Global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews

Objective To identify, critically appraise, and summarize existing systematic reviews on the impact of global cardiovascular risk assessment in the primary prevention of CVD in adults. Design Systematic review of systematic reviews published between January 2005 to April 2015 in The Cochrane Library, EMBASE, MEDLINE, or CINAHL databases, and post hoc analysis of primary trials. Participants, Interventions, Outcomes Systematic reviews of interventions involving global cardiovascular risk assessment relative to no formal risk assessment in adults with no history of CVD. The primary outcomes of interest were CVD-related morbidity and mortality and all-cause mortality; secondary outcomes were systolic blood pressure, cholesterol, and smoking. Results We identified six systematic reviews of variable but generally low quality (mean AMSTAR 4.2/11, range 0/11 to 7/11). No studies identified by the systematic reviews reported CVD-related morbidity or mortality or all-cause mortality. Meta-analysis of reported RCTs showed small reductions in systolic blood pressure (MD -2.22 mmHg [95% CI -3.49, -0.95]; I2=66%; n=9; GRADE: very low), total cholesterol (MD -0.11 mmol/L [95% CI -0.20, -0.02]; I2=72%; n=5; GRADE: very low), LDL cholesterol (MD -0.15 mmol/L [95% CI -0.26,-0.05], I2=47%; n=4; GRADE: very low), and smoking cessation (RR 1.62 [95% CI 1.08, 2.43]; I2=17%; n=7; GRADE: low). The median follow-up time of reported RCTs was 12 months (range two to 36 months). Conclusions The quality of existing systematic reviews was generally poor and there is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality. There are reductions in systolic blood pressure, cholesterol, and smoking but they may not be clinically significant given their small effect size and short duration. Resources need to be directed to conduct high quality systematic reviews focusing on hard patient outcomes, and likely further primary randomized trials.