to proceed. “Many times–based on known diagnoses–additional testing is ordered,” says Kim. That testing could include a comprehensive metabolic panel, which measures glucose, electrolytes, fluid balance, and kidney function, too.
So, if, for example, you have high blood pressure, I may not even treat the cholesterol, I may treat the blood pressure first,” says Kim. “But if I know that a family member died early with heart disease, then I might want to be more aggressive. I have to see the whole patient and not just focus on an LDL number.”
Treatment beyond lifestyle, exercise, and diet modifications
That said, when it comes to your cardiovascular health, an elevated LDL level may be reason enough to go on prescription statins.
According to the US Preventative Task Force (USPTF), the American Academy of Family Physicians, and others, statins are best for people:
- Aged 40 - 75 who have one or more cardiovascular risk factors and an estimated 10-year cardiovascular disease (CVD) risk of 10% or greater.
- With cardiovascular disease related to hardening of the arteries
- With very high LDL
- With diabetes
But if your clinician tests for other lipids and they are elevated, statins might not be the recommended treatment.
And while, according to Kim, there is not yet a known treatment to lower Lp(a), there are randomized control studies coming out in the next year to guide treatment options. In the meantime, some cardiologists are recommending treating a high level of Lp(a) with a so-called PCSK9 inhibitor, such as Repatha (evolocumab).
If you have elevated levels of apoB, you also could be recommended a PCSK9 inhibitor or another form of medication.
But Kim notes that when it comes to prescribing cardiovascular medications other than statins, he and other internists may prefer to refer patients to a cardiologist to decide on the best course of treatment.
So, what can you expect at your next annual physical?
Whether or not he is the one who treats, Kim remains a big proponent of assessing the cardiovascular risks of his patients beginning at age 30.
But how risk is assessed will vary by patient and doctor.
“At the end of the day, it's still the clinician's decision to make the overall risk stratification decision. We're still clinicians, we have to look at everything. PREVENT is just one tool,” he says.
And do be forewarned, it can take a while for any guidelines to be put into practice, so your clinician may not yet be using PREVENT or following the new guidelines.
If you have concerns or wonder why, don’t be afraid to ask, says Kim.
“We learn from our patients, too,” he says.
