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Guideline Summary
Guideline Title
2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Bibliographic Source(s)
Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JM, Kushner FG, Lauer MS, Shaw LJ, Smith SC Jr, Taylor AJ, Weintraub WS, Wenger NK, Jacobs AK, Smith SC Jr, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Nishimura R, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW, American College of Cardiology Foundation, American Heart Association. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010 Dec 14;56(25):e50-103. [446 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Cardiovascular disease

Guideline Category
Diagnosis
Evaluation
Risk Assessment
Screening
Clinical Specialty
Cardiology
Family Practice
Internal Medicine
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Guideline Objective(s)
  • To assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions
  • To assist healthcare providers in the initial assessment of the apparently healthy adult for risk of developing cardiovascular events associated with atherosclerotic vascular disease
  • To provide the foundation for targeted preventive efforts based on that individual's predicted cardiovascular risk
Target Population

Adults age 20 and older who are asymptomatic for cardiovascular disease (CVD)

Note: This guideline specifically excludes from consideration patients with a diagnosis of CVD or a coronary event, for example, angina or anginal equivalent, myocardial infarction, or revascularization with percutaneous coronary intervention or coronary artery bypass graft surgery.

Interventions and Practices Considered

Evaluation/Risk Assessment

  1. Global risk scoring
    • Framingham risk score (FRS)
  2. Family history of atherothrombotic cardiovascular disease
  3. Genotype testing (considered, but not recommended)
  4. Standard fasting lipid profile (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides)
  5. Circulating blood markers
    • Natriuretic peptides (considered, but not recommended)
    • C-Reactive protein
    • Hemoglobin A1C
    • Urinary albumin excretion
  6. Lipoprotein-associated phospholipase A2
  7. Cardiac and vascular tests
    • Resting electrocardiogram
    • Transthoracic echocardiography
    • Carotid intima-media thickness on ultrasound
    • Brachial/peripheral flow-mediated dilation (considered, but not recommended)
    • Measures of arterial stiffness (considered, but not recommended)
    • Ankle-brachial index
    • Exercise electrocardiography
    • Stress echocardiography (considered, but not recommended in low/intermediate risk asymptomatic patients)
    • Myocardial perfusion imaging
    • Computed tomography for coronary calcium
    • Coronary computed tomography angiography (considered, but not recommended)
    • Magnetic resonance imaging of plaque (considered, but not recommended)
  8. Special circumstances
    • Patients with diabetes mellitus
    • Women
Major Outcomes Considered
  • Cardiovascular disease (CVD) incidence
  • Progression of symptoms
  • Mortality (all-cause and cardiovascular)
  • Cardiovascular events (stroke, myocardial infarction)
  • Sensitivity and specificity of tests for assessing risk of CVD

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force) is charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, and the Task Force directs and oversees this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update, or revise recommendations for clinical practice.

The recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted for the period beginning March 2008 through April 2010.

For development of this particular guideline, staff and writing committee members used PubMed to conduct the literature searches. Searches were limited to studies, reviews, and other evidence conducted in human subjects and published in English. Key search words included, but were not limited to, African Americans, Asian Americans, albuminuria, asymptomatic, asymptomatic screening and brachial artery reactivity, atherosclerosis imaging, atrial fibrillation, brachial artery testing for atherosclerosis, calibration, cardiac tomography, compliance, carotid intima-media thickness (IMT), coronary calcium, coronary computed tomography angiography (CCTA), C-reactive protein (CRP), detection of subclinical atherosclerosis, discrimination, endothelial function, family history, flow-mediated dilation, genetics, genetic screening, guidelines, Hispanic Americans, hemoglobin A, glycosylated, meta-analysis, Mexican Americans, myocardial perfusion imaging (MPI), noninvasive testing, noninvasive testing and type 2 diabetes, outcomes, patient compliance, peripheral arterial tonometry (PAT), peripheral tonometry and atherosclerosis, lipoprotein-associated phospholipase A2, primary prevention of coronary artery disease (CAD), proteinuria, cardiovascular risk, risk scoring, receiver operating characteristics (ROC) curve, screening for brachial artery reactivity, stress echocardiography, subclinical atherosclerosis, subclinical and Framingham, subclinical and Multi-Ethnic Study of Atherosclerosis (MESA), and type 2 diabetes.

Additionally, the writing committee reviewed documents related to the subject matter previously published by the ACCF and AHA, American Diabetes Association (ADA), European Society of Cardiology, and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)7.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Applying Classification of Recommendations and Level of Evidence

  Size of Treatment Effect
  CLASS I

Benefit >>> Risk

Procedure/Treatment
SHOULD be performed/ administered
CLASS IIa

Benefit >> Risk
Additional studies with focused objectives needed


IT IS REASONABLE to perform procedure/administer treatment
CLASS IIb

Benefit ≥ Risk
Additional studies with broad objectives needed; additional registry data would be helpful


Procedure/Treatment
MAY BE CONSIDERED
CLASS III No Benefit
or Class III Harm
  Procedure/Test Treatment
COR III:
No Benefit
Not helpful No proven benefit
COR III:
Harm
Excess Cost without Benefit or Harmful Harmful to Patients
Estimate of Certainty (Precision) of Treatment Effect LEVEL A

Multiple populations evaluated*

Data derived from multiple randomized clinical trials or meta-analyses
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials or meta-analyses
LEVEL B

Limited populations evaluated*

Data derived from a single randomized clinical trials or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C

Very limited populations evaluated*

Only consensus opinion of experts, case studies or standard of care
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard-of-care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard-of-care

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

To provide clinicians with a comprehensive set of data, whenever deemed appropriate or when published in the article, data from the clinical trial will be used to calculate the absolute risk difference and number needed to treat or harm; data related to the relative treatment effects will also be provided, such as odds ratio (OR), relative risk (RR), hazard ratio (HR), or incidence rate ratio (IRR), along with confidence interval (CI) when available.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

An extensive evidence review was conducted for the period beginning March 2008 through April 2010. The committee was composed of physicians and others expert in the field of cardiology. The committee included representatives from the American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society of Atherosclerosis Imaging and Prevention (SAIP), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR).

Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected health outcomes where data exist. Patient-specific modifiers, co-morbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.

The schema for Classification of Recommendations (COR) and Level of Evidence (LOE) is summarized in the table above in the "Rating Scheme for the Strength of the Evidence," which also illustrates how the grading system provides an estimate of the size as well as the certainty of the treatment effect. A new addition to the American College of Cardiology/American Heart Association (ACCF/AHA) methodology is a separation of the Class III recommendations to delineate whether the recommendation is determined to be of "no benefit" or associated with "harm" to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment/strategy with respect to another for COR I and IIa, LOE A or B only, have been added.

The committee reviewed and ranked evidence supporting current recommendations, with the weight of evidence ranked as Level A if the data were derived from multiple randomized clinical trials or meta-analyses. The committee ranked available evidence as Level B when data were derived from a single randomized trial or nonrandomized studies. Evidence was ranked as Level C when the primary source of the recommendation was consensus opinion, case studies, or standard of care. In the narrative portions of these guidelines, evidence is generally presented in chronological order of development. Studies are identified as observational, retrospective, prospective, or randomized when appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and ranked as Level C. An example is the use of penicillin for pneumococcal pneumonia, where there are no randomized trials and treatment is based on clinical experience. When recommendations at Level C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues where sparse data are available, a survey of current practice among the clinicians on the writing committee was the basis for Level C recommendations and no references are cited.

Rating Scheme for the Strength of the Recommendations

See "Rating Scheme for the Strength of the Evidence" field, above.

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

This document was reviewed by 2 outside reviewers nominated by the American College of Cardiology Foundation (ACCF) and 2 outside reviewers nominated by the American Heart Association (AHA), as well as 2 reviewers each from the American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society of Atherosclerosis Imaging and Prevention (SAIP), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR), and 23 individual content reviewers (including members from the Appropriate Use Criteria Task Force, ACCF Cardiac Catheterization Committee, ACCF Imaging Council, and ACCF Prevention of Cardiovascular Disease Committee).

This document was approved for publication by the governing bodies of the ACCF and AHA and endorsed by ASE, ASNC, SAIP, SCCT, and SCMR.

Recommendations

Major Recommendations

The American College of Cardiology/American Heart Association (ACC/AHA) Classification of the recommendations for patient evaluation and treatment (Classes I-III) and the levels of evidence (A-C) are defined at the end of the "Major Recommendations" field.

General Approach to Risk Stratification

Global Risk Scoring

Class I

  1. Global risk scores (such as the Framingham Risk Score [FRS]) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of coronary heart disease (CHD). These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to target preventive interventions (D'Agostino et al., 2001). (Level of Evidence: B)

Family History and Genomics

Family History

Class I

  1. Family history of atherothrombotic cardiovascular disease (CVD) should be obtained for cardiovascular risk assessment in all asymptomatic adults (Ridker et al., 2007; Assmann, Cullen, & Schulte, 2002). (Level of Evidence: B)

Genotypes: Common Genetic Variants for CHD

Class III: No Benefit

  1. Genotype testing for CHD risk assessment in asymptomatic adults is not recommended (Paynter et al., 2009; Scheuner, Sieverding, & Shekelle, 2008). (Level of Evidence: B)

Lipoprotein and Apolipoprotein Assessments

Class III: No Benefit

  1. Measurement of lipid parameters, including lipoproteins, apolipoproteins, particle size, and density, beyond a standard fasting lipid profile is not recommended for cardiovascular risk assessment in asymptomatic adults (Ip et al., 2009). (Level of Evidence: C)

Other Circulating Blood Markers and Associated Conditions

Measurement of Natriuretic Peptides

Class III: No Benefit

  1. Measurement of natriuretic peptides is not recommended for CHD risk assessment in asymptomatic adults (Di Angelantonio et al., 2009). (Level of Evidence: B)

Measurement of C-Reactive Protein (CRP)

Class IIa

  1. In men 50 years of age or older or women 60 years of age or older with low-density lipoprotein (LDL) cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy (Ridker et al., "Rosuvastatin to prevent vascular events", 2008). (Level of Evidence: B)

Class IIb

  1. In asymptomatic intermediate-risk men 50 years of age or younger or women 60 years of age or younger, measurement of CRP may be reasonable for cardiovascular risk assessment (Ridker et al., 2007; Ridker et al., "C-reactive protein and parental history," 2008). (Level of Evidence: B)

Class III: No Benefit

  1. In asymptomatic high-risk adults, measurement of CRP is not recommended for cardiovascular risk assessment (Baigent et al., 2005). (Level of Evidence: B)
  2. In low-risk men younger than 50 years of age or women 60 years of age or younger, measurement of CRP is not recommended for cardiovascular risk assessment (Ridker et al., 2007; Ridker et al., "C-reactive protein and parental history," 2008). (Level of Evidence: B)

Metabolic: Hemoglobin A1C (HbA1C)

Class IIb

  1. Measurement of HbA1C may be reasonable for cardiovascular risk assessment in asymptomatic adults without a diagnosis of diabetes (Khaw et al., 2004; Khaw & Wareham, 2006; Knowler et al., 2002; Lachin et al., 2007; Selvin et al., 2004; Selvin et al., 2010). (Level of Evidence: B)

Urinary Albumin Excretion

Class IIa

  1. In asymptomatic adults with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk assessment (Ibsen et al., 2005; Ninomiya et al., 2009; Wachtell et al., 2003). (Level of Evidence: B)

Class IIb

  1. In asymptomatic adults at intermediate risk without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment (Arnlov et al., 2005). (Level of Evidence: B)

Lipoprotein-Associated Phospholipase A2 (Lp-PLA2)

Class IIb

  1. Lp-PLA2 might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults (Lp-PLA2 Studies Collaboration et al., 2007; Daniels et al., 2008; Garza et al., 2007; Koenig et al., 2004). (Level of Evidence: B)

Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults

Resting Electrocardiogram (ECG)

Class IIa

  1. A resting ECG is reasonable for cardiovascular risk assessment in asymptomatic adults with hypertension or diabetes (De Bacquer & De Backer, 2002; Okin et al., 2004). (Level of Evidence: C)

Class IIb

  1. A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes (Ashley, Raxwal & Froelicher, 2001; Schlant et al., 1992; "Screening for coronary heart disease," 2004). (Level of Evidence: C)

Resting Echocardiography for Left Ventricular Structure and Function and Left Ventricular Hypertrophy (LVH): Transthoracic Echocardiography

Class IIb

  1. Echocardiography to detect LVH may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension (Verdecchia et al., 2001; Rodriguez et al., 2006). (Level of Evidence: B)

Class III: No Benefit

  1. Echocardiography is not recommended for cardiovascular risk assessment of CHD in asymptomatic adults without hypertension. (Level of Evidence: C)

Carotid Intima-Media Thickness (IMT) on Ultrasound

Class IIa

  1. Measurement of carotid artery IMT is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (Nambi et al., 2010; Stein et al., 2008). Published recommendations on required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high quality results (Stein et al., 2008). (Level of Evidence: B)

Brachial/Peripheral Flow-Mediated Dilation (FMD)

Class III: No Benefit

  1. Peripheral arterial FMD studies are not recommended for cardiovascular risk assessment in asymptomatic adults (Kuvin et al., 2007; Takase et al., 1998). (Level of Evidence: B)

Pulse Wave Velocity and Other Arterial Abnormalities: Measures of Arterial Stiffness

Class III: No Benefit

  1. Measures of arterial stiffness outside of research settings are not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C)

Ankle-Brachial Index (ABI)

Class IIa

  1. Measurement of ABI is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (Ankle Brachial Index Collaboration et al., 2008). (Level of Evidence: B)

Exercise ECG

Class IIb

  1. An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity (Gulati et al., 2003; Adabag et al., 2008; Wei et al., 1999). (Level of Evidence: B)

Stress Echocardiography

Class III: No Benefit

  1. Stress echocardiography is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress echocardiography is primarily used for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known coronary artery disease (CAD) or the assessment of patients with known or suspected valvular heart disease.) (Level of Evidence: C)

Myocardial Perfusion Imaging (MPI)

Class IIb

  1. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or asymptomatic adults with a strong family history of CHD or when previous risk assessment testing suggests high risk of CHD, such as a coronary artery calcium (CAC) score of 400 or greater. (Level of Evidence: C)

Class III: No Benefit

  1. Stress MPI is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults (Exercise or pharmacologic stress MPI is primarily used and studied for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known CAD.) (Gibbons et al., 2003). (Level of Evidence: C)

Computed Tomography for Coronary Calcium

(See section 'Diabetes Mellitus' below).

Class IIa

  1. Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk) (Detrano et al., 2008; Greenland et al., 2004). (Level of Evidence: B)

Class IIb

  1. Measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low to intermediate risk (6% to 10% 10-year risk) (Greenland et al., 2004; Lakoski et al., 2007; Taylor et al., 2005). (Level of Evidence: B)

Class III: No Benefit

  1. Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment (Detrano et al., 2008; Greenland et al., 2004; Budoff et al., 2009). (Level of Evidence: B)

Coronary Computed Tomography Angiography (CCTA)

Class III: No Benefit

  1. CCTA is not recommended for cardiovascular risk assessment in asymptomatic adults (Choi et al., 2008). (Level of Evidence: C)

Magnetic Resonance Imaging (MRI) of Plaque

Class III: No Benefit

  1. MRI for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C)

Special Circumstances and Other Considerations

Diabetes Mellitus

Class IIa

  1. In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment (Anand et al., 2006; Becker et al., "Predictive value of coronary calcifications for future cardiac events in asymptomatic patients with diabetes mellitus," 2008; Elkeles et al., 2008; Scholte et al., 2008). (Level of Evidence: B)

Class IIb

  1. Measurement of HbA1C may be considered for cardiovascular risk assessment in asymptomatic adults with diabetes (Becker et al., "Predictive value of coronary calcifications for future cardiac events in asymptomatic individuals," 2008). (Level of Evidence: B)
  2. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests a high risk of CHD, such as a CAC score of 400 or greater. (Level of Evidence: C)

Special Considerations: Women

Class I

  1. A global risk score should be obtained in all asymptomatic women (Ridker et al., 2007; Pasternak et al., 2003). (Level of Evidence: B)
  2. Family history of CVD should be obtained for cardiovascular risk assessment in all asymptomatic women (Ridker et al., 2007; Assmann, Cullen, & Schulte, 2002). (Level of Evidence: B)

Definitions:

Applying Classification of Recommendations and Level of Evidence

  Size of Treatment Effect
  CLASS I

Benefit >>> Risk

Procedure/Treatment
SHOULD be performed/ administered
CLASS IIa

Benefit >> Risk
Additional studies with focused objectives needed


IT IS REASONABLE to perform procedure/administer treatment
CLASS IIb

Benefit ≥ Risk
Additional studies with broad objectives needed; additional registry data would be helpful


Procedure/Treatment
MAY BE CONSIDERED
CLASS III No Benefit
or Class III Harm
  Procedure/Test Treatment
COR III:
No Benefit
Not helpful No proven benefit
COR III:
Harm
Excess Cost without Benefit or Harmful Harmful to Patients
Estimate of Certainty (Precision) of Treatment Effect LEVEL A

Multiple populations evaluated*

Data derived from multiple randomized clinical trials or meta-analyses
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials or meta-analyses
LEVEL B

Limited populations evaluated*

Data derived from a single randomized clinical trials or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C

Very limited populations evaluated*

Only consensus opinion of experts, case studies or standard of care
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard-of-care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard-of-care

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate and effective assessment of cardiovascular risk in asymptomatic adults

Potential Harms

Patient radiation exposure associated with coronary computed tomography angiography (CCTA) and magnetic perfusion imaging (MPI) using single-photon emission computed tomography (SPECT) or positron emission tomography (PET)

Qualifying Statements

Qualifying Statements
  • These practice guidelines represent a consensus of expert opinion after a thorough and systematic review of the available current scientific evidence and are intended to improve patient care. The guidelines attempt to define practices that meet the needs of most patients in most situations. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care.
  • The Task Force recognizes that situations arise in which additional data are needed to better inform patient care; these areas will be identified within each respective guideline when appropriate.
  • Prescribed courses of treatment in accordance with these recommendations are effective only if they are followed.
  • This guideline is not intended to replace other sources of information on cardiovascular risk assessment in specific disease groups or higher-risk groups such as those with known hypertension or diabetes who are receiving treatment.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Pocket Guide/Reference Cards
Quick Reference Guides/Physician Guides
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JM, Kushner FG, Lauer MS, Shaw LJ, Smith SC Jr, Taylor AJ, Weintraub WS, Wenger NK, Jacobs AK, Smith SC Jr, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Nishimura R, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW, American College of Cardiology Foundation, American Heart Association. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010 Dec 14;56(25):e50-103. [446 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Dec 14
Guideline Developer(s)
American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association
Source(s) of Funding

The American College of Cardiology Foundation

The American Heart Association

Guideline Committee

American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Composition of Group That Authored the Guideline

Writing Committee Members: Philip Greenland, MD, FACC, FAHA, (Chair); Joseph S. Alpert, MD, FACC, FAHA; George A. Beller, MD, MACC, FAHA; Emelia J. Benjamin, MD, SCM, FACC, FAHA; Matthew J. Budoff, MD, FACC, FAHA; Zahi A. Fayad, PhD, FACC, FAHA; Elyse Foster, MD, FACC, FAHA; Mark. A. Hlatky, MD, FACC, FAHA; John McB. Hodgson, MD, FACC, FAHA, FSCAI; Frederick G. Kushner, MD, FACC, FAHA; Michael S. Lauer, MD, FACC, FAHA; Leslee J. Shaw, PhD, FACC, FAHA; Sidney C. Smith, JR, MD, FACC, FAHA; Allen J. Taylor, MD, FACC, FAHA; William S. Weintraub, MD, FACC, FAHA; Nanette K. Wenger, MD, MACC, FAHA

Task Force Members: Alice K. Jacobs, MD, FACC, FAHA, (Chair, 2009–2011); Sidney C. Smith, Jr*, MD, FACC, FAHA, (Immediate Past Chair, 2006–2008); Jeffrey L. Anderson, MD, FACC, FAHA, (Chair-Elect); Nancy Albert, PhD, CCNS, CCRN; Christopher E. Buller*, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Robert A. Guyton, MD, FACC; Jonathan L. Halperin, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Rick Nishimura,* MD, FACC, FAHA; E. Magnus Ohman, MD, FACC; Richard L. Page*, MD, FACC, FAHA; William G. Stevenson, MD, FACC, FAHA; Lynn G. Tarkington*, RN; Clyde W. Yancy, MD, FACC, FAHA

*Former American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Task Force member during this writing effort.

Financial Disclosures/Conflicts of Interest

Author Relationships with Industry and Other Entities: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults

Committee Member Employment Consultant Speaker Ownership/
Partnership
/Principal
Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness
Philip Greenland, Chair Northwestern University
Feinberg School of
Medicine—Professor of Preventive Medicine and Professor of Medicine; Director, Northwestern University Clinical and Translational Sciences Institute
  • GE/Toshiba
  • Pfizer
None None None
  • NHLBI (MESA)
None
Joseph S. Alpert University of Arizona—Professor of Medicine; Head, Department of Medicine
  • Bayer
  • Bristol-Myers Squibb
  • Exeter CME
  • Johnson & Johnson
  • King Pharmaceuticals
  • Merck
  • Novartis
  • Roche Diagnostics
  • Sanofi-aventis
None None None None None
George A. Beller University of Virginia Health System—Ruth C. Heede Professor of Cardiology
  • BSP Advisory Board
None
  • Adenosine Therapeutics
None None
  • Stress testing case, defense, 2009
Emelia J. Benjamin Boston University Schools of Medicine and Public Health—Professor of Medicine and Epidemiology; Framingham Heart Study—Director, Echocardiography/Vascular Laboratory None None None
  • GlaxoSmithKline
  • Itamar*
  • NHLBI
  • NIH/NHLBI*
  • NIH/NIA
None None
Matthew J. Budoff Los Angeles Biomedical Research Institute—Program Director, Division of Cardiology None
  • GE Healthcare
None None
  • CDC
  • NIH/NHLBI
  • MESA
None
Zahi A. Fayad Mount Sinai School of Medicine—Professor of Radiology and Medicine (Cardiology)
  • BG Medicine
  • Merck
  • Roche
  • VIA Pharmaceuticals
None None
  • Merck
  • Roche
  • Siemens
None None
Elyse Foster University of California San Francisco—Professor of Clinical Medicine and Anesthesia; Director, Echocardiography Laboratory None None None
  • Boston Scientific
  • Evalve
  • EBR Systems, Inc.
None None
Mark A. Hlatky Stanford University School of Medicine—Professor of Health Research and Policy; Professor of Medicine (Cardiovascular Medicine)
  • BCBS Technology Evaluation Center Medical Advisory Panel*
  • California Pacific Medical Center*
  • CV Therapeutics
  • GE Medical*
  • The Medicines Company
None None
  • Aviir
None None
John McB. Hodgson Geisinger Health System—Chairman of Cardiology
  • Volcano*
  • Boston Scientific
  • GE Medical
  • Pfizer
  • Volcano*
  • Volcano*
  • Boston
  • Scientific*
  • FAME
  • GE Medical*
  • RADI Medical*
  • Volcano
None None
Frederick G. Kushner Tulane University Medical Center—Clinical Professor of Medicine; Heart Clinic of Louisiana—Medical Director None
  • Abbott
  • Bristol-Myers Squibb
  • CV Therapeutics
None
  • AstraZeneca
  • Atherogenics
  • Cogentus
  • Eli Lilly
  • NIH
  • Novartis
  • Pfizer
  • FDA Science Board Member
None
Michael S. Lauer NHLBI, NIH—Director, Division of Cardiovascular Sciences None None None None None None
Leslee J. Shaw Emory University School of Medicine—Professor of Medicine None None None
  • GE Healthcare*
None None
Sidney C. Smith, Jr. University of North Carolina at Chapel Hill—Professor of Medicine and Director, Center for Cardiovascular Science and Medicine None None None
  • AstraZeneca (DSMB)
None None
Allen J. Taylor Washington Hospital Center, Cardiology Section—Director, Advanced Cardiovascular Imaging, Cardiovascular Research Institute
  • Abbott
  • Merck
  • Pfizer
None None
  • Abbott
  • SAIP
  • SCCT
None
William S. Weintraub Christiana Care Health System—Section Chief, Cardiology
  • Bristol-Myers Squibb
  • Gilead
  • Eli Lilly
  • Sanofi-aventis
None None
  • Abbott*
  • AstraZeneca*
  • Bristol-Myers Squibb*
  • Gilead*
  • Otsuka*
  • Sanofi-aventis*
  • AstraZeneca*
  • Bayer*
  • Pfizer*
  • Quetiapine case, defense, 2008
  • Celebrex case, defense, 2008
Nanette K. Wenger Emory University School of Medicine—Professor of Medicine (Cardiology)
  • Abbott
  • AstraZeneca
  • Boston Scientific
  • Genzyme
  • Gilead*
  • LCIC
  • Medtronic
  • Merck
  • Pfizer
  • Sanofi-aventis
  • Schering-Plough*
None None
  • Gilead*
  • Eli Lilly*
  • Merck*
  • NHLBI*
  • Pfizer*
  • Sanofi-aventis*
None None

Note: This table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.

*Indicates significant relationship.

Refer to Appendix 2 in the original guideline document for 2010 peer reviewer relationships with industry and other entities.

Guideline Endorser(s)
American Society of Echocardiography - Professional Association
American Society of Nuclear Cardiology - Professional Association
Society for Cardiovascular Magnetic Resonance - Professional Association
Society of Atherosclerosis Imaging and Prevention - Disease Specific Society
Society of Cardiovascular Computed Tomography - Professional Association
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American College of Cardiology Web site External Web Site Policy and the Circulation Web site External Web Site Policy.

Print copies: Available from the American College of Cardiology, 2400 N Street NW, Washington DC, 20037; (800) 253-4636 (US only).

Availability of Companion Documents

The following are available:

  • 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Executive summary. 2010 Dec. Electronic copies: Available from the Journal of the American College of Cardiology (JACC) Web site External Web Site Policy.
  • 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults. Slide set. 2010. 46 p. Electronic copies: Available from the JACC Web site External Web Site Policy.
  • 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults. Pocket guideline. 2010 Nov. 31 p. Electronic copies: Available in Portable Document Format (PDF) from the JACC Web site External Web Site Policy.
  • Methodology manual and policies from the ACCF/AHA Task Force on Practice Guidelines. 2010 Jun. 88 p. American College of Cardiology Foundation and American Heart Association, Inc. Electronic copies: Available in PDF from the American Heart Association (AHA) Web site External Web Site Policy.

Print copies: Available from the American College of Cardiology, 2400 N Street NW, Washington DC, 20037; (800) 253-4636 (US only).

Patient Resources

Patient risk assessment tools and resources for various cardiovascular conditions are available from the American Heart Association (AHA) Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on April 14, 2011. The information was verified by the guideline developer on May 20, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of Cardiology Foundation (ACCF) and the American Heart Association, Inc. (AHA). NGC users are free to download a single copy for personal use. Reproduction without permission of the ACC/AHA guidelines is prohibited. Permissions requests should be directed to copyright_permissions@acc.org.

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