Should NICE guidelines be universally accepted for the evaluation of stable coronary disease? A debate.

The 2016 National Institute of Health and Care Excellence clinical guideline for the assessment and diagnosis of chest pain positions coronary computed tomography angiography as the first test for all stable chest pain patients without confirmed coronary artery disease and discards the previous emphasis on calculation of pre-test likelihood recommended in their 2012 edition of the guidelines. On the other hand, the American College of Cardiology Foundation/American Heart Association and the European Society of Cardiology guidelines continue to present the stress testing functional modalities as the tests of choice. The aim of this review is to present, in the form of a debate, the pros and cons of these paradigm changing recommendations, with an emphasis on literature review and projection of future needs, with conclusions to be drawn by the reader.

Coronary artery calcium scanning: the key to the primary prevention of coronary artery disease.

Coronary artery calcium scanning (CAC) is the most powerful prognosticator of cardiac risk in the asymptomatic primary prevention population, far exceeding the role of risk factor-based paradigms. The primary utility of risk factors is to identify treatable targets for risk reduction after risk has been determined by CAC. Serial calcium scanning to evaluate progression of calcified plaque is useful for determining the response to treatment. The 2013 cholesterol treatment guidelines understate the value of CAC scanning for atherosclerotic disease risk assessment.

Digital thermal monitoring of vascular function: a novel tool to improve cardiovascular risk assessment.

Digital thermal monitoring (DTM) of vascular function during cuff-occlusive reactive hyperemia relies on the premise that changes in fingertip temperature during and after an ischemic stimulus reflect changes in blood flow. To determine its utility in individuals with and without known coronary heart disease (CHD), 133 consecutive individuals (age 54 +/- 10 years, 50% male, 19 with known CHD) underwent DTM during and after 2 minutes of supra-systolic arm cuff inflation. Fingertip temperatures of the occluded and non-occluded fingertips were measured simultaneously. Post-cuff deflation temperature rebound (TR) was lower in the CHD patients and in those with an increased Framingham risk score (FRS) compared to the normal group. After adjustment for age, sex, and cardiac risk factors, TR was significantly lower in those with CHD compared to those without CHD (p < 0.05). This study demonstrates that vascular dysfunction measured by DTM is associated with CHD and an increased FRS, and could potentially be used to identify high-risk patients.

Coronary artery calcium scanning: Clinical paradigms for cardiac risk assessment and treatment.

BACKGROUND: Coronary artery calcium (CAC) scanning is being increasingly used for cardiac risk assessment in asymptomatic patients, particularly in those with a Framingham 10-year risk of 10% to 20%. Physician awareness of this technology and its appropriate uses and limitations is crucial to appropriate use. METHODS: With the goal of establishing clinical paradigms, this document integrates the results of key published articles, Framingham Risk Score, National Cholesterol Education Program Adult Treatment Plan III guidelines, American College of Cardiology/American Heart Association exercise testing and angiographic guidelines, and the authors' extensive clinical experience. RESULTS: Coronary artery calcium scanning is best used in the asymptomatic population with a 10% to 20% risk of cardiac events over 10 years, with selected application in higher and lower risk categories. In the 10%-20% risk patient, coronary artery calcium scores >100 or >75th percentile for age and sex transform the moderately high-risk patient to higher risk status with the attendant recommendation for more aggressive therapy; scores from 11 to 100 and <75th percentile are consistent with the 10%-20% 10-year risk status and scores from 0 to 10 and <75th percentile convert the patient to lesser risk categories. If stress testing is planned in the asymptomatic patient, it should be preceded by coronary artery calcium scanning and performed only for scores >400; it should always precede coronary angiography in these patients. CONCLUSIONS: Coronary artery calcium scanning is an important risk assessment tool with direct clinical applications; it is of particular utility in the Framingham 10%-20% 10-year risk population.

The first SHAPE (Screening for Heart Attack Prevention and Education) guideline.

Atherosclerotic cardiovascular disease (A-CVD) is preventable. Major causal risk factors are known, and effective and safe treatments exist. However, A-CVD remains the leading cause of death and severe disability not only in affluent countries, but also globally. The burden of A-CVD is growing faster in poor and developing countries threatening their future economic development. Traditional methods for prevention of A-CVD have proven largely insufficient. Although many societal factors contribute to the epidemic of A-CVD (eg, smoking, obesity, diabetes, insufficient physical activity, and so on) and deserve renewed attention, early detection of the asymptomatic vulnerable patient who has significant subclinical atherosclerosis presents as a low hanging fruit in primary prevention of A-CVD. The Screening for Heart Attack Prevention and Education (SHAPE) Task Force, comprised of an international group of experts, has proposed the First SHAPE Guideline to address a major shortcoming in the existing guidelines in primary prevention of A-CVD. It is based on the observation that most heart attacks and strokes occur in people who are not classified as high risk by the traditional risk factor-based approach recommended in the United States (Framingham Risk Score) and Europe (SCORE). Unfortunately, these guidelines provide inadequate warning to asymptomatic individuals with subclinical atherosclerosis who are unaware of their high-risk status and are not aggressively treated by their physicians who follow the existing recommendations. Consequently, most of these asymptomatic individuals, who are vulnerable to a near-future heart attack, are not offered the benefit of existing prophylactic therapies. Unlike decades ago when screening for risk factors of A-CVD was the only available risk stratification method in primary prevention, today, noninvasive detection of atherosclerosis is feasible and widely available. It provides a direct and individualized method for risk assessment. A large body of evidence has been compiled in recent years showing the superior prognostic value of detecting atherosclerosis rather than risk factors of atherosclerosis. The First SHAPE Guideline calls for noninvasive screening of all asymptomatic men 45 to 75 years old and asymptomatic women 55 to 75 years old (except those defined as very low risk) to detect and treat individuals with subclinical atherosclerosis. The intensity of treatment should correlate with the severity of the disease. Among existing tools for detection of subclinical atherosclerosis, the SHAPE Task Force has created the SHAPE Flow Chart based on the following 2 noninvasive imaging techniques: coronary artery calcium scoring using computed tomography and carotid intima media thickness and plaque using B-mode ultrasonography.