Cardiac Risk Assessment
M3: I just saw our next patient who is here for a general physical. His father recently had a heart attack at age 70, and now he wants to be sure he’s healthy. I took his history, and he had cholesterol levels checked at work last month, but I’m not quite sure what else to do. Doesn’t he also need more blood work and an ECG, a stress test, and some other testing to be sure he’s healthy?
Dr C: That’s a good question—how might you go about deciding what to recommend?
M3: Well, he’s pretty healthy and active, and he doesn’t smoke, so it seems like a lot of testing might be overkill. On the other hand, since he’s 40 and a man, isn’t his risk higher than a woman or someone younger?
Dr C: Good thought. As it turns out, the United States Preventive Services Task Force (USPSTF) addresses exactly that kind of question. They put together all of the evidence into comprehensive reviews, related to preventive medicine topics. Fortunately, in the age of the Internet, it’s easy to find their most up-to-date recommendations at USpreventiveservicestaskforce.org.
M3: Wow! That’s a pretty long list—do I have to review each one of those articles?
Dr C: That would take all day, wouldn’t it? Their “Electronic Preventive Services Selector” (EPSS) gives you specific guidance quickly. You just have to type in gender and age and then answer if the patient is currently pregnant, sexually active, or using tobacco. Let’s look at the EPSS Web site at http://epss.ahrq.gov/ePSS/search.jsp.
M3: That’s great—I assume those ratings of A, B, C, D, and I have something to do with how important each type of testing is?
Dr C: Right. A and B grade recommendations should be routinely offered to patients. You can consider some of the C recommendations and I recommendations depending on the actual patient, but D recommendations are discouraged. What does this table say about cardiac screening in particular?
M3: Hmm. We should definitely screen for blood pressure, which we did with his vitals, and for cholesterol levels—he had those drawn recently. We should also talk about healthy diet, and about weight control, although he’s already active and his BMI is 25.
Dr C: Read on. What about some of the other testing you mentioned?
M3: It says that for low-risk adults, we should NOT use ECG, a stress test, or CT scan to screen for heart disease!
Dr C: That’s right, and there is also a link to the details of the recommendations if you want to read further.
M3: This is great information. I’d like to give it to the patient, but this medical jargon might be a bit confusing.
Dr C: Right again, but they do have another patient-oriented tool that conveys similar information in patient-friendly language, at http://www.healthfinder.gov/.
M3: These are great resources. But what about his cholesterol level? His LDL was 125. If his father had a heart attack, don’t we need to be sure he has a really low cholesterol level?
Dr C: Let’s look at some of the specific tools that USPSTF suggests. The “Tools” page lists many helpful clinical calculators, including the link to the “Framingham CHD Risk Calculator” maintained by the National Cholesterol Education Program (NCEP).
M3: OK, so if we put in his age of 40, his blood pressure of 135, and the fact he’s not on medications, and his cholesterol levels of 200 (LDL) and 35 (HDL), plus the fact he does not smoke, they tell us his cardiac risk is only 2%.
Dr C: Very good, and that final summary page makes a nice handout to give the patient as well. I’ll tell you what: we need to keep moving right now. But let me ask you to skim through the summary of the Adult Treatment Panel (ATP) guidelines. Here’s the link at the bottom of that summary page. And we’ll talk about the cutoffs for treatment tomorrow. Bottom line is that he does not need a statin today!
William Cayley, MD, MDiv, University of Wisconsin, Author
Alec Chessman, MD, Medical University of South Carolina, Editor
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