16.2 Cardiovascular & Metabolic Screening and Primary Prevention

1. Cardiovascular & Metabolic Screening and Primary Prevention

A. Hypertension Screening

• USPSTF Recommendation (Grade A):
  • Adults aged >=40 years and those at increased risk (Black race, high-normal BP 130–139/85–89 mmHg, overweight/obese): Screen annually.
  • Adults aged 18 to 39 years with normal BP (<130/85 mmHg) and no risk factors: Screen every 3 to 5 years.
• Mandatory Confirmation: Elevated in-office blood pressure readings must be confirmed with out-of-office BP measurement before establishing a formal diagnosis of hypertension and initiating lifetime pharmacotherapy:
  • 24-Hour Ambulatory Blood Pressure Monitoring (ABPM): Gold standard (mean daytime BP >=130/80 mmHg or 24-hour mean >=125/75 mmHg confirms HTN).
  • Home Blood Pressure Monitoring (HBPM): Documented average BP >=130/80 mmHg across multiple morning and evening readings over 7 days.
  • Purpose: Rules out White-Coat Hypertension (elevated clinic BP, normal out-of-office BP) and detects Masked Hypertension (normal clinic BP, elevated out-of-office BP).

B. Lipid Screening & Statin Primary Prevention

• USPSTF 2022 Statin Primary Prevention Recommendations:
  • Grade B (Prescribe Statin): Adults aged 40 to 75 years with NO history of CVD who have >=1 CVD risk factor (dyslipidemia [LDL >130 mg/dL or HDL <40 mg/dL], diabetes mellitus, hypertension, or current smoking) AND a calculated 10-year Atherosclerotic Cardiovascular Disease (ASCVD) risk of >=10%.
  • Grade C (Individualize Statin): Adults aged 40 to 75 years with >=1 CVD risk factor and a calculated 10-year ASCVD risk of 7.5% to <10%.
  • Grade I (Insufficient Evidence): Adults aged >=76 years with no prior history of CVD.
• Severe Hypercholesterolemia Rule: Any patient aged 20–75 with baseline LDL-C >=190 mg/dL has an absolute indication for High-Intensity Statin (Atorvastatin 40–80 mg or Rosuvastatin 20–40 mg) without needing ASCVD risk calculation (Class I ACC/AHA recommendation).
• Diabetes Mellitus Rule: Any patient aged 40–75 with Diabetes Mellitus warrants at least Moderate-Intensity Statin therapy regardless of calculated 10-year ASCVD score.

C. Abdominal Aortic Aneurysm (AAA) Screening

• USPSTF 2019 Recommendation:
  • Men aged 65 to 75 years who have EVER smoked (>=100 lifetime cigarettes): One-time screening with abdominal ultrasonography (Grade B).
  • Men aged 65 to 75 years who have NEVER smoked: Selective screening based on family history of AAA, personal cardiovascular disease history, and preferences (Grade C).
  • Women who have NEVER smoked: Recommend against routine screening (Grade D).
  • Women who have smoked: Grade I (insufficient evidence; consider if first-degree relative had AAA).
• Management Based on AAA Diameter:
  • < 3.0 cm: Normal aortic caliber; no surveillance required.
  • 3.0 to 3.9 cm: Abdominal ultrasound surveillance every 2 to 3 years.
  • 4.0 to 5.4 cm: Abdominal ultrasound or CT angiography every 6 to 12 months.
  • >= 5.5 cm in Men (or >= 5.0 cm in Women), OR rapid expansion (>0.5 cm in 6 months or >1.0 cm in 1 year), OR symptomatic: Indication for Elective Repair (Endovascular Aneurysm Repair [EVAR] or Open Surgical Repair).

D. Diabetes Mellitus & Prediabetes Screening

• USPSTF 2021 Recommendation (Grade B): Screen for prediabetes and type 2 diabetes in non-pregnant adults aged 35 to 70 years who are overweight or obese (BMI >=25 kg/m2, or BMI >=23 kg/m2 in Asian American individuals).
• Diagnostic Testing:
  • Fasting Plasma Glucose (FPG: normal <100 mg/dL; prediabetes 100–125 mg/dL; diabetes >=126 mg/dL),
  • Hemoglobin A1c (normal <5.7%; prediabetes 5.7–6.4%; diabetes >=6.5%), OR
  • 2-Hour 75g Oral Glucose Tolerance Test (OGTT: normal <140 mg/dL; prediabetes 140–199 mg/dL; diabetes >=200 mg/dL).
• Rescreening Interval: If initial testing is normal, repeat screening every 3 years.

E. Osteoporosis Screening

• USPSTF 2018 Recommendation (Grade B): Screen for osteoporosis with Dual-Energy X-ray Absorptiometry (DEXA) of the hip and lumbar spine in:
  1. All women aged >=65 years, AND
  2. Postmenopausal women aged <65 years who have an increased fracture risk equivalent to or greater than that of a 65-year-old white woman (calculated 10-year major osteoporotic fracture risk >=8.4% or 10-year hip fracture risk >=3.0% using the FRAX tool; risk factors include low BMI <21 kg/m2, history of fragility fracture, parental hip fracture, current smoking, alcohol >=3 drinks/day, or chronic systemic glucocorticoid use >=5 mg prednisone daily for >=3 months).
• Men: Grade I (insufficient evidence for routine screening in asymptomatic men without secondary causes of bone loss).
• Diagnostic T-Score Thresholds:
  • Normal: T-score >= -1.0
  • Osteopenia: T-score between -1.0 and -2.5
  • Osteoporosis: T-score <= -2.5 (or presence of a fragility fracture regardless of T-score)

2. Comprehensive Screening Summary Table