454 - Coronary Artery Calcium Scores, Life's Essential 8, Being Helped
Take 3 – Practical Practice Pointers©
From the Literature and the US Preventive Services Task Force
1) Coronary Artery Calcium Scores – No Evidence They Help
In 2018, the US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend cardiovascular (CV) risk assessment with coronary artery calcium (CAC) scores obtained by computerized tomography (or, by the way, with ankle-brachial index or high-sensitivity C-reactive protein). When we examine the predictive ability of statistical models like the risk assessment equations that we use to determine CV risk, there are three common concepts used:
· Calibration – how close the predictions are to observed outcomes (e.g., does the ACC/AHA risk score accurately predict CV events?)
· Discrimination – how well does the model to distinguish two levels of the outcome (e.g., can the ACC/AHA risk score separate patients into high and low risk for CV events?)
· Reclassification – the ability of a new model to change the predicted outcome over the old model (e.g., if we add CAC to the ACC/AHA score, does it accurately reclassify patients from low to higher CV risk?)
The USPSTF found that adding CAC scores to standard risk assessments increased calibration and discrimination of the standard risk scores very slightly, but not in a clinically meaningful manner. Reclassification seemed to happen in both directions (low risk to high risk and vice-versa), but the clinical impact of this was uncertain.
A new systematic review updates this work. The authors examined six cohort studies published since the USPSTF review that used CAC scores added to one of the major guideline-recommended CV risk models. They found a small gain in discrimination by adding CAC. For patients reclassified from low to high risk, no additional CV events were seen and for those reclassified from high to low risk, no fewer events were seen.
Overall, the authors conclude that CAC scoring seems to have no clinical benefit.
CAC scoring seems to be another example of a technology searching for an indication. It may be useful to further refine risk assessment in some certain sets of patients seen in specialists’ offices but does not seem applicable to routine primary care-based CV risk assessment.
· Bell KJL, White S, Hassan O, et al. Evaluation of the Incremental Value of a Coronary Artery Calcium Score Beyond Traditional Cardiovascular Risk Assessment: A Systematic Review and Meta-analysis. JAMA Intern Med. 2022;182(6):634-642. Link
· 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. Link
From the American Heart Association (AHA) and the Literature
2) Life’s Essential 8
In 2010, the American Heart Association (AHA) published a “Presidential Advisory” on defining optimal cardiovascular health (CVH) in adults. Called “Life’s Simple 7”, these were seven metrics which had been shown to improve cardiovascular health and promote cardiovascular disease prevention. Extensive subsequent evidence has provided insights into strengths and limitations of the original approach to defining and quantifying CVH. In response, the AHA convened a writing group to recommend enhancements and updates, which it has recently published as “Life’s Essential 8.”
The components of Life’s Essential 8 include:
· Diet (updated): Encourages the DASH diet components for population measure and the Mediterranean Eating Pattern for Americans (MEPA) for individuals.
· Physical activity: Measured by the total number of minutes of moderate or vigorous physical activity per week, as defined by the US Physical Activity Guidelines for Americans (2nd edition). The optimal level is 150 minutes (2.5 hours) of moderate physical activity or more per week or 75 minutes per week of vigorous-intensity physical activity for adults.
· Nicotine exposure (updated): Includes use of inhaled nicotine-delivery systems, which includes e-cigarettes or vaping devices, and exposure to second-hand smoke.
· Sleep health (new): Measured by average hours of sleep per night, the ideal target level is 7-9 hours daily for adults.
· Body mass index: BMI continues as a "reasonable" gauge to assess weight categories that may lead to health problems, though acknowledged as being imperfect. BMI of 18.5–24.9 is associated with the highest levels of CV health.
· Blood lipids (updated): Encourages use of non-HDL cholesterol (Total cholesterol minus HDL cholesterol) as the preferred number to monitor. Target is < 130.
· Blood glucose (updated): Use of fasting blood sugar (FBS) or hemoglobin A1C. Target is < 100 or < 5.7.
· Blood pressure: Target measure is < 120/80.
The model also takes into consideration the impact of psychological health and the social determinants/influencers of health (SDOH).
For overall CVH, the writing group endorsed a composite, aggregate score for measuring, monitoring, and assessing change in cardiovascular health. The new aggregate score is also scaled from 0 to 100 points, calculated as the unweighted average of all 8 component metric scores. The group also recommends categorical assessment of overall CVH, with scores of 80-100 be considered high CVH; 50 to 79 as moderate CVH; and 0 to 49 points, low CVH.
In a companion paper (2nd reference), the authors used the metrics of “Life’s Essential 8” to quantify US levels of CVH. Utilizing the National Health and Nutrition Examination Surveys (NHANES) date for 2013-2018, CVH scores were assessed across strata of age, sex, race/ethnicity, family income, and depression. The authors found that the overall mean CVH score was 64.7 among adults. There were significant differences in mean overall CVH scores by sex (women: 67.0 vs. men: 62.5), age (range of mean values 62.2-68.7), and racial/ethnic group (range 59.7-68.5). Mean scores were lowest for diet, PA, and BMI metrics. Overall, only 0.45% of adults had a perfect score of 100; 20% had high CV health (score of 80+), 63% moderate (score of 50 to 79), and 18% had low CV health (score of less than 50). They concluded that overall CVH in the US population remains well below optimal levels, and there are both broad and targeted opportunities to monitor, preserve, and improve CVH across the life course in both individuals and the population.
I’m a big fan of “simplifying without oversimplifying” and through that lens, I found this update to be a helpful guide and reminder. The tool provided at the 3rd reference below provides a nice “check-up” for one’s own cardiovascular health, as well as a delineation of areas for improvement (though no references for the “how”). In full disclosure, I scored an “88” and am actively addressing those areas in which I did not achieve the desired target.
While the national data overall was not surprising, it is disturbing to be reminded yet again how unhealthy we are as a society. Let’s continue to do our part to try and help change this, starting with ourselves and our loved ones. Take the assessment and share it with others. Then make a plan and work it.
· Lloyd-Jones, D et al. Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association. Circulation. Published ahead of Print 29 June 2022. Link
· Lloyd-Jones, D et al. Status of Cardiovascular Health in US Adults and Children Using the American Heart Association's New "Life's Essential 8" Metrics: Prevalence Estimates from the National Health and Nutrition Examination Survey (NHANES), 2013-2018. Circulation. Published ahead of print 29 June 2022. Link
· American Heart Association “My Life Check” Cardiovascular Health Assessment (Register for Free): Link
From PeerRxMed ( www.PeerRxMed.org )
3) Getting to “I Love Being Helped”
“Having a need and needing help is not a sign that you’re weak, it’s a sign that you’re human.” – Kate Northrup, Author
I’ve written previously on the PeerRxMed blog that asking for help is not something that comes naturally for me. Perhaps you can relate? Indeed, our selection, training, and socialization in medicine often has us believing that our exclusive role in all aspects of our lives is as “helpers” and “caregivers,” rather than as “helped” and “cared for”.
In that context, my ongoing almost 2-year healing from a serious back injury has provided me the opportunity to overhaul this professional “brain-washing” that we’ve received regarding help seeking and being helped, framed around the question: What if accepting help was a sign of strength and wisdom rather than being perceived as “selfish” or “weak”?
Early in my healing journey, a conversation with a colleague and PeerRxMed participant wonderfully reframed and completely changed my perspective about this. In discussing the challenges we in healthcare face in accepting help, she shared: “Whenever someone offers to help me, regardless of what it is, I always find a way to say yes, even when I could easily do it myself! It allows for them to feel useful and for us to spend some time together that we may not have otherwise had.”
Wow … I immediately thought of all the times I have declined assistance when someone offered to do something as simple as help with the dishes – or as important as help carry a heavy load (ala back injury) or professionally, to assist with a medical procedure. What if I viewed these offers not as an inconvenience for them or a need to declare my independence (or protect my ego), but rather as an opportunity to connect? And why would I pass up such an opportunity when I know we all hunger for such connection, myself included?!
Since that time I have extended her wisdom by looking for opportunities to ask others for help as well, even when it would be tempting to do something on my own or I don’t think I really need the help. This has most importantly resulted in my asking colleagues for their opinion about patient care questions more often. By doing so, I’ve been blessed by often taking away some insights and pearls that I otherwise would have missed.
So this week, my challenge to you is to accept help whenever someone offers. It can be for anything. Then continue to do so regularly until you find that you have broken the very unhelpful habit of trying to be too independent. Then look for opportunities to ask for their help as well. Afterall, not going it alone is what PeerRxMed is all about. And we certainly need each other’s help to accomplish that!
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.