Coronary Artery Disease Risk Assessment and Noninvasive Testing

Case 2. TK is a 54-year-old patient with high blood pressure, type 2 diabetes, and dyslipidemia. She tells you that over the weekend, she developed shortness of breath and chest discomfort while walking with her grandson. The symptoms lasted about 5 minutes, then stopped; she has had no symptoms since then. What is the next step in assessing her risk of coronary artery disease?

Cardiovascular disease (CVD) risk assessment is an evolving field with new research indicating that more recommendations tailored to and personalized for patients are possible. Risk assessment tools and tests can help clinicians stratify their patients’ atherosclerotic cardiovascular disease (ASCVD) risks and develop individualized treatment plans. Pharmacotherapy in high-risk patients has the potential to mitigate much of the community burden of CVD. Risk assessments are typically performed in asymptomatic patients, but they may also be valuable in patients presenting with symptoms concerning for CVD.

Physicians should routinely assess adults 40 to 75 years of age for cardiovascular risk factors using a pooled cohort equation to estimate their 10-year ASCVD risk.¹ Few real-world studies have prospectively compared the actual incidence of coronary heart disease within a cohort to that group’s estimated risk as calculated using the pooled cohort equation. A concordance statistic (C statistic) is one way to accurately test the ability of a model to predict the rate of a studied outcome.² A score of 1 indicates that the model perfectly predicted outcomes in a real-world study. A value greater than 0.7 is considered useful, whereas a value less than 0.5 is inaccurate and should not be adopted in clinical medicine.² An early study confirmed the utility of the American College of Cardiology/American Heart Association (ACC/AHA) ASCVD risk calculator with a C statistic of 0.78.³

In 2023, the AHA developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) calculator. The calculator is based on a large, diverse, contemporary population sample and estimates the 10-year risk of CVD, which includes ASCVD and heart failure, in adults 30 to 79 years of age and the 30-year risk of these outcomes in adults 30 to 59 years of age. In addition to typical CVD risk factors, the calculator includes optional inputs such as glomerular filtration rate, A1C, urine albumin to creatinine ratio, and zip code (used as a proxy for social determinants of health). After 4.8 years of follow-up, the PREVENT calculator had a C statistic of 0.794.⁴ Table 1 shows the C statistic values for the major CVD risk calculators and demonstrates that all major calculators have similar predictive outcomes in longitudinal studies.^3,5–7