Screening Strategies for Cardiovascular Disease in Asymptomatic Adults

Any summary of scientific evidence is somewhat constrained as a particular snapshot in time, and lack of current evidence must not be equated with evidence against effectiveness. Many methods for CVD screening have insufficient evidence to currently recommend use in a general, asymptomatic adult population. This corresponds well with a 2012 Cochrane Review evaluating the impact of general health checks (including screening measures) that found general health checks did not improve either overall health or cardiovascular morbidity and mortality.101 Nonetheless, there is good evidence for some specific CVD screening modalities when used in the proper risk setting. Lipid measurement and abdominal aortic ultrasound, for example, are two screening techniques with strong data regarding who benefits from screening and the impact of screening on outcomes. While current evidence does not support the use of other newer screening modalities for primary prevention of CVD, this may very well change as more high-quality trials are completed in the future. Risk assessment is a vital first step in determining the appropriate approach to CVD screening. As discussed above, even with elevated LDL, younger adults without other risk factors such as HTN, smoking, or diabetes will not likely qualify for cholesterol lowering medications according to the ATP-III or ACC/AHA guidelines. In this segment of the population, lipid screening may not be necessary. One study found that prescribed lipid management (ie, lifestyle counseling and medication initiation) was more closely related to pretreatment LDL than to calculated 10-year risk despite a body of research to the contrary, resulting in under-treatment of many intermediate and high-risk individuals.81 This highlights the importance of moving the assessment of CVD risk factors beyond the traditional focus on LDL and dyslipidemia to a more holistic and individualized approach as outlined by the 2013 ACC/AHA risk assessment guidelines and championed by the PCMH movement. Risk assessment tools, such as the Pooled Cohort Risk Equations or Framingham calculator in a US population and SCORE cards or PROCAM calculator in a European population can facilitate the estimation of risk and open the door for shared decision-making regarding interventions to reduce cardiovascular risk. Shared decision making tools are sometimes built into risk assessment tools (eg, QINTERVENTION tool for use in the UK: http://qintervention.org/; Mayo Clinic Shared Decision Making National Resource Center Statin/Aspirin Choice tool http://shareddecisions.mayoclinic.org/decision-aids-for-diabetes/cardiovascular-prevention/). These tools are designed to support patient-provider conversations regarding risk factor identification and the potential benefits and harms of screening for and/or treating a health condition. Including patients in the conversation regarding evidence, potential risks, and the various options for CVD screening will provide patients with the knowledge to make informed decisions regarding their health. Further research is needed on the facilitators of and barriers to efforts to implement global risk assessment strategies in a primary care setting. The absolute benefit of treating risk factors to prevent CVD varies considerably as a function of baseline risk. In light of the current evidence, health organizations should be encouraged to reprioritize quality metrics by shifting the focus away from measuring individual biomarkers to performing global risk assessment to achieve CVD screening best practice.