Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology.

The past decade has witnessed major strides in the prevention of coronary heart disease (CHD) through modification of its causes. The most dramatic advance has been the demonstration that aggressive medical therapy will substantially reduce the likelihood of recurrent major coronary syndromes in patients with established CHD (secondary prevention). The American Heart Association (AHA) and the American College of Cardiology (ACC) have published joint recommendations for medical intervention in patients with CHD and other forms of atherosclerotic disease.1 A similar potential exists for risk reduction in patients without established CHD (primary prevention). However, the risk status of persons without CHD varies greatly, and this variability mandates a range in the intensity of interventions. Effective primary prevention thus requires an assessment of risk to categorize patients for selection of appropriate interventions. The present statement is being published jointly by the AHA and ACC to outline current issues and approaches to global risk assessment for primary prevention. The approaches described in this statement can be used for guidance at several levels of primary prevention; however, the statement does not attempt to specifically link risk assessment to treatment guidelines for particular risk factors. Nonetheless, it provides critical background information that can be used in the development of new treatment guidelines. The major and independent risk factors for CHD are cigarette smoking of any amount, elevated blood pressure, elevated serum total cholesterol and low-density lipoprotein cholesterol (LDL-C), low serum high-density lipoprotein cholesterol (HDL-C), diabetes mellitus, and advancing age (Table 1). The quantitative relationship between these risk factors and CHD risk has been elucidated by the Framingham Heart Study2 and other studies. These studies2 show that the major risk factors are additive in predictive power. Accordingly, the total risk of a person can be estimated by a summing of the risk imparted by each of the major risk factors. Other factors are associated with increased risk for CHD (Table 2). These are of 2 types: conditional risk factors and predisposing risk factors. The conditional risk factors are associated with increased risk for CHD, although their causative, independent, and quantitative contributions to CHD have not been well documented. The predisposing risk factors are those that worsen the independent risk factors. Two of them—obesity and physical inactivity—are designated major risk factors by the AHA.3,4 The adverse effects of obesity are worsened when it is expressed as abdominal obesity,5 an indicator of insulin resistance.