ARTICLE: Coronary Artery Calcium Scores of Zero and Establishing the Concept of Negative Risk Factors

AUTHORS: Michael J. Blaha, Ron Blankstein and Khurram Nasir

JOURNAL: J Am Coll Cardiol. 2019 Jul 9;74(1):12-14. doi: 10.1016/j.jacc.2019.05.032.

The term “risk factor” was first coined in 1961 in a seminal article by Kannel et al. (1) from the Framingham Heart Study. Since then, risk factors for atherosclerotic cardiovascular disease (ASCVD) have largely been used to identify high-risk patients who might benefit from preventive pharmacotherapy. This emphasis on use of risk factors for upgrading risk made sense in an era when the bar to justify pharmacological intervention in primary prevention was high. For example, in the early Adult Treatment Panel guidelines, presence of multiple risk factors was required for an otherwise healthy patient to reach a risk category in which potentially lifelong medical therapy would be recommended (2).

In contemporary medicine, the bar for preventive therapy has justifiably fallen, reaching a point where many patients will qualify based on their age alone (3). In this context, a new role for risk factors has gained momentum. The negative risk factor is one that might meaningfully downgrade risk and help identify truly low-risk patients—individuals who may choose to safely concentrate on lifestyle therapies while deferring initiation of preventive medication. The fundamental difference in approach cannot be understated (Figure 1). Although the traditional interpretation of risk factor is inextricably tied to more testing and more treatment, the negative risk factor may be used to justify conservative treatment and less follow-up testing.

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