A systematic approach incorporating family history improves identification of cardiovascular disease risk.

ABSTRACT

BACKGROUND: Although family history (FH) is an independent predictor of cardiovascular disease (CVD) risk, traditional risk scores do not incorporate FH. Nurse practitioners routinely solicit FH but have no mechanism to incorporate the information into risk estimation. Underestimation of risk leaves clinicians misinformed and patients vulnerable to the CVD epidemic. OBJECTIVE: We examined a systematic approach incorporating FH in CVD risk assessment, validating risk reclassification using carotid intima-media thickness (CIMT), a surrogate measure of atherosclerosis. METHODS: Of 413 consecutive patients prospectively enrolled in the Integrative Cardiac Health Project Registry, a subgroup of 239 was low or intermediate risk by the Framingham Risk Score. A systematic approach for the assessment of FH was applied to this subgroup of the registry. A positive FH for premature CVD, defined as a first-degree relative having a CVD event before the age of 55 years in men and 65 years in women, conferred reclassification to high risk. Reclassification was validated with CIMT results. RESULTS: Chart audits revealed adherence to the systematic approach for FH assessment in 100% of cases. This systematic approach identified 115 of 239 (48%) patients as high risk because of positive FH. Of the reclassified patients, 75% had evidence of subclinical atherosclerosis by CIMT versus 55% in the patients not reclassified, P < 0.001. Logistic regression identified positive FH for premature CVD (odds ratio, 2.6; P = 0.001) among all variables, as the most significant predictor of abnormal CIMT, thus increasing risk for CVD. CONCLUSIONS: The Integrative Cardiac Health Project systematic approach incorporating FH into risk stratification enhances CVD risk assessment by identifying previously unrecognized high-risk patients, reduces variability in practice, and appropriately targets more stringent therapeutic goals for prevention.