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Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the U.S. Preventive
Mark Helfand1, David I Buckley, Michele Freeman
1Oregon Evidence-based Practice Center, Veterans Affairs Medical Center, andOregon Health & Science University, Portland, Oregon 97239, USA.
Insights
New coronary heart disease (CHD) risk factors show limited clinical usefulness for stratifying intermediate-risk individuals. Current evidence does not support their routine use in risk assessment.
Area of Science:
- Cardiovascular Disease Epidemiology
- Preventive Cardiology
- Risk Factor Assessment
Background:
- Traditional risk factors incompletely explain coronary heart disease (CHD) incidence.
- Emerging risk factors offer potential for improved global CHD risk assessment.
Purpose of the Study:
- To systematically review novel risk factors for CHD.
- To evaluate the clinical utility of these factors for the U.S. Preventive Services Task Force (USPSTF).
Main Methods:
- Conducted 9 systematic reviews of English-language articles (1966-2008).
- Included cohort studies with no baseline cardiovascular disease, adjusted for 6+ Framingham risk factors.
- Assessed study quality and evidence strength using USPSTF and GRADE criteria.
Main Results:
- C-reactive protein (CRP) was the most studied novel factor, but evidence for primary prevention is inconclusive.
- Other factors included coronary artery calcium, lipoprotein(a), homocysteine, leukocyte count, fasting glucose, periodontal disease, ankle-brachial index, and carotid intima-media thickness.
- Evidence quality, consistency, and applicability varied; most factors lacked data on reclassifying intermediate-risk individuals.
Conclusions:
- No firm conclusions on risk prediction differences among racial/ethnic groups due to data limitations.
- Routine use of these 9 novel risk factors for intermediate-risk stratification is not supported by current evidence.
Background:
Traditional risk factors do not explain all of the risk for incident coronary heart disease (CHD) events. Various new or emerging risk factors have the potential to improve global risk assessment for CHD.
Purpose:
To summarize the results of 9 systematic reviews of novel risk factors to help the U.S. Preventive Services Task Force (USPSTF) evaluate the factors' clinical usefulness.
Data Sources:
Results from a MEDLINE search for English-language articles published from 1966 to September 2008, using the Medical Subject Heading terms cohort studies and cardiovascular diseases in combination with terms for each risk factor.
Study Selection:
Studies were included if the participants had no baseline cardiovascular disease and the investigators adjusted for at least 6 Framingham risk factors.
Data Extraction:
Study quality was evaluated by using USPSTF criteria and overall quality of evidence for each risk factor by using a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation framework. Each factor's potential clinical value was evaluated by using a set of criteria that emphasized the importance of the effect of that factor on the reclassification of intermediate-risk persons.
Data Synthesis:
9 systematic reviews were conducted. C-reactive protein (CRP) was the best candidate for use in screening and the most rigorously studied, but evidence that changes in CRP level lead to primary prevention of CHD events is inconclusive. The other evaluated risk factors were coronary artery calcium score as measured by electron-beam computed tomography, lipoprotein(a) level, homocysteine level, leukocyte count, fasting blood glucose, periodontal disease, ankle-brachial index, and carotid intima-media thickness. The availability and validity of the evidence varied considerably across the risk factors in terms of aggregate quality, consistency of findings, and applicability to intermediate-risk persons in the general population. For most risk factors, no studies assessed their usefulness for reclassifying intermediate-risk persons.
Limitations:
Because of lack of access to original data, no firm conclusions could be drawn about differences in risk prediction among racial and ethnic groups. The review did not emphasize within-cohort comparisons of multiple risk factors.
Conclusion:
The current evidence does not support the routine use of any of the 9 risk factors for further risk stratification of intermediate-risk persons.
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