1. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults
Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance

2. Citation
This slide set was adapted from the 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults (Journal of the American College of Cardiology). Published ahead of print on XXX, 2010, available at:
The full-text guidelines are also available on the following Web sites:
ACC ( and,
AHA (

3. Special Thanks To Slide Set Editors
Nanette K. Wenger, MD and Philip Greenland, MD
The Guideline for CV Risk Assessment in Asymptomatic Adults 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
*ACCF/AHA Task Force on Performance Measures Liaison; †Recused from Section , Lipoprotein-Associated Phospholipase A2; ‡ Recused from Section , Coronary Computed Tomography Angiography; §Recused from Section , Diabetes Mellitus; ║SAIP Representative; ¶SCMR Representative; #ASE Representative; **Recused from Section , Computed Tomography for Coronary Calcium; †† SCAI Representative; ‡‡Recused from Section 2.3., Lipoprotein and Apolipoprotein Assessments; §§ASNC Representative; ║║ACCF/AHA Task Force on Practice Guidelines Liaison; ¶¶Recused from Section , Recommendations for Measurement of C-Reactive Protein; ##SCCT Representative.

4. Classification of Recommendations and Levels of Evidence
*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.
†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

5. Icons representing the Classification and Evidence Levels for Recommendations
IIa
IIb
III B I
IIa
IIb
III I
IIa
IIb
III I
IIa
IIb
III A B I
IIa
IIb
III I
IIa
IIb
III I
IIa
IIb
III A B I
IIa
IIb
III I
IIa
IIb
III I
IIa
IIb
III A B I
IIa
IIb
III I
IIa
IIb
III

6. Key Considerations when Testing for CV Risk
Efficacy of test procedure in assignment of risk status
Short-term risk
Long-term risk
Independent statistical association with risk beyond traditional readily available inexpensive risk markers
Incremental predictive value of test
Effect on reclassification of risk compared to traditional risk factors alone
Accuracy and reproducibility of test
Requirement for serial testing, which may be indicated to assess risk accurately for some tests
2010 ACCF/AHA Guideline, JACC 55:e27, 2010

7. Key Considerations when Testing for CV Risk (continued)
Cost of test or procedure
Financial
Test risks
Effect on performance of added testing
Noninvasive, invasive
Post-test referral bias
Effect on initiation of interventions
Lifestyle
Pharmacologic
Effect on individual undergoing testing
Emotional
Effect on outcomes
Short-term
Long-term

8. Opportunity for Early Preventive Interventions
Long asymptomatic latent period of Coronary Heart Disease (CHD)
Half of all cardiovascular sudden death not preceded by cardiac symptoms, diagnoses
High prevalence of atherosclerotic risk factors in US population
Methodology available to evaluate prognostic value of risk factors, risk markers
Target intensity of intervention to severity of risk
Lower the high burden of coronary death in asymptomatic adults

9. Recommended Approaches to Risk Stratification
Guideline for Cardiovascular Risk Assessment in Asymptomatic Adults
Recommended Approaches to Risk Stratification

10. General Approaches to Risk Stratification
Recommended Approaches to Risk Stratification
General Approaches to Risk Stratification

11. Recommendations for General Approaches to Risk Stratification
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 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. B I
IIa
IIb
III

12. Comparison of a Sample of Global Coronary and Cardiovascular Risk Scores
Framingham
SCORE
PROCAM (Men)
Reynolds (Women)
Reynolds (Men)
Sample size
5345
205,178
5389
24,558
10,724
Age, range (y)
30 to 74; M:49
19 to 80; M:46
35 to 65; M:47
>45; M:52
>50; M:63
Mean follow-up (y) 12 13 10
10.2
10.8
Risk factors
considered
Age, sex, total
cholesterol, HDL
cholesterol,
smoking, systolic
blood pressure,
antihypertensive
Medications
Age, sex, total-
HDL cholesterol
ratio, smoking,
systolic blood
pressure
Age, LDL
family history,
diabetes,
triglycerides
Age, HbA1C (with
diabetes), smoking,
systolic blood pressure,
total cholesterol, HDL
cholesterol, hsCRP,
parental history of MI
at <60 y of age
Age, systolic blood
pressure, total
cholesterol, smoking,
hsCRP, parental history
of MI at <60 y of age
Endpoints
CHD (MI and
CHD death)
Fatal CHD
Fatal/nonfatal
MI or sudden
cardiac death
(CHD and CVD
combined)
MI, ischemic stroke,
coronary
revascularization,
cardiovascular death
MI, stroke, coronary
URLs for risk
calculators
hin.net/atpiii/calcul
ator.asp?usertype=
prof 
ore.org/pages/welc
ome.aspx 
taskforce.com/co
ronary_risk_asse
ssment.html
kscore.org/   
Note: Table 2 in full-text Guideline

13. Family History and Genomics
Recommended Approaches to Risk Stratification
Family History and Genomics

14. Recommendations for Family History and Genomic Testing
Family history of atherothrombotic cardiovascular disease (CVD) should be obtained for cardiovascular risk assessment in all asymptomatic adults.
Genotype testing for CHD risk assessment in asymptomatic adults is not recommended. B I
IIa
IIb
III B I
IIa
IIb
III

15. Lipoprotein and Apolipoprotein Assessments
Recommended Approaches to Risk Stratification
Lipoprotein and Apolipoprotein Assessments

16. Recommendation for Lipoprotein and Apolipoprotein Assessments
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. I
IIa
IIb
III

17. Other Circulating Blood Markers and Associated Conditions
Recommended Approaches to Risk Stratification
Other Circulating Blood Markers and Associated Conditions

18. Recommendation for Natriuretic PeptidesB I
IIa
IIb
III
Measurement of natriuretic peptides is not recommended for CHD risk assessment in asymptomatic adults.

19. Recommendations for Measurement of C-Reactive Protein (CRP)B I
IIa
IIb
III
In men 50 years of age or older or women 60 years of age or older with 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.

20. Recommendations for Measurement of C-Reactive Protein (continued)B I
IIa
IIb
III
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.
In asymptomatic high-risk adults, measurement of CRP is not recommended for cardiovascular risk assessment.
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. B I
IIa
IIb
III B I
IIa
IIb
III

21. Recommendation for Measurement of Hemoglobin A1C
IIa
IIb
III
Measurement of hemoglobin A1C (HbA1C) may be reasonable for cardiovascular risk assessment in asymptomatic adults without a diagnosis of diabetes.

22. Recommendations on testing for Microalbuminuria (Urinary Albumin Excretion)
In asymptomatic adults with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk assessment.
In asymptomatic adults at intermediate risk without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment. B I
IIa
IIb
III B I
IIa
IIb
III

23. Recommendation for Lipoprotein-associated Phospholipase A2
Lipoprotein-associated phospholipase A2 (Lp-PLA2) might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults. B I
IIa
IIb
III

24. Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults
Recommended Approaches to Risk Stratification
Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults

25. Recommendations for Resting Electrocardiogram
A resting electrocardiogram (ECG) is
reasonable for cardiovascular risk assessment
in asymptomatic adults with hypertension or
diabetes.
A resting ECG may be considered for
cardiovascular risk assessment in
asymptomatic adults without hypertension or I
IIa
IIb
III I
IIa
IIb
III

26. Recommendation for Transthoracic Echocardiogram
Echocardiography to detect left ventricular hypertrophy may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension.
Echocardiography is not recommended for cardiovascular risk assessment of CHD in asymptomatic adults without hypertension. B I
IIa
IIb
III I
IIa
IIb
III

27. Recommendation for Measurement of Carotid Intima-Media Thickness
Measurement of carotid artery intima-media thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk. 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. B I
IIa
IIb
III

28. Recommendation for Brachial / Peripheral Flow-mediated Dilation
Peripheral arterial flow-mediated dilation studies are not recommended for cardiovascular risk assessment in asymptomatic adults. B I
IIa
IIb
III

29. Recommendation for Specific Measures of Arterial Stiffness
Measures of arterial stiffness outside of research settings are not recommended for cardiovascular risk assessment in asymptomatic adults. I
IIa
IIb
III

30. Recommendation for Measurement of Ankle-Brachial Index
IIa
IIb
III
Measurement of ankle-brachial index is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk.

31. Recommendation for Exercise Electrocardiography
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. B I
IIa
IIb
III

32. Recommendation for Stress Echocardiography
Stress echocardiography is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacological 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 CAD or the assessment of subjects with valvular heart disease.) I
IIa
IIb
III

33. Recommendations for Myocardial Perfusion Imaging
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.
Stress MPI is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress MPI is a technology 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 coronary artery disease.) I
IIa
IIb
III I
IIa
IIb
III

34. Recommendations for Calcium Scoring Methods
Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk.
Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year risk).
Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment. B I
IIa
IIb
III B I
IIa
IIb
III B I
IIa
IIb
III

35. Recommendation for Coronary Computed Tomography Angiography
Coronary computed tomography angiography is not recommended for cardiovascular risk assessment in asymptomatic adults. I
IIa
IIb
III

36. Recommendation for Magnetic Resonance Imaging of Plaque
Magnetic resonance imaging for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. I
IIa
IIb
III

37. Special Circumstances and Other Considerations
Recommended Approaches to Risk Stratification
Special Circumstances and Other Considerations

38. Risk Assessment Considerations for Patients with Diabetes Mellitus
In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment.
Measurement of hemoglobin A1C may be considered for cardiovascular risk assessment in asymptomatic adults with diabetes.
Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests high risk of CHD, such as a CAC score of 400 or greater. B I
IIa
IIb
III B I
IIa
IIb
III I
IIa
IIb
III

39. Risk Assessment Considerations for Women
There is frequent reporting of underutilization of diagnostic and preventive services among female patients. Therefore, it is recommended that: B I
IIa
IIb
III
A global risk score should be obtained in all asymptomatic women.
Family history of CVD should be obtained for cardiovascular risk assessment in all asymptomatic women. B I
IIa
IIb
III

40. Guideline for Cardiovascular Risk Assessment in Asymptomatic Adults
Summary of Tests Not Recommended for Assessing CV Risk in Asymptomatic Adults

41. Procedural Tests Not Recommended for Asymptomatic Adults ~ Non-cardiac tests ~
Genotype testing (III B)
Lipid parameters including lipoproteins, apolipoproteins, particle size and density assessments beyond standard fasting lipid profile (III C)
Natriuretic peptide measurement (III B)
C-Reactive Protein measurement in asymptomatic high-risk adults (III B)
CRP in low-risk men younger than 50 years of age or women 60 years of age (III B)

42. Procedural Tests Not Recommended for Asymptomatic Adults (cont
Procedural Tests Not Recommended for Asymptomatic Adults (cont.) ~ Cardiac or Vascular tests ~
Transthoracic echocardiogram for asymptomatic adults without hypertension (III C)
Brachial/peripheral arterial flow mediated dilation studies (III B)
Measures of arterial stiffness outside of research settings (III C)
Stress echocardiography in low- or intermediate-risk adults (III C)
Stress myocardial perfusion imaging in low- or intermediate-risk adults
(III C)
Coronary artery calcium scoring in low risk adults (<6% 10 year risk) (III B)
Coronary computed tomography angiography (CCTA) (III C)
Detection of coronary artery plaque by magnetic resonance imaging (III C)

43. Limited Data Role of novel biomarkers/imaging studies in risk
assessment of selected populations – asymptomatic
adults
Selected populations
Women
Older adults
Racial and ethnic minorities
Diabetes
Chronic kidney disease
Geographic, environmental, neighborhood risk

44. Unmet Needs Ascertainment among tests of value
Whether test/procedure useful to motivate patients to adhere to recommended interventions
Whether test/procedure useful to guide therapy
Whether test/procedure useful as a repeat measure to monitor effects of therapy
Whether test/procedure of value in improving health outcomes

45. Risk Assessment: Clinical Implications
Designed to aid clinician in informed decision-making
about lifestyle and pharmacologic interventions to
reduce CV risk
Patients broadly characterized into low-, intermediate-
and high-risk subsets
Intensity, type of treatments based on assessments of risk

46. Risk Assessment: Clinical Implications (continued)
Initial step: Ascertainment of global risk score and family history
of atherosclerotic CV disease
Class I recommendations
Simple, inexpensive
If a patient is low-risk – no further testing is necessary
If a patient is high-risk (CHD, CHD risk equivalents) – he/she is
candidate for intensive preventive interventions – no incremental benefit
added testing
If a patient is intermediate-risk – additional testing can further define
risk status
IIa - benefit exceeds cost and risk
IIb - less robust evidence for benefit, but shown to be helpful in selected patients
III - not recommended for use; has no or limited evidence of benefit, or can cause harm