19 Jul USPSTF and PAD: Uncertain if Nontraditional Risk Factors Can Predict Heart Disease or Stroke Risk
MedicalResearch.com Interview with:
Dr. Michael Barry MD
Director of the Informed Medical Decisions Program
Health Decision Sciences Center at Massachusetts General Hospital
Physician at Massachusetts General Hospit
Professor of Medicine,Harvard Medical School
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Peripheral artery disease—which is known as PAD—is a disease that reduces blood flow to a person’s limbs, especially the legs. PAD can cause leg and foot pain when resting or walking, wounds to not heal properly, and loss of limbs. Additionally, people with PAD are more likely to experience a cardiovascular disease event, such as heart attack and stroke.
The U.S. Preventive Services Task Force looked at the latest research to see if screening people without signs or symptoms of PAD using the ankle brachial index (ABI) can prevent heart attack, stroke, or other adverse health effects. We found that more research is needed to determine if screening with ABI can help to identify PAD and/or prevent heart attack or stroke in people without signs or symptoms.
Additionally, in a separate recommendation statement, we looked into the effectiveness of what we call nontraditional risk factors for assessing a person’s risk of cardiovascular disease. Clinicians typically check someone’s risk for cardiovascular disease using traditional risk factors, such as age, race, and smoking status. The Task Force looked at the current evidence to see if three additional, nontraditional risk factors can help prevent heart disease or stroke. The nontraditional factors considered were ABI measurements, an elevated amount of high-sensitivity C-reactive protein (hsCRP) in the blood, and an elevated amount of calcium in the coronary arteries (CAC score).
In this recommendation, we also found that there is insufficient evidence to recommend for or against using nontraditional risk factors in addition to those normally used to assess cardiovascular disease risk in people without signs or symptoms.
MedicalResearch.com: What should readers take away from your report?
Response: The Task Force found that more research is needed to determine whether screening with the ABI can help identify PAD in people without signs and symptoms, as well as whether adding ABI, hsCRP, or CAC scores to the traditional risk factors for assessing cardiovascular disease risk helps better prevent heart attack or stroke. Until we have better evidence, we can’t make a recommendation for or against these preventive services.
It’s important to note that there are other resources and screening tools available to clinicians that have been proven to be effective, such as the Pooled Cohort Equations. The Task Force has several other recommendations related to prevention of cardiovascular disease, which are available on our Web site.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: There are several areas that need more research before we can make definitive recommendations. Regarding the ABI, we need large, randomized trials that assess whether screening for PAD using the ABI can prevent heart attack, stroke, or other PAD complications. In particular, it would be helpful to see studies that address whether or not ABI screening can help people who are at higher risk for PAD but are not already receiving treatment to reduce their risk for cardiovascular disease.
Additionally, right now, we don’t have enough studies that evaluate the effectiveness of nontraditional risk factors to assess cardiovascular disease risk. Until we have more quality evidence, we can’t say for sure whether adding ABI, hsCRP, or CAC scores to the traditional risk factors used in the Pooled Cohort Equations can help prevent cardiovascular disease events such as heart attack and stroke.
For both topics, we also need to see more evidence looking at the effects of these preventive services in more diverse populations such as women and racial minorities.
MedicalResearch.com: Is there anything else you would like to add?
Response: The recommendation on screening for PAD and cardiovascular disease with the ABI applies to adults who do not have signs or symptoms or a known diagnosis of PAD, cardiovascular disease, or severe chronic kidney disease. The recommendation on cardiovascular disease risk assessment with nontraditional risk factors applies to people without a history, signs, or symptoms of cardiovascular disease.
Until additional research is available, clinicians can use the standard risk factors incorporated into the Pooled Cohort Equations, such as age, smoking status, and whether or not a patient has diabetes, to make screening and treatment decisions. Anyone concerned about their risk for PAD or cardiovascular disease should talk to his or her doctor.
US Preventive Services Task Force. Risk Assessment for Cardiovascular Disease With Nontraditional Risk Factors US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(3):272–280. doi:10.1001/jama.2018.8359
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