Cardiovascular Disease Prevention Initial Assessment

History

History-taking for atherosclerotic cardiovascular disease (ASCVD) risk assessment should include evaluation of conventional risk factors such as age, smoking, sedentary lifestyle, unhealthy diet (eg excessive salt and fat intake), alcohol use, overweight or obesity, hypertension, DM, hypercholesterolemia, or the presence of combined clinical entities like metabolic syndrome. Patients with DM should be screened for severe target organ damage (TOD) and ASCVD symptoms. Current symptoms of atherosclerosis such as angina, intermittent claudication, myocardial infarction (MI), transient ischemic attack (TIA), or stroke should also be investigated. A personal history of conditions like polycystic ovary syndrome, gout, chronic inflammatory conditions, sexual dysfunction, kidney disease, or periodontitis may also contribute to cardiovascular risk. Additionally, it is important to identify the use of drugs known to raise blood pressure, including oral contraceptives, nonsteroidal anti-inflammatory drugs (NSAIDs), licorice, cocaine, amphetamines, Erythropoietin, Ciclosporin, and steroids. A family history of high blood pressure, diabetes, dyslipidemia, CHD, stroke, renal disease, and premature CVD should also be elicited, as the risk of CHD increases with the number of family members with CHD increases and the younger the age at which family members develop the disease (<55 years of age in first-degree male relatives or <65 years in female relatives). Furthermore, personal, psychosocial, occupational, and environmental factors that can influence long-term care, such as depression, anxiety, type D personality, lack of social support, social isolation, and stressful working conditions, should be assessed, along with the patient’s alcohol consumption.

Physical Examination

Physical examination for assessing ASCVD risk involves measuring blood pressure, pulse rate, and the ABI, along with determining height, weight, and waist circumference. Body mass index (BMI) is calculated by dividing the patient’s weight in kilograms by the square of their height in meters (m²).  

A comprehensive physical examination should be conducted across multiple systems. In the cardiovascular (CV) system, it is essential to evaluate heart size, any displacement of the apex beat, signs of heart failure, and detect disease in the carotid, renal, and peripheral arteries, as well as identify coarctation of the aorta. Pulmonary examination should check for signs of congestion or lung disease. The abdominal examination includes listening for bruits and checking for enlarged kidneys, liver, or other abdominal masses. Ocular examination involves evaluating the optic fundi, as well as looking for corneal arcus and xanthelasma. Examination of the central nervous system (CNS) should identify any evidence of CVD and complications of diabetes (ie neuropathy). Additionally, the skin should be examined for signs such as tendon xanthomas. Finally, examination for features of secondary hypertension (eg pheochromocytoma, Cushing’s syndrome) is important.

Cardiovascular Disease Prevention_Initial Assesment

Diagnosis or Diagnostic Criteria

Coronary Risk Charts for Determination of CVD Risk  

Coronary risk charts for the determination of CVD risk utilize factors such as age, gender, smoking status, DM, BP, and lipid levels. Overall CVD risk is considered more important than the mere presence or absence of specific individual risk factors. Risk assessment tools that may be used to estimate CVD risk in patients who have not yet experienced symptomatic CVD or other atherosclerotic conditions include the Framingham Risk Assessment Tool, Multi-Ethnic Study of Atherosclerosis (MESA) 10-year ASCVD risk calculator with coronary artery calcification, Systematic Coronary Risk Estimation (SCORE), Reynold’s Risk Score, QRESEARCH risk estimator version 3 (QRISK3), and the United Kingdom Prospective Diabetes Study (UKPDS) risk engine, which is specific for individuals with type 2 DM. However, risk assessment tools should not be used in individuals who are at high risk of CVD (eg type 1 DM, estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m² and/or albuminuria, inherited disorders of lipid metabolism [familial hypercholesterolemia], those aged 85 years and older). After estimating the 10-year fatal and non-fatal CVD risk in apparently healthy individuals, additional considerations should include risk modifiers such as ethnicity, family history, genetics, frailty, body composition, psychosocial factors, socioeconomic determinants, environmental factors, blood or urine biomarkers, and imaging findings. Furthermore, lifetime risk, treatment benefits, polypharmacy, and patient preferences should be considered. Patients with an estimated 10-year CVD risk of ≥10% should be given a full formal risk assessment.