The brand new AHA/ACC 2013 cardiovascular risk calculator: is it applicable to a low-risk southern European population?
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1 XXXV Congresso Português de Cardiologia The brand new AHA/ACC 2013 cardiovascular risk calculator: is it applicable to a low-risk southern European population? Manuel Oliveira-Santos, Rui Baptista, Marta Rebelo, Diana Oliveira, Patrícia Dias, Rui Martins, José Pereira de Moura, Mariano Pêgo Serviço de Cardiologia A Serviço de Medicina Interna A
2 Background The brand new AHA/ACC risk calculator estimates atherosclerotic cardiovascular disease (ASCVD) risk at ten years: nonfatal myocardial infarction, CHD death, fatal or nonfatal stroke variables: age, total and HDL-cholesterol, systolic blood pressure (including treated or untreated status), diabetes and current smoking status Goff DC et al., 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Journal of the American College of Cardiology Europe: Systematic COronary Risk Evaluation (SCORE) system estimates the individual risk of fatal non-coronary atherosclerotic and coronary heart disease (CHD) variables: age, gender, lipids, blood pressure, and smoking Conroy RM et al., Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J Perk J et al., European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J Catapano AL et al., ESC/EAS Guidelines for the management of dyslipidaemias. Atherosclerosis. 2011
3 Background (II) ASCVD risk 7.5% (40-75 ys + LDL mg/dL): indication for statin 5-7.5% -therapy? Stone NJ et al., 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Journal of the American College of Cardiology The ASCVD calculator has been criticised for risk overestimation, potentially leading to undue prescription Ridker PM et al., Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013
4 Objective To investigate whether the ASCVD calculator overestimates cardiovascular (CV) risk in a Mediterranean cohort of patients, comparing it with the Systematic COronary Risk Evaluation (SCORE) stratification system from the European Society of Cardiology
5 Population and Methods Lipidology Clinic Centro Hospitalar e Universitário de Coimbra Inclusion: CV naïve patients Ten year Follow-up Acute myocardial infarction; Stroke; CV death Yusuf, S et al., The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med Baseline SCORE system (low risk countries) and ASCVD risks calculation Four risk groups: <1% 1 to <5% 5 to <10% 10% <5% 5 to <7.5% 7.5 to <10% 10% compare the median expected event rate with the observed rate
6 Results Nº 446 Age (years) 48.9 ± 14.4 Male (%) 58.3 Systolic blood pressure (mmhg) Diastolic blood pressure (mmhg) Antihypertensive drug treatment (%) ± ± Type 2 diabetes (%) 24.8 Body mass index (kg/m 2 ) 28.1 ± years (85% follow-up) Total cholesterol (mg/dl) ± 77.6 High density lipoprotein-cholesterol (mg/dl) Low density lipoprotein-cholesterol (mg/dl) Statin treatment (%) ± ± 66.7 Creatinine (mg/dl) 0.96 ± 0.5 Glomerular filtration rate (ml/min/1.73m 2 ) Current smokers (%) ± 25.3 Acute myocardial infarction 3.4% Stroke 2.4% CV death 1.5%
7 Event rate (%) Results - ASCVD (II) % % 9.0% Observed events Expected events % 0 <5% 5-<7.5% 7.5-<10% 10% ASCVD risk group
8 Event rate (%) Results - SCORE (II) % % Observed events Expected events % % <1% 1-<5% 5-<10% 10% SCORE risk group
9 Risk SCORE and ASCVD SCORE<5% % SCORE 5% Age (years) 46.6 ± ± 6.8 Male (%) Systolic blood pressure (mmhg) ± ± 24.1 Diastolic blood pressure (mmhg) 83.8± ± 9.7 Antihypertensive treatment (%) Type 2 diabetes (%) Body mass index (kg/m 2 ) 28.1 ± ± 3.5 Total cholesterol (mg/dl) ± ± 85.7 Low density lipoprotein-c (mg/dl) ± ± 74.6 Statin treatment (%) Current smokers (%) ASCVD<7.5% ASCVD 7.5% ± ± ± ± ± ± ± ± ± ± ± ±
10 Discussion In our cohort, the predicted CV risks are larger than the actual event rate patients under anti-dyslipidemic therapy in a Lipidology Clinic Matter for concern? overestimation in the highest levels of CV disease risk it s not problematic In patients with lower predicted risk >> undue prescription! Safety? Lloyd-Jones DM et al., Statins, risk assessment, and the new American prevention guidelines. Lancet. 2014
11 Event Event rate rate (%) (%) Discussion Risk overestimation in Czech Republic and Poland Vikhireva O et al., SCORE performance in Central and Eastern Europe and former Soviet Union: MONICA and HAPIEE results. Eur Heart J Observed events Expected Observed events events Expected events <5% 5-<7.5% 7.5-<10% 10% ASCVD risk group <1% 1-<5% 5-<10% 10% SCORE risk group
12 Discussion (II) Expected event rates were increased by % compared with the observed rates in three large-scale primary prevention cohorts, roughly doubling the actual observed risk; Possible explanation: the external validation cohorts are more contemporary than the original populations of the risk prediction algorithm, with improvements in healthcare Ridker PM et al., Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013
13 Discussion (III) New guidelines: 56 million Americans (48.6%) would be eligible for statin Net increase of 12.8 million potential new statin users (+11.1%) over the previous guidelines Increased sensivity but decreased specificity Pencina MJ et al., Application of new cholesterol guidelines to a population-based sample. N Engl J Med Europe: men years old at risk according to ACC/AHA criteria versus European recommendations 30 times more! Vaucher J et al., Population and economic impact of the 2013 ACC/AHA guidelines compared with European guidelines to prevent cardiovascular disease. Eur Heart J. 2014
14 Conclusion In a large real-life European cohort of patients under anti-dyslipidemic therapy: The predicted CV risks (SCORE and ASCVD) are superior to the actual event rate The 7.5% recommended cut-off point of the ASCVD calculator is extremely effective in discriminating highrisk subjects
15 References Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J Jul;33(13): Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al. ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis Jul;217(1):3-46. Goff DC, Jr., Lloyd-Jones DM, Bennett G, O'Donnell CJ, Coady S, Robinson J, et al ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology Nov 12. Yusuf S, Dagenais G, Pogue J, Bosch J, Sleight P. Vitamin E supplementation and cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med Jan 20;342(3): Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, et al ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology Nov 7. Vikhireva O, Pajak A, Broda G, Malyutina S, Tamosiunas A, Kubinova R, et al. SCORE performance in Central and Eastern Europe and former Soviet Union: MONICA and HAPIEE results. Eur Heart J Mar;35(9): Vaucher J, Marques-Vidal P, Preisig M, Waeber G, Vollenweider P. Population and economic impact of the 2013 ACC/AHA guidelines compared with European guidelines to prevent cardiovascular disease. Eur Heart J Feb 25. Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J Jun;24(11): Keaney JF, Jr., Curfman GD, Jarcho JA. A pragmatic view of the new cholesterol treatment guidelines. N Engl J Med Jan 16;370(3): Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet Nov 30;382(9907): Pencina MJ, Navar-Boggan AM, D'Agostino RB, Sr., Williams K, Neely B, Sniderman AD, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med Apr 10;370(15):
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