Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease
Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease
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DOI：
10.1016/j.jacc.2018.11.005
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发表时间：
2019-06-25
影响因子：
24
通讯作者：
Blumenthal, Roger S.
中科院分区：
文献类型：
--
作者：
Lloyd-Jones, Donald M.;Braun, Lynne T.;Blumenthal, Roger S.
风险评估是目前动脉粥样硬化性心血管疾病一级预防方法中的关键步骤。对动脉粥样硬化性心血管疾病10年风险的了解表明，高危人群中的患者可能有更大的净收益，而他汀类药物和降压药物治疗所需的人数较少。目前美国关于血压和胆固醇管理的预防指南建议使用汇集的队列方程来启动临床医生和患者在初级预防中共同决策的过程。汇集的队列方程已得到广泛验证，并广泛适用于美国普通临床人群。但是，他们可能系统性地低估了来自特定种族/民族群体、社会经济地位较低或患有慢性炎症性疾病的患者的风险，而高估了社会经济地位较高或密切参与预防性医疗服务的患者的风险。如果处于边缘或中等风险的患者仍然存在不确定性，或者如果患者在考虑到风险增加因素(例如，家族史)后与患者-临床医生讨论后仍未做出决定，额外的冠状动脉钙化测试可能有助于重新分类风险估计，并改进对使用或避免他汀类药物治疗的患者的选择。这份特别报告总结了定量风险评估的理论基础和证据基础，回顾了现有风险评分的优点和局限性，讨论了改进患者个人风险评估的方法，并就临床实践中实施风险评估和决策策略提供了实用建议。
Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current U.S. prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general U.S. clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (e.g., family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.