In the JournalsPerspective

New risk score could improve identification of people at risk for CVD

A new American College of Cardiology/American Heart Association guideline includes a risk score that could help clinicians better identify those likely to develop atherosclerotic CVD within 10 years.

The 2013 Guideline on the Assessment of Cardiovascular Risk, includes a formula to calculate CVD risk in people without CVD based on various factors, and incorporates stroke risk into the equation.

“The intensity of our prevention efforts for CVD should match the absolute predicted risk of the patient,” Donald M. Lloyd-Jones, MD, ScM, co-chair of the work group that developed the guideline, said at a press conference. “In this framework … patients who are at higher risk for an event in the next 10 years are recommended for things like an immediate drug therapy to lower their risk, as well as lifestyle interventions, whereas those who are at lower predicted risk receive appropriate lifestyle interventions, and probably not drug therapy. We’ll maximize the effectiveness of those [drug] therapies if we apply them in the selected individuals who are at the highest risk over the short term.”

Prediction of MI and stroke

The 10-year risk score incorporates factors to help clinicians predict the likelihood of MI and stroke, said Lloyd-Jones, of Northwestern University Feinberg School of Medicine. “Previous equations predicted the risk just for having a CHD event,” he said. “But we realized quickly that we were leaving a lot of risk on the table by not also including stroke in our risk assessment algorithm. Stroke is a particularly important endpoint for women and for African-Americans.”

There are separate equations for non-Hispanic white men, non-Hispanic white women, black men and black women, Lloyd-Jones said. For other ethnicities, clinicians may use the sex-appropriate equation for non-Hispanic whites, he said.

“As time goes on, we’re hopeful that other data sources will mature and will allow for specific risk prediction equations to be developed in Hispanic and Latino populations, as well as Asian-American groups,” he said.

Nine factors to input

The equations require the input of the following factors: age, sex, race, total cholesterol, HDL cholesterol, BP level, BP treatment status, diabetes status and current smoking status.

“These measures were selected using statistical techniques and were found to be the strongest predictors of the 10-year risk for atherosclerotic CVD,” Lloyd-Jones said. “We did consider a large number of other possible risk markers for inclusion … but we did not find any that provided sufficient additional information that they should merit inclusion in these equations.”

The panel also identified four markers that may be considered by clinicians if there is still uncertainty after calculating the risk score, Lloyd-Jones said. These include family history of premature CVD, measurement of coronary artery calcification, measurement of high-sensitivity C-reactive protein and measurement of ankle-brachial index. Of those four, family history, if known and reliable, is the easiest to consider in clinical practice, but measurement of coronary artery calcification has the strongest evidence for it, he said.

The panel recommended against performing carotid intima-media thickness measurements because it found consistent evidence that the test had no benefit, he said.

The guideline also outlines other methods for determining long-term and lifetime risk for CVD, which could be useful in identifying at-risk young people, he said. It recommends that long-term and lifetime risk assessment be calculated alongside 10-year risk assessment for patients aged 20 years to 59 years.

The equations can be incorporated into electronic health record platforms, or performed on a downloadable Excel spreadsheet available to the public, he said.

For more information:

Goff DC. Circulation. 2013;doi:10.1161/01.cir.0000437741.48606.98.

Goff DC. J Am Coll Cardiol. 2013;doi:10.1016/j.jacc.2013.11.005.

Disclosure: See the full guideline for a list of the panel members’ relevant financial disclosures.

A new American College of Cardiology/American Heart Association guideline includes a risk score that could help clinicians better identify those likely to develop atherosclerotic CVD within 10 years.

The 2013 Guideline on the Assessment of Cardiovascular Risk, includes a formula to calculate CVD risk in people without CVD based on various factors, and incorporates stroke risk into the equation.

“The intensity of our prevention efforts for CVD should match the absolute predicted risk of the patient,” Donald M. Lloyd-Jones, MD, ScM, co-chair of the work group that developed the guideline, said at a press conference. “In this framework … patients who are at higher risk for an event in the next 10 years are recommended for things like an immediate drug therapy to lower their risk, as well as lifestyle interventions, whereas those who are at lower predicted risk receive appropriate lifestyle interventions, and probably not drug therapy. We’ll maximize the effectiveness of those [drug] therapies if we apply them in the selected individuals who are at the highest risk over the short term.”

Prediction of MI and stroke

The 10-year risk score incorporates factors to help clinicians predict the likelihood of MI and stroke, said Lloyd-Jones, of Northwestern University Feinberg School of Medicine. “Previous equations predicted the risk just for having a CHD event,” he said. “But we realized quickly that we were leaving a lot of risk on the table by not also including stroke in our risk assessment algorithm. Stroke is a particularly important endpoint for women and for African-Americans.”

There are separate equations for non-Hispanic white men, non-Hispanic white women, black men and black women, Lloyd-Jones said. For other ethnicities, clinicians may use the sex-appropriate equation for non-Hispanic whites, he said.

“As time goes on, we’re hopeful that other data sources will mature and will allow for specific risk prediction equations to be developed in Hispanic and Latino populations, as well as Asian-American groups,” he said.

Nine factors to input

The equations require the input of the following factors: age, sex, race, total cholesterol, HDL cholesterol, BP level, BP treatment status, diabetes status and current smoking status.

“These measures were selected using statistical techniques and were found to be the strongest predictors of the 10-year risk for atherosclerotic CVD,” Lloyd-Jones said. “We did consider a large number of other possible risk markers for inclusion … but we did not find any that provided sufficient additional information that they should merit inclusion in these equations.”

The panel also identified four markers that may be considered by clinicians if there is still uncertainty after calculating the risk score, Lloyd-Jones said. These include family history of premature CVD, measurement of coronary artery calcification, measurement of high-sensitivity C-reactive protein and measurement of ankle-brachial index. Of those four, family history, if known and reliable, is the easiest to consider in clinical practice, but measurement of coronary artery calcification has the strongest evidence for it, he said.

The panel recommended against performing carotid intima-media thickness measurements because it found consistent evidence that the test had no benefit, he said.

The guideline also outlines other methods for determining long-term and lifetime risk for CVD, which could be useful in identifying at-risk young people, he said. It recommends that long-term and lifetime risk assessment be calculated alongside 10-year risk assessment for patients aged 20 years to 59 years.

The equations can be incorporated into electronic health record platforms, or performed on a downloadable Excel spreadsheet available to the public, he said.

For more information:

Goff DC. Circulation. 2013;doi:10.1161/01.cir.0000437741.48606.98.

Goff DC. J Am Coll Cardiol. 2013;doi:10.1016/j.jacc.2013.11.005.

Disclosure: See the full guideline for a list of the panel members’ relevant financial disclosures.

    Perspective
    Nanette K. Wenger

    Nanette K. Wenger

    The writing committees have done a commendable job. One of the most important changes concerns the global risk score. For years, many have been unhappy with the Framingham Risk Score because there were a number of important variables that were not captured. The Pooled Cohort Equations are very important. The panel members included Framingham and the Framingham offspring data, but they also included recent studies such as ARIC, MESA and other NHLBI databases in these race- and sex-specific pooled cohort equations.

     This format is online for the clinicians to use, and we must aggressively add this to the major electronic medical record formats. The organizations who endorsed this have signed on to that concept. It must be formulated as the best and simplest tool for the clinician to use and for patients to understand. As there’s current excitement about it and as people are talking about it, having it immediately available is important.

    • Nanette K. Wenger, MD
    • Cardiology Today Editorial Board member

    Disclosures: Wenger reports financial ties with Arbor Pharmaceuticals.