Cardiovascular disease screening

CVD Risk Assessment - Gauging the Threat

• Primary Tool: 10-year atherosclerotic cardiovascular disease (ASCVD) risk, estimated via Pooled Cohort Equations (PCE).
• Screening Age: All adults aged 40-75 years.
• Core Inputs: Age, sex, race, total & HDL cholesterol, systolic BP, HTN treatment, diabetes, smoking.

⭐ For borderline or intermediate-risk patients, the presence of "risk-enhancing factors" (e.g., family history, CKD, inflammatory disease) can justify starting statin therapy.

Lipid Screening - Cholesterol Check

• Initiation (Fasting Lipid Profile):
  • Men: Start at age 35.
  • Women: Start at age 45.
  • With ↑ ASCVD risk factors (diabetes, HTN, smoking, family hx): Start at age 20.
• Frequency:
  • Repeat every 5 years for average-risk individuals.
  • More frequently if lipid levels are near a treatment threshold.
• Pediatrics: Universal screening once between ages 9-11 and again at 17-21.

⭐ Suspect familial hypercholesterolemia and consider aggressive treatment for any patient with an LDL-C >190 mg/dL.

Hypertension Screening - The BP Beat

• Who: All adults ≥ 18 years (USPSTF Grade A).
• How Often:
  • Annually for increased risk: BP 130-139/85-89 mmHg (high-normal), overweight/obese, or Black adults.
  • Every 3-5 years for adults with normal BP (<130/85 mmHg) and no other risk factors.
• Confirmation: Initial elevated office readings require confirmation with out-of-office measurements.
  • Gold Standard: 24-hr ambulatory BP monitoring (ABPM).
  • Alternative: Self-measured home BP monitoring (HBPM).

⭐ White coat hypertension: elevated office BP but normal home/ambulatory readings. Masked hypertension: normal office BP but elevated home/ambulatory readings, carrying a higher cardiovascular risk.

AAA Screening - Sizing Up the Aorta

• Who: Men aged 65-75 who have ever smoked (a "smoking history").
• How: One-time screening with abdominal duplex ultrasound.
• Management by Size:
  • 3.0-3.9 cm: Rescan every 3 years.
  • 4.0-5.4 cm: Rescan every 6-12 months.
  • ≥5.5 cm: Refer for surgical evaluation; intervention is generally recommended.

⭐ The biggest risk factor for AAA is smoking, followed by male sex and advanced age.

Aspirin Prophylaxis - A Daily Dose?

• Primary prevention of ASCVD in select adults. The decision to initiate is individualized.
• USPSTF Guidelines:
  • Age 40-59 with ASCVD risk ≥10%: Individual decision. Net benefit is small.
  • Age ≥60: Do NOT initiate for primary prevention due to ↑ bleeding risk.
• Dose: Low-dose aspirin (81 mg daily).

⭐ The major adverse effect of aspirin therapy is an increased risk for gastrointestinal (GI) and intracranial hemorrhage, which rises with age.

High-Yield Points - ⚡ Biggest Takeaways

• The USPSTF recommends blood pressure screening for all adults ≥18 years.
• Screen for hyperlipidemia in adults aged 40-75 years; consider earlier screening for patients with significant risk factors.
• Low-dose aspirin for primary prevention is an individualized decision, particularly for adults 40-59 years with a ≥10% 10-year CVD risk.
• Screen for diabetes mellitus in adults aged 35-70 years who are overweight or obese.
• A one-time ultrasound for Abdominal Aortic Aneurysm (AAA) is recommended for men aged 65-75 who have ever smoked.