If anyone is keeping score of cardiology risk scores, the count has
soared into triple digits. But how many truly see regular use? Which
ones tally up as “can’t miss” scores and which are lookin’ for some love?
Are we besieged with too many scores for our own good such that some
physicians avoid nearly all of them based on lack of certainty?
An important component of public health and medical care, risk assessment is also heavily relied upon
to facilitate the shared decision-making process. But
risk prediction can be a tricky business and a highstakes one, too. Just ask the gambler at the roulette
table or the credit ratings agencies during the 200809 market meltdown. The big difference: when risk
prediction fails in medicine, the results can be deadly.
By one count, there are well in excess of 100 different cardiovascular risk scores developed for use
in the general population.1 Seems like every other
week you’ll read a journal article proposing new
additions to established scores – new biomarkers,
genetic information, findings from advanced imaging, etc. – as well as proposals for altogether new
scores. Yet, the number of risk scores whose use
is actually mandated by performance standards or
guidelines remains quite small. Are the new components really adding value or just amping up a score?
How should a clinician truly separate the wheat
from the chaff? Are risk scores being used as often
as they should be? And, perhaps, most importantly,
are they being used appropriately?
“When you’re using something to decide if someone should get open-heart surgery or hospice care,
these life and death decisions, I think we justifiably
want to be really certain were getting accurate
information,” said Thomas M. Maddox, MD, from
the University of Colorado School of Medicine in
Denver, in an interview.
Dr. Maddox is a cardiologist at the Department
of Veterans Affairs (VA) Eastern Colorado Health
Care System and the national director of the VA
Clinical Assessment, Reporting, and Tracking
(CART) program. His research is focused on the
use of real-time clinical data to inform high-value
cardiology practice and research.
ASCVD SCORE VINDICATED
For a risk score that stirred up a lot of fuss when
first introduced, the ASCVD (atherosclerotic cardiovascular disease) Pooled Cohort Equations (PCEs)
appears to have made the cut and is very possibly
the most commonly used tool to predict coronary
heart disease (CHD) risk in the United States. (It is
not validated for use in non-U.S. populations.)
The 2013 American College of Cardiology/American Heart Association updated cholesterol guidelines recommend the use of the PCEs to estimate
10-year absolute risk for ASCVD in