NCHR Comments to USPSTF on Non-traditional Screening Methods for Heart Disease

We appreciate the opportunity to comment publicly on the U.S Preventive Services Task Force (USPSTF) upcoming decision to assess the possibility of adding non-traditional risk factors for cardiovascular disease (CVD) when considering whether asymptomatic adults would benefit from treatment to prevent CVD.  The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research, policies, and programs on a range of issues related to health and safety. We do not accept funding from companies that make products that are the subject of our work.

We recognize and respect the importance of the USPSTF to help provide clinicians with evidence-based tools for patient-centered clinical practice.  Decisions must  balance  high quality care with  cost-efficient and feasible options  for the individual patient.  Because, as you are aware, CVD is the most common cause of death for adults in the United States, and therefore it is necessary for  providers to consider many risk factors, including non-traditional ones, when assessing asymptomatic adults.  We agree with the USPSTF  that current evidence is insufficient to assess potential benefits and harms of adding the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP), or coronary artery calcification (CAC) score to the traditional risk assessments for CVD.

We offer the following comments:

  • More research is needed before including non-traditional risk assessments to determine treatment for asymptomatic adults

Several studies have indicated that assessing non-traditional risk factors, including ABI, hsCRP, and CAC slightly increase ability to predict CVD in asymptomatic adults.  For example, assessing CAC with the Framingham Risk Score (FRS) improves overall accuracy of risk predictions for patients by 19.3%, and improves the accuracy of risk prediction for patients at intermediate risk by 39.3%.  The other two tests, ABI and hsCRP, do not increase predictive power nearly as much; research has indicated that adding CAC to the FRS is the only option that increases a provider’s ability to accurately predict risk in asymptomatic patients of the non-traditional risk assessments. However, ABI and hsCRP are non-invasive tests, while CAC testing is minorly invasive and exposes patients to small levels of radiation.   But, because use of the CAC test , and follow up testing for CVD is invasive and additional testing can cause patients undue stress and anxiety, we recommend maintaining traditional risk factor testing for asymptomatic male adults until there is more conclusive research demonstrated any added benefit.  

  • These results may not be generalizable to non-white, non-European individuals.

The Framingham Heart Study was conducted on white Europeans.  While the research is incredibly important for the breakthroughs in medical knowledge, it is important to consider the influence of socioeconomic factors and gender.

2a. These results may underestimate the risk to individuals with lower SES.

Numerous studies have demonstrated when studying the Framingham Heart Study and included analyses of SES, those with a lower SES had a higher risk of coronary heart disease. Therefore, standard FRS, including those in the  USPSTF review, underestimates the risk for people with low SES, and therefore may preclude them from receiving more aggressive risk management or treatments before disease has progressed.   Therefore, more research is needed for this subpopulation to determine if these additional risk factors aid in improving early detection, which in turn may help to improve earlier diagnosis and enable secondary prevention efforts.  

2b. These results may underestimate the risk to women.

Heart disease in women tends to be underestimated for many reasons, including biological differences. Currently, there is insufficient data on women’s experience with CVD diagnosis  and whether these non-traditional risk factors are appropriate for for diagnosing CVD risk in asymptomatic women. There is evidence to show additional risk factors increase diagnosing risk for women at intermediate risk, but there is not enough evidence to demonstrate the same benefit for asymptomatic women.  Furthermore,  we agree that the psychological effects of added tests may be more harmful  than the potential physical harm of the tests. Finally, as mentioned in KQ2a, more research is needed in order to better characterize gendered cardiovascular health differences in diagnosis and treatment and identify potential solutions to close the existing gaps in prevention and treatment.

Thank you for the opportunity to comment.