Mixed Consensus on Cardiovascular Screening Guidelines

Primary care physicians play an important role in the prevention of cardiovascular disease (CVD) but still find implementation of prevention strategies challenging, which may be limiting their usage. A review of guidelines developed by various organizations identified considerable discrepancies in primary prevention guidelines for adult cardiovascular risk assessment, according to findings published in Annals of Internal Medicine.

Mohammed Y Khanji, MB, BCh, Queen Mary University (London), and colleagues identified 21 guidelines on cardiovascular screening interventions that could be performed within a cardiovascular health check program. They found that 17 of the guidelines were rigorously developed. These recommendations address assessment of total cholesterol risk, dysglycemia, dyslipidemia, and hypertension. 
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Researchers reported that most of the guidelines supported CVD risk assessment as a primary or secondary step and the consideration of ethnicity as a risk factor. Many of the guidelines recommended integrating age, sex, smoking, blood pressure, and lipid levels into CVD risk assessment; however, there was no consensus on which prediction model to use. There was agreement on the importance of addressing lifestyle factors in all target groups independently of pharmacotherapy, as well as the limited role of novel biomarkers or markers of subclinical atherosclerosis.

Guidelines advocated a conservative approach for primary prevention with aspirin. “Of the 8 guidelines that make recommendations on aspirin use, 3 do not recommend routine use for primary prevention, 3 of the dysglycemia guidelines recommend considering aspirin therapy but only in the presence of additional factors putting patients in a high-risk category, and only 2 guidelines based the recommendation on age alone,” said the researchers.

Guidelines differed in the target population for screening. The US guidelines recommend screening at 20 years of age, while European and Australian guidelines recommend an older target population of individuals aged ≥ 40 years. They also disagreed on when to initiate statin treatment, and there was no consensus about CVD risk threshold. Recommendations on initiating antihypertensive medication varied, and the guidelines could not agree on global risk or blood pressure thresholds. Additionally, there was no consensus among guidelines on which subclinical atherosclerosis screening to test to use.

“Cardiovascular screening guidelines still have considerable discrepancies, with no consensus on optimum screening strategies or treatment threshold,” concluded the investigators. “Physicians should assess the strength of the recommendations and the level of evidence to decide which of the recommendations they should implement.”—Eileen Koutnik-Fotopoulos

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Khanji MY, Bicalho VV, van Waardhuizen CN, Ferket BS, Petersen SE, Hunink MG. Cardiovascular risk assessment: a systematic review of guidelines [published online ahead of print September 13, 2016]. Ann Intern Med. doi:10.7326/M16-1110.