Cardiovascular Disease (Traditional Risk Markers) - Risk Markers - CVD (Traditional)

Diagnosis

Indications for Testing

  • Adults – obtain baseline lipid testing and repeat testing every 5 years if normal initial baseline testing

Criteria for Diagnosis

  • Newest ACC/AHA calculator (2013) incorporates additional data versus the Framingham ATP III calculator
    • May overestimate risk of atherosclerotic cardiovascular disease (ASCVD) even more excessively than ATP III calculator
    • Four risk groups for statin use
      • Adults with ASCVD – includes stroke, transient ischemic attack, peripheral vascular disease
      • Adults with diabetes, aged 40-75 years with low-density lipoprotein (LDL) levels 70-189 mg/dL
      • Adults with LDL cholesterol levels of ≥190 mg/dL
      • Adults aged 40-75 years who have LDL levels 70-189 mg/dL and ≥7.5% 10-year risk of atherosclerotic cardiovascular disease
  • Framingham ATP III
    • Identify risk factors present for cardiovascular disease (referred to as ASCVD in current ACC/AHA guidelines) 
      • Elevated LDL-C – current gold standard diagnostic risk marker
      • Tobacco use
      • Hypertension – blood pressure >140/90 mmHg or on medication for hypertension
      • Low high-density lipoprotein cholesterol (HDL-C) – <40 mg/dL
        • HDL-C ≥60 mg/dL is considered beneficial and removes one risk factor from the total count
      • Family history of early CVD – <55 years in first-degree male relative or <65 years in first-degree female relative
      • Increased age – men ≥45 years; women ≥55 years
    • If >2 risk factors are present, assess Framingham criteria projections for 10-year CVD risk
  • Treatment goals are determined by final risk category

    Source

    Risk

    Target LDL-C

    American Diabetes Association (ADA)/
    American College of Cardiology (ACC)
    Consensus (2008)

    Highest

    • Known CVD
    • DM plus ≥1 risk
      factor(s) for CVD

    <70 mg/dL

    High

    • ≥2 risk factors for CVD
    • DM (no other CVD
      risk factors)

    <100 mg/dL

    ADA Practice 
    Guidelines (2012)

    • DM

    <100 mg/dL

    • Known CVD plus DM

    <70 mg/dL

    Adult Treatment Panel (ATP) III 
    Guidelines (2004)

    Very high

    <70 mg/dL

    High

    • Known CVD
    • DM
    • CVD risk factor

    <100 mg/dL

    Intermediate

    <130 mg/dL

    Low

    <160 mg/dL

    American College of Cardiology (ACC)/American Heart Association (AHA) (2013)

    High

    • Known ASCVD
    • LDL ≥190 mg/dL
    • DM with estimated ASCVD risk ≥7.5% at 10 years

    Intermediate

    • DM with estimated ASCVD risk <7.5% at 10 years
    • 40-75 years with ≥7.5% ASCVD risk at 10 years
    Deemphasizes actual goal level, but rather high- vs. low-intensity statin therapy based on risk group
    • Initiate lifestyle modifications and/or drug therapy to reduce LDL-C to target concentrations
    • High triglycerides (TG) – >150 mg/dL
      • Lifestyle modifications
      • If TG ≥200 mg/dL, non-HDL-C target is set 30 mg/dL higher than LDL-C target

Laboratory Testing 

  • Determine lipoprotein concentrations using fasting lipid testing 
    • LDL-C, HDL-C and TG – minimum testing recommendation
    • No consensus guidelines support use of LDL-C subclasses

Screening

  • Adults
    • ≤75 years – screen all individuals
    • >75 years – screen individuals who have multiple coronary artery disease risk factors
  • Initial screen – fasting lipid panel with LDL-C, HDL-C, and TG

Monitoring

  • ADA/ACC consensus – consider Apo B monitoring in patients with LDL-C <130 mg/dL with a goal of 80 mg/dL in highest-risk patients
  • New AHA (2013) guideline deemphasizes fixed goals for LDL-C and HDL
    • Lipid measurement – 1-3 months after statin initiation and yearly thereafter

Clinical Background

Cardiovascular disease (CVD) (referred to as atherosclerotic cardiovascular disease [ASCVD] in current ACC/AHA guidelines) is a major cause of morbidity and mortality in the U.S.

Epidemiology

Risk Factors for CVD

Basis of Risk Assessment

  • Statins shown to reduce LDL-C concentrations and to reduce cardiovascular mortality in numerous trials
    • Identifying patients who will benefit from drug therapy is important for early prevention and intervention
  • Adult Treatment Panel (ATP) III guidelines (Framingham Heart Study)
    • Identify patients at risk for development of CVD
    • Develop plan of action for at-risk patients, including target goals for LDL-C and triglycerides (TG)

Pediatrics

Clinical Background

Epidemiology

  • Prevalence – in last 10 years, increasing prevalence of hyperlipidemia in children, which mirrors increasing level of obesity
    • ~20% of youth 12-19 years have abnormal cholesterol values

Diagnosis

Indications for Testing

Laboratory Testing

  • Lipid profile
     CholesterolLDL
    Acceptable<170 mg/dL<110 mg/dL
    Borderline170-199 mg/dL110-129 mg/dL
    Elevated≥200 mg/dL≥130 mg/dL

Screening

  • U.S. Preventive Services Task Force (USPSTF, 2007) – insufficient evidence to recommend screening
  • American Academy of Pediatrics (2008) – screen children and adults (fasting lipid profile)
    • Recommended if family history of CVD or other CVD risk factors 
    • No definitive data exists to show which cholesterol level predicts risk of adult CVD
    • If levels acceptable, repeat every 3-5 years

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
Lipid Panel 0020421
Method: Quantitative Enzymatic

Diagnose risk factors for CVD; test of choice in patients with TG <400 mg/dL

Panel includes cholesterol, TG, HDL-C, LDL-C (calculated), VLDL cholesterol (calculated)

   
Lipid Panel, Extended 0020468
Method: Quantitative Spectrophotometry/Quantitative Enzymatic

Identify risk factors for CVD; panel of choice in patients with TG >400 mg/dL

Panel includes cholesterol, TG, HDL-C, LDL-C, VLDL cholesterol (calculated)

LDL-C is measured, not calculated, in this panel; standard panel is test of choice in patients with TG <400 mg/dL

   
LDL Cholesterol, Direct 0020257
Method: Quantitative Detergent Solubilization/ Enzymatic

Monitor response to therapy

   
Glucose, Plasma or Serum 0020024
Method: Quantitative Enzymatic

Standard screen for DM

   
Additional Tests Available
 
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
Triglycerides, Serum or Plasma 0020040
Method: Quantitative Enzymatic
LDL Subclasses 0050021
Method: Quantitative Electrophoresis

Not validated to assess CVD risk

HDL Cholesterol 0020053
Method: Detergent Solubilization/Enzymatic
Cholesterol, Serum or Plasma 0020031
Method: Quantitative Enzymatic
Glucose Tolerance Test 0020542
Method: Quantitative Enzymatic

Diagnose DM and establish criteria for metabolic syndrome

Patient must be fasting

Components include fasting glucose and 2-hr glucose

Apolipoprotein B 0050029
Method: Quantitative Nephelometry