JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 64, NO. 10, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2014.06.1185
EDITORIAL COMMENT
Primary Prevention of Atherosclerotic Cardiovascular Disease Bringing Clinicians and Patients to the Starting Line* Michael E. Farkouh, MD, MSC
T
he recent American College of Cardiology/
artery disease (3). Most troubling, however, was that
American Heart Association clinical practice
physicians did a particularly poor job of estimating
guidelines for the treatment of lipids have
the cardiovascular risk in elderly patients, in that
been received with a great deal of fanfare. The debate
their risk was underestimated. Even more discon-
over the most effective risk tool to estimate the
certing is that only 40% of family physicians, in-
10-year cardiovascular risk remains an ongoing con-
ternists, and cardiologists used the assessment tool
troversy. There is widespread consensus that we
when assessing the prognosis of cardiovascular risk
need to identify high-risk primary prevention pa-
(4). Therefore, regardless of which tool one prefers, it
tients for consideration of more aggressive therapy.
is very clear that we are underutilizing effective
The new guidelines introduce Pooled Cohort Equations (1), which differ from the more traditional Adult Treatment Panel III calculator, which was based
means available to educate our patients about their future risk of ASCVD. SEE PAGE 959
on Framingham. The most important changes have been the adoption of stroke as a primary outcome
In this issue of the Journal, Karmali et al. (5) report
measure for atherosclerotic cardiovascular disease
on an evaluation of the distribution of 10-year risk for
(ASCVD), the adoption of sex- and race-specific
ASCVD using hypothetical patient data in the Pooled
models in addition to the traditional cardiovascular
Cohort Equations. An ASCVD risk of 7.5% risk over 10
risk factors, and the inclusion of diabetes as an
years was believed to demonstrate a threshold at
important determinant. These modifications are
which initiation of statin therapy could be consid-
important advances as we bring risk prediction to a
ered. In their analysis, they were able to demonstrate
diverse population and have been validated in an
that for non-Hispanic white and African-American
analysis from the REGARDS (Reasons for Geographic
men and women, the age at which a given individ-
and Racial Differences in Stroke) prospective obser-
ual would cross over the 7.5% threshold varied ac-
vational study (2).
cording to the number and degree of risk factors.
In general, many analyses suggest that physicians
Even when optimal risk profiles were present,
do a poor job of cardiovascular risk prediction. When
including total cholesterol of 170 mg/dl or less, high-
U.S. physicians were studied, there was low concor-
density lipoprotein cholesterol of 50 mg/dl or more,
dance between the cardiovascular risk calculated by
untreated systolic blood pressure of 110 mm Hg, and
the Framingham risk score and physicians’ percep-
no diabetes or smoking, the age to reach the 7.5%
tions of their patients’ risk for developing coronary
threshold ranged from 65 years in non-Hispanic white men to 70 years in African-American men and women and 75 years in non-Hispanic white women.
*Editorials published in the Journal of the American College of Cardiology
Overall, the use of this risk calculator will substan-
reflect the views of the authors and do not necessarily represent the
tially increase the number of all Americans, including
views of JACC or the American College of Cardiology. From the Peter Munk Cardiac Centre and Heart & Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, Ontario, Canada. Dr. Farkouh has reported that he has no relationships relevant to the contents of this paper to disclose.
women and African Americans, who will be considered potential candidates for statin therapy (6). The inclusion of diabetes in the equation could also have a major public health impact. For patients
970
Farkouh
JACC VOL. 64, NO. 10, 2014
Primary Prevention of ASCVD
SEPTEMBER 9, 2014:969–70
without blood pressure treatment in the 4 major sex
commitment to intervention. Across the spectrum
and race groups, all but non-Hispanic white women
of evidence from observational studies to clinical
would reach the 7.5% threshold by the age of 55
trials to practice guidelines, knowledge translation
years. If blood pressure is treated, all 3 major groups
is the underpinning of the clinician-patient dia-
except non-Hispanic white women would reach the
logue. Every patient has a unique risk profile and
threshold by the age of 50 years. Prior risk calculators
demographic background that will influence his or
that exclude diabetes could significantly underesti-
her decision making.
mate ASCVD risk, particularly in light of the obesity epidemic.
The use of hypothetical patients to evaluate a risk score is not unusual and allows for a full evaluation
Perhaps the greatest lesson from this controversy
of the range of risk for ASCVD. There are a number
and the evaluation of the modeling of the Pooled
of settings in which hypothetical patient data are
Cohort Equation is the emphasis placed on the
used to model risk, both for evaluating physician
starting line, the opportunity to have an informed
behavior and for educating patients. The modeling of
discussion with our patients. It reaffirms that medi-
changes in multiple risk factors simultaneously has
cine is an art as much as a science. By beginning at
the potential to miss important interactions between
a point of providing our patients with an under-
risk factors, which can lead to errors in predicting
standing of their 10-year risk of ASCVD, we then
risk; however, without hypothetical data, it is diffi-
allow the patient to understand the magnitude of
cult to fully define the full impact of a risk calculator.
the problem and the potential interventions that
In the end, the findings of the study by Karmali
may lie ahead. No risk calculator is perfect, but we
et al. (5) will enhance the clinician-patient discussion
can start with one built on evidence and consensus.
and afford us the opportunity to educate our pa-
Some also have questioned the 7.5% 10-year
tients. It allows us to bring a viable model to the
threshold, which was chosen arbitrarily and may
patient but will not lead to intervention for all
vary depending on patient and physician preference.
patients who attain a threshold of 7.5%. Patients,
In some healthcare systems, a 10-year risk of 10%
aided by knowledge provided by their physicians,
may be more appropriate, particularly for patients
should make their decisions regarding statin therapy
who are at risk of adverse effects of therapies such as
using multiple considerations, including their own
statins. For others who are younger and whose car-
preferences and by weighing the adverse effects
diovascular health is at greater risk because of a
against any perceived benefits of intervention. Ulti-
positive family history, for example, a 5% threshold
mately, if we are to improve the health of Americans
may be more suitable.
and decrease the burden of disease from ASCVD,
The next logical step in the implementation of the risk calculator is the appropriate adoption of
we need to bring our patients, and ourselves, to the starting line.
therapies to prevent ASCVD. At the starting line, clinicians should be prepared to initiate a discus-
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
sion about the benefits and risks of statins. The
Michael E. Farkouh, Peter Munk Cardiac Centre,
current guidelines are a mechanism to begin such
585 University Avenue–4N474, Toronto, Ontario M5G
a discussion with our patients, but they are not a
2N2, Canada. E-mail: [email protected].
REFERENCES 1. Goff DC Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American Col-
and adherence to cardiovascular disease prevention guidelines. Circulation 2005;111: 499–510.
lege of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2935–59.
4. Shillinglaw B, Viera AJ, Edwards T, Simpson R,
2. Muntner P, Colantonio LD, Cushman M, et al. Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations. JAMA 2014;311:1406–15. 3. Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness
Sheridan SL. Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians. BMC Health Serv Res 2012;12:20. 5. Karmali KN, Goff DC Jr., Ning H, LloydJones DM. A systematic examination of the 2013 ACC/AHA Pooled Cohort risk assessment
tool for atherosclerotic cardiovascular disease. J Am Coll Cardiol 2014;64:959–68. 6. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr., et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med 2014;370:1422–31.
KEY WORDS cardiovascular, evaluation, prevention
VOL. 64, NO. 10, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2014.06.1185
EDITORIAL COMMENT
Primary Prevention of Atherosclerotic Cardiovascular Disease Bringing Clinicians and Patients to the Starting Line* Michael E. Farkouh, MD, MSC
T
he recent American College of Cardiology/
artery disease (3). Most troubling, however, was that
American Heart Association clinical practice
physicians did a particularly poor job of estimating
guidelines for the treatment of lipids have
the cardiovascular risk in elderly patients, in that
been received with a great deal of fanfare. The debate
their risk was underestimated. Even more discon-
over the most effective risk tool to estimate the
certing is that only 40% of family physicians, in-
10-year cardiovascular risk remains an ongoing con-
ternists, and cardiologists used the assessment tool
troversy. There is widespread consensus that we
when assessing the prognosis of cardiovascular risk
need to identify high-risk primary prevention pa-
(4). Therefore, regardless of which tool one prefers, it
tients for consideration of more aggressive therapy.
is very clear that we are underutilizing effective
The new guidelines introduce Pooled Cohort Equations (1), which differ from the more traditional Adult Treatment Panel III calculator, which was based
means available to educate our patients about their future risk of ASCVD. SEE PAGE 959
on Framingham. The most important changes have been the adoption of stroke as a primary outcome
In this issue of the Journal, Karmali et al. (5) report
measure for atherosclerotic cardiovascular disease
on an evaluation of the distribution of 10-year risk for
(ASCVD), the adoption of sex- and race-specific
ASCVD using hypothetical patient data in the Pooled
models in addition to the traditional cardiovascular
Cohort Equations. An ASCVD risk of 7.5% risk over 10
risk factors, and the inclusion of diabetes as an
years was believed to demonstrate a threshold at
important determinant. These modifications are
which initiation of statin therapy could be consid-
important advances as we bring risk prediction to a
ered. In their analysis, they were able to demonstrate
diverse population and have been validated in an
that for non-Hispanic white and African-American
analysis from the REGARDS (Reasons for Geographic
men and women, the age at which a given individ-
and Racial Differences in Stroke) prospective obser-
ual would cross over the 7.5% threshold varied ac-
vational study (2).
cording to the number and degree of risk factors.
In general, many analyses suggest that physicians
Even when optimal risk profiles were present,
do a poor job of cardiovascular risk prediction. When
including total cholesterol of 170 mg/dl or less, high-
U.S. physicians were studied, there was low concor-
density lipoprotein cholesterol of 50 mg/dl or more,
dance between the cardiovascular risk calculated by
untreated systolic blood pressure of 110 mm Hg, and
the Framingham risk score and physicians’ percep-
no diabetes or smoking, the age to reach the 7.5%
tions of their patients’ risk for developing coronary
threshold ranged from 65 years in non-Hispanic white men to 70 years in African-American men and women and 75 years in non-Hispanic white women.
*Editorials published in the Journal of the American College of Cardiology
Overall, the use of this risk calculator will substan-
reflect the views of the authors and do not necessarily represent the
tially increase the number of all Americans, including
views of JACC or the American College of Cardiology. From the Peter Munk Cardiac Centre and Heart & Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, Ontario, Canada. Dr. Farkouh has reported that he has no relationships relevant to the contents of this paper to disclose.
women and African Americans, who will be considered potential candidates for statin therapy (6). The inclusion of diabetes in the equation could also have a major public health impact. For patients
970
Farkouh
JACC VOL. 64, NO. 10, 2014
Primary Prevention of ASCVD
SEPTEMBER 9, 2014:969–70
without blood pressure treatment in the 4 major sex
commitment to intervention. Across the spectrum
and race groups, all but non-Hispanic white women
of evidence from observational studies to clinical
would reach the 7.5% threshold by the age of 55
trials to practice guidelines, knowledge translation
years. If blood pressure is treated, all 3 major groups
is the underpinning of the clinician-patient dia-
except non-Hispanic white women would reach the
logue. Every patient has a unique risk profile and
threshold by the age of 50 years. Prior risk calculators
demographic background that will influence his or
that exclude diabetes could significantly underesti-
her decision making.
mate ASCVD risk, particularly in light of the obesity epidemic.
The use of hypothetical patients to evaluate a risk score is not unusual and allows for a full evaluation
Perhaps the greatest lesson from this controversy
of the range of risk for ASCVD. There are a number
and the evaluation of the modeling of the Pooled
of settings in which hypothetical patient data are
Cohort Equation is the emphasis placed on the
used to model risk, both for evaluating physician
starting line, the opportunity to have an informed
behavior and for educating patients. The modeling of
discussion with our patients. It reaffirms that medi-
changes in multiple risk factors simultaneously has
cine is an art as much as a science. By beginning at
the potential to miss important interactions between
a point of providing our patients with an under-
risk factors, which can lead to errors in predicting
standing of their 10-year risk of ASCVD, we then
risk; however, without hypothetical data, it is diffi-
allow the patient to understand the magnitude of
cult to fully define the full impact of a risk calculator.
the problem and the potential interventions that
In the end, the findings of the study by Karmali
may lie ahead. No risk calculator is perfect, but we
et al. (5) will enhance the clinician-patient discussion
can start with one built on evidence and consensus.
and afford us the opportunity to educate our pa-
Some also have questioned the 7.5% 10-year
tients. It allows us to bring a viable model to the
threshold, which was chosen arbitrarily and may
patient but will not lead to intervention for all
vary depending on patient and physician preference.
patients who attain a threshold of 7.5%. Patients,
In some healthcare systems, a 10-year risk of 10%
aided by knowledge provided by their physicians,
may be more appropriate, particularly for patients
should make their decisions regarding statin therapy
who are at risk of adverse effects of therapies such as
using multiple considerations, including their own
statins. For others who are younger and whose car-
preferences and by weighing the adverse effects
diovascular health is at greater risk because of a
against any perceived benefits of intervention. Ulti-
positive family history, for example, a 5% threshold
mately, if we are to improve the health of Americans
may be more suitable.
and decrease the burden of disease from ASCVD,
The next logical step in the implementation of the risk calculator is the appropriate adoption of
we need to bring our patients, and ourselves, to the starting line.
therapies to prevent ASCVD. At the starting line, clinicians should be prepared to initiate a discus-
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
sion about the benefits and risks of statins. The
Michael E. Farkouh, Peter Munk Cardiac Centre,
current guidelines are a mechanism to begin such
585 University Avenue–4N474, Toronto, Ontario M5G
a discussion with our patients, but they are not a
2N2, Canada. E-mail: [email protected].
REFERENCES 1. Goff DC Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American Col-
and adherence to cardiovascular disease prevention guidelines. Circulation 2005;111: 499–510.
lege of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2935–59.
4. Shillinglaw B, Viera AJ, Edwards T, Simpson R,
2. Muntner P, Colantonio LD, Cushman M, et al. Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations. JAMA 2014;311:1406–15. 3. Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness
Sheridan SL. Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians. BMC Health Serv Res 2012;12:20. 5. Karmali KN, Goff DC Jr., Ning H, LloydJones DM. A systematic examination of the 2013 ACC/AHA Pooled Cohort risk assessment
tool for atherosclerotic cardiovascular disease. J Am Coll Cardiol 2014;64:959–68. 6. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr., et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med 2014;370:1422–31.
KEY WORDS cardiovascular, evaluation, prevention
