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Circulation. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625 June 18/25, 2019 e1123 CLINICAL STATEMENTS AND GUIDELINES

use of risk-assessment algorithms (eg, Framingham risk scoring or PCE) to estimate risk. Although these equations are useful, they may overestimate or underestimate risk for individual patients. For this reason, the 2013 ACC/AHA guidelinesS8.2-1 introduced the clinician– patient risk discussion to facilitate clinical decisions about appropriate therapy. In the present guidelines, the clinician–patient risk discussion has been amplified and made an integral part of the clinical decision. In addition, in cases in which uncertainty exists, the measurement of CAC has been proposed as a third step in making a treatment decision. Each of these steps could be improved for future guidelines.

8.2.1 Continuing Refinement of PCE

Because the population baseline risk may be continually declining in the US population, ongoing epidemiological study is needed to assess and update population risk. An example is the development of QRISK in the U.K. population, which is continually expanding its scope.

8.2.2 Improvement in Lifetime Risk Estimate

The present guidelines include a lifetime ASCVD risk algorithm for those 20 to 59 years of age, but it is based on an insufficient database. Along with a risk algorithm for short-term risk of ASCVD (eg, 10 years), a more robust lifetime risk algorithm would facilitate the clinician–patient risk discussion for treatment decisions. 8.2.3. Refinement of Clinician–Patient Risk Discussion An ongoing study of how a clinician can best interact with a patient to arrive at an informed decision must be done, taking multiple factors into consideration. This is particularly important because cholesterol-lowering therapy is meant to be a lifetime therapy.

8.2.4 Monitoring and Adjustment of Treatment

The clinician–patient risk discussion will likely prove inadequate unless an ongoing interaction between the patient and clinician occurs. This involves monitoring the effectiveness of therapy and adherence to therapy. Thus, the clinician–patient risk discussion should include more than the initial treatment decision. Ongoing research on how to improve the entire process of initial decision-making and long-term follow-up is necessary.

8.2.5 Prognostic Significance of CAC

The present guideline makes use of the available data to predict the risk associated with CAC. These data need to be amplified by new and ongoing studies to guide treatment decisions. Particular uncertainty exists about the predictive value of intermediate CAC scores. In addition, the predictive significance of a CAC score of zero must be further verified in follow-up studies. For patients with a CAC score of zero, it is currently uncertain when and if follow-up CAC measurements should be done to reassess risk status. ACC/AHA TASK FORCE MEMBERS

Glenn N. Levine, MD, FACC, FAHA, Chair; Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect; Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Joshua A. Beckman, MD, MS, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Biykem Bozkurt, MD, PhD, FACC, FAHA*; Ralph G. Brindis, MD, MPH, MACC*; Joaquin E. Cigarroa, MD, FACC; Lesley H. Curtis, PhD, FAHA*; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Samuel Gidding, MD, FAHA*; Zachary D. Goldberger, MD, MSc, FACC, FAHA; Mark A. Hlatky, MD, FACC, FAHA; John Ikonomidis, MD, PhD, FAHA*; José A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAHA; Susan J. Pressler, PhD, RN, FAHA*; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD

PRESIDENTS AND STAFF American College of Cardiology

C. Michael Valentine, MD, FACC, President Timothy W. Attebery, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Education, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science,

Education, Quality, and Publishing

American College of Cardiology/ American Heart Association

Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S.D. Getchius, Manager, Guideline Operations

American Heart Association

Ivor Benjamin, MD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Prashant Nedungadi, PhD, Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Sci-

entific Publications, Office of Science Operations

*Former Task Force member; current member during the writing effort.

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