Screening for Coronary Artery Disease in Patients With Family History…How, When, and in Whom?

Despite multiple studies showing that family history of premature coronary heart disease (CHD) is associated with an increased risk of cardiovascular events, the predictive value of adding family history to established risk scores is often small,1 and many individuals with family history may not be at increased risk.Article see p 446This apparent discrepancy has several potential explanations. First, in many epidemiological studies, it is difficult to consistently and accurately account for the presence of a strong family history of premature CHD. For instance, many studies only consider parental history, although there are data to suggest that sibling history of premature CHD may have a stronger association with coronary atherosclerosis.2,3 Moreover, most studies do not consider exposure to other risk factors (eg, smoking; diabetes mellitus) among affected family members from prior generations, and only a few studies account for the number of afflicted family members with premature disease. Finally, the age cut point that is used to define premature disease has varied across studies, and almost all studies have used a binary threshold for each sex, which does not allow for any gradation in risk. Put simply, is a 50-year-old nonsmoking active woman at the same level of risk if she has a father who was a smoker and had a myocardial infarction at age 57 than if she has a history of myocardial infarction of multiple first-degree family members, including a mother who had her first myocardial infarction in her 40s?Second, even if we were able to adequately capture detailed information on family history of CHD as well as risk factors that existed in these members (as we often do in the clinical setting), the incremental value of such data beyond risk factors is often small. In a prospective study of parents and …