302. Guidelines: 2021 ESC Cardiovascular...

BMI is easily measured and can be used to define categories of body weight. However, body fat stores in visceral tissue carry higher risk than subcutaneous fat and therefore, waist circumference can be a simple way to measure global and abdominal fat. When waist circumference is ≥102 cm in men and ≥88 cm in women, weight reduction is advised. While these WHO thresholds are widely accepted in Europe, it is important to note that different cut-offs may be appropriate in different ethnic groups.

Work stress is important to ascertain as well because there is preliminary evidence of the detrimental impact of worse stress on ASCVD health, independent of conventional risk factors and their treatment. Work stress is determined by job strain (i.e., the combination of high demands and low control at work) and effort-reward imbalance.

Pre-eclampsia is associated with increase in CVD risk by factor of 1.5-2.7 compared with all women. Both preterm (RR 1.6) and still birth (RR 1.5) are also associated with a moderate increase in CVD risk. Taking a thorough pregnancy history is important in determining future cardiovascular risk in women. The ESC guidelines give a Class IIb (LOE B) recommendation that in women with history of premature or stillbirth, periodic screening for hypertension and DM may be considered. Of note, the 2018 ACC/AHA guidelines include preeclampsia and premature menopause (occurring at age <40 years) as risk-enhancing factors for statin therapy but state that the mechanism or cause of preterm birth is often unknown, so it is difficult to include it as a risk-enhancing factor.

Choice A (sending additional lab workup including CRP and LPa) is incorrect. The ESC guidelines do not recommend using routine circulating biomarkers as they do not improve risk prediction and publication bias distorts the evidence (Class III, LOE B). While some biomarkers like lipoprotein (a) are promising, further work is still needed. Conversely, the 2019 ACC/AHA guidelines do include, if measured, elevated high-sensitivity C-reactive protein (≥2mg/L) and elevated Lp(a) (>50mg/dL or >125nmol/L) and elevated apoB (≥130 mg/dL) as risk-enhancing factors. Specific indications for measuring Lp(a) include family history of premature ASCVD and specific indications for measuring apoB include triglyceride ≥200mg/dL.