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Cardiovascular screening guidelines exhibit 'considerable' variation in strategies, treatment

Researchers reported persistent and significant deviations in cardiovascular screening guidelines, which may be limiting their usage, according to a review published in the Annals of Internal Medicine.

The guidelines, which are implemented to identify high-risk individuals in order to reduce their CVD risk factors, do not agree on screening strategies or treatment threshold, Mohammed Y. Khanji, MB, BCh, from Queen Mary University London and colleagues wrote.

"Primary care physicians maintain a central role in the prevention of CVD but still find implementation of prevention strategies challenging, and management of persons with increased CVD risk remains suboptimal," Khanji and colleagues wrote "Time constraints, lack of perceived usefulness, inadequate knowledge, and inconsistency in published recommendations have been cited as common reasons for not using CVD prevention guidelines or global CVD risk assessment tools. Concerns exist about poor uptake of the National Health Service Health Check program; only about 50% of those invited — much lower than the 75% government target — attended. In addition, a Cochrane review and subsequent Danish randomized, controlled trial raised doubts about the morbidity and mortality benefits from such programs."

The researchers systematically reviewed 21 guidelines developed by various organizations, including the American College of Cardiology, the American Diabetes Association, the U.S. Preventive Services Task Force and the CDC, on screening interventions that could be performed in a cardiovascular health check program. They noted that 17 of the studies were rigorously developed.

Khanji and colleagues reported that many of the guidelines supported CVD risk assessment as a primary or secondary step and the consideration of ethnicity as a risk factor. Many supported using prediction models to integrate smoking, sex, age, blood pressure and lipid levels into risk assessment, but there was no agreement on which prediction model to use. There was consensus on the importance of lifestyle factors as well as the limited role of novel biomarkers and markers of subclinical atherosclerosis.

The researchers also found that many of the guidelines agreed on a conservative approach for primary prevention with aspirin.

"Of the eight guidelines that make recommendations on aspirin use, three do not recommend routine use for primary prevention, three of the dysglycemia guidelines recommend considering aspirin therapy but only in the presence of additional factors putting patients in a high-risk category, and only two guidelines based the recommendation on age alone," Khanji and colleagues wrote.

The guidelines differed on the target population for screening, when to initiate statin treatment, when to initiate antihypertensive medication and the type of subclinical atherosclerosis screening test.

The researchers acknowledged that doubts regarding screening benefits may contribute to guideline variations.

"Although evidence supports the effectiveness of particular interventions to appropriate persons, screening programs face such difficulties as achievement of sufficiently high uptake rates to invitations, ability to deliver effective interventions, and patient adherence to recommendations," Khanji and colleagues wrote.

They concluded: "Cardiovascular screening guidelines still have considerable discrepancies, with no consensus on optimum screening strategies or treatment threshold. Physicians should assess the strength of the recommendations and the level of evidence to decide which of the recommendations they should implement." – by Chelsea Frajerman Pardes

Disclosure: One author reports royalties from Cambridge University Press, grants and nonfinancial support from European Society of Radiology, and nonfinancial support from European Institute of Biomedical Imaging Research outside the submitted work. All other authors report no relevant financial disclosures.