5 Steps to prevent Heart Disease

Thursday, March 24, 2016

Lifetime risk is why statins should be used earlier and longer

JAMA, Maarten J. G. Leening, MD, March 2016

Some quotes from the above article:

"Despite expanding primary prevention efforts, the majority of individuals will develop cardiovascular disease (CVD) during their lifetime.1,2
The discordance between short-term (10-year) and long-term (30-year to lifetime) cardiovascular risk is well established and is now reflected in the most recent clinical practice guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) on lipid-lowering treatment for primary prevention of atherosclerotic CVD (ASCVD).3,4

Specifically, these guidelines recommend that lifetime risk estimation can be used as a communication strategy for adults younger than 60 years who are free of ASCVD and not candidates for lipid-lowering therapy.

Although a high lifetime ASCVD risk has not been recommended as a class I indication for lipid-lowering treatment, the acknowledgment of lifetime risk in the guidelines indicates a more comprehensive awareness of the importance of prevention of ASCVD over a life span.
Risk estimation remains an imperfect science."

45-year-old nonsmoking white man with a systolic blood pressure of 138 mm Hg, no diabetes, normal HDL-C, and an LDL-C level of 150 mg/dL (3.9 mmol/L; corresponding to a total cholesterol level of 220 mg/dL [5.7 mmol/L]) would have a similar 10-year risk of hard ASCVD events of 3.6%, but current guidelines would not recommend lipid-lowering therapy for this patient.3

However, using the Framingham Heart Study 30-year risk calculator, these individuals have identical 30-year risks of hard ASCVD events, approximately 24%.5
Given the clinical trial evidence of a similar relative benefit of lipid-lowering therapy across a broad range of LDL-C in the short term, it would be reasonable that lipid-lowering therapy should be considered in both cases, and the second patient should be treated because of the presence of a “lifetime risk equivalent.”

The most recent iteration of the ACC/AHA prevention guidelines adds stroke to hard CHD events to form a composite ASCVD outcome of the 10-year risk calculators.4
This is a major step forward, as this better reflects the overall burden of CVD in women and African Americans, among whom the stroke-to-CHD ratio is known to be greater.2

However, limiting predicted ASCVD risk to end points of hard CHD and stroke does not reflect the entire risk of developing ASCVD over a lifetime.
Most first manifestations of ASCVD are not hard end points with fatal or incapacitating consequences and include
1- angina,
2-transient ischemic attacks, or
3-intermittent claudication.2

"These “soft” end points should be incorporated in global ASCVD risk prediction algorithms as they represent a greater portion of the events in women and, particularly, younger individuals.2"

"Experiencing an ASCVD event and its consequences during life may be of greater importance to patients than their mode of death when balancing the risks and benefits of preventive measures."

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