PURPOSE OF RISK ASSESSMENT
Primarily, screening for CHD is conducted to identify patients whose prognosis could be improved with intervention. Furthermore, screening allows physicians to identify existing disease, rather than estimating the likelihood of a further CHD event
HISTORY AND PHYSICAL EXAMINATION
History: focus is on the detection of angina equivalent symptoms as well as assessment of lifestyle factors. Most important include, level of exercise and overall fitness, dietary choices, smoking status and intake of alcohol and illicit drugs.
Family History: examine any prior incidence of family members suffering from sudden cardiac death as it is often associated with increased risk of CHD in the patient being screened.
Risk score calculation: primary prevention treatment strategies are determined by assessment of cardiovascular risk. Risk scores provide an estimation of cardiovascular risk in asymptomatic patients being screened and this can influence further preventative treatment options.
AVAILABLE SCREENING TESTS AND THEIR USE
cholesterol levels can be used to assess cardiovascular risk.
Resting 12-lead ECG and 24-hour ambulatory ECG monitoring:
Stress testing: exercise stress testing can indirectly identify the presence or absence of underlying CHD by assessing for myocardial ischemia – Exercise ECG testing: useful for diagnostic evaluation of patients with known or suspected CHD. This type of screening can also provide prognostic information. –
Stress radionuclide myocardial perfusion imaging and stress echocardiography: alternative screening approaches for those who are unable to exercise.
Coronary calcium score and CT angiography: Electron beam or multidetector row computer tomography (EBCT and MDCT): a noninvasive technique used to detect and quantify CAC using tomograms from the aorta through the apex of the heart. These observations provide the rationale for the use of CAC scanning to screen for CHD in asymptomatic adults suspected of having or being at risk for coronary disease. CAC: is an excellent predictor of cerebrovascular disease as well as CHD in the primary prevention setting.
Invasive coronary angiography: this screening is not recommended in patients who are asymptomatic. Coronary angiography may be considered in select patients who require CHD screening if other screening modalities have yielded non-diagnostic results. This method of screening and detection of CHD has long been considered the ‘gold standard’ however the invasive nature of this procedure in a patient who is otherwise asymptomatic may outweigh the potential benefits of the test.
RECOMMENDATIONS FROM MAJOR SOCITIES
United States Preventive Services Task Force (USPSTF): Recommendations regarding the use of the resting or exercise electrocardiography testing for screening for CHD: – recommended against routine screening in adults at low risk of CHD events
American College of Cardiology/American Heart Association (ACC/AHA): – there is little evidence in support of routine exercise testing in asymptomatic adults, however patients with diabetes would benefit from screening. – exercise testing could be considered in patients with multiple risk factors for CHD; men over 45 years and women over 55 years who are sedentary but want to begin vigorous exercise, individuals who partake in occupations linked to public safety.