CVD Risk Assessment and Prevention in 2019 and Beyond: How, When, and Why? Donald M. Lloyd‐Jones, MD ScM FACC FAHA Eileen M. Foell Professor Chair, Dept. of Preventive Medicine Senior Associate Dean Director, NUCATS Institute Northwestern Feinberg School of Medicine Disclosures • Dr. Lloyd‐Jones has no RWI/COI Grant funding: NIH, CMS, AHA • Members of the 2018 Cholesterol Guidelines and 2019 Primary Prevention Guidelines Panels had no RWI/COI
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CVD Risk Assessment and Prevention in 2019and Beyond: How, When, and Why?Donald M. Lloyd‐Jones, MD ScM FACC FAHAEileen M. Foell ProfessorChair, Dept. of Preventive MedicineSenior Associate DeanDirector, NUCATS InstituteNorthwestern Feinberg School of Medicine
Disclosures
•Dr. Lloyd‐Jones has no RWI/COIGrant funding: NIH, CMS, AHA
•Members of the 2018 Cholesterol Guidelines and 2019 Primary Prevention Guidelines Panels had no RWI/COI
Case
52‐year‐old South Asian male presents for routine follow‐up
Question #1: According to the 2018 ACC/AHA cholesterol and 2019 primary prevention guidelines, which risk category is most applicable for this patient?
A. Low risk primary preventionB. Borderline risk primary preventionC. Intermediate risk primary preventionD. High risk primary prevention
Case
Question #2: According to the 2018 ACC/AHA cholesterol and 2019 primary prevention guidelines, which initial treatment strategy should be considered for this patient?
•Rationale and evidence base for quantitative risk assessment
•Current guideline recommendations
•Strengths/limitations of existing risk scores
•Refining risk estimates for individual patients
Clinician‐patient discussionRisk‐enhancing factorsMeasurement of CAC
• Implementing risk assessment and shared decision making –practical approaches
Lloyd‐Jones et al. Circulation 2019; JACC 2019
Cholesterol Treatment Trialists
Blood Pressure Lowering
Treatment Trialists
•Allows identification of patients at sufficient risk to merit treatment with higher likelihood of net individual and societal benefit
•Allows direct comparison of potential benefits and harms from drug therapy
CTT, Lancet 2012BPLTTC, Lancet 2014Lloyd‐Jones et al., Circ and JACC 2018
Rationale for Absolute Risk Estimation
Karmali et al., Cochrane Reviews 2017Lloyd‐Jones et al., Circ and JACC 2018
Evidence Base for Risk Estimation
• Providing CVD risk score data had
statistically significant but
modest effects on:
• Initiation/intensification of BP and cholesterol medications
• Levels of CVD risk factors
• Estimated 10‐year CVD risk at follow‐up
• Harm very unlikely
• Use of validated, quantitative risk assessment scores appears to be appropriate, safe, and moderately efficacious in helping to control risk factors … with the potential for additional value to improve decision‐making
Approach to Risk Assessment in 1o PreventionEstimate Absolute 10‐year ASCVD Risk
Low Risk0 ‐ <5%
High Risk≥20%
Intermediate Risk 7.5% ‐ <20%
If uncertainty or patient indecision remains, consider CAC score
and revise decision based on results
Lifestyleand drug therapy
Lifestylemodification
Borderline Risk 5% ‐ <7.5%
Clinician‐patient discussion considering risk‐enhancing factors and net benefit of therapy
Calculate
Personalize
Reclassify
C= Calculate: Use Pooled Cohort Equations for ASCVD Risk Estimation
•Recommended for use based on: Broad utilization and desired endpoint of hard ASCVD Most widely validated score in contemporary US populations
• SR identified 23 manuscripts evaluating PCE in diverse populations
PCE are well calibrated near decision thresholds (e.g., 7.5% 10‐year risk) in broad US clinical population
As with all risk scores, PCE can under‐ and over‐estimate true risk in some subgroups Reclassification by CAC well understood
•New recommendations ‐ Deploy PCE with: Expanded clinician‐patient discussion with consideration of risk‐enhancing factors Judicious use of CAC measurement in intermediate risk and selected borderline risk patients to reclassify risk
Performance of Pooled Cohort Equations in Diverse Population Samples: Predictable
‐Over‐EstimateRisk
Under‐Under‐EstimateRisk
Low SES, HIV,Inflammatory dz
High SES,engaged patients
Broad USClinical
Population
Reasonable Calibration
Clinician-Patient Discussion
Estimated 10-y ASCVD Risk
C = Calculate: Tools for Risk Estimation
•Pooled Cohort Equations – App or Online (or EHR programmable)
•ACC ASCVD Risk Estimator Plus (online/app) http://tools.acc.org/ASCVD‐Risk‐Estimator‐Plus/#!/calculate/estimate/
If uncertainty or patient indecision remains, consider CAC score
and revise decision based on results
Lifestyleand drug therapy
Lifestylemodification
Borderline Risk 5% ‐ <7.5%
Clinician‐patient discussion considering risk‐enhancing factors and net benefit of therapy
R = Reclassify Risk in Selected Patients
10‐year risk 5% ‐ <7.5% or 7.5% ‐ <20%
Below Threshold for Statin BenefitConsider avoiding or
postponing drug therapy.*
Above Threshold for Statin Benefit Recommend statin therapy.
Consider CAC measurement If performed:
Engage patient in discussion regarding net benefit of statin
therapy
CAC = 0
Decision for No Drug Therapy
Decision for Drug Therapy
CAC 1 – 99 and <75th
%ile for age/sex raceCAC ≥ 100 or ≥75th
%ile for age/sex/race
Subclinical atherosclerosis present; risk estimate similar. Repeat clinician‐patient discussion with new information. Consider statin therapy now or postpone
statin and consider repeat CAC in 5 years
Decision
Patient Undecided or Clinical Uncertainty Regarding Net Benefit of Statin Therapy
See ACC/AHA 2018 Guideline for Cholesterol Management
Consider risk‐enhancing factors
*Clinicians and patients may not wish to postpone therapy in patients with a CAC score of 0 and diabetes mellitus, heavy current cigarette smoking, or strong family history of premature ASCVD.
R = Reclassify Risk in Selected Patients
Nasir et al., MESA Study, JACC 2015
Example: MESA Study
7.5% 10‐year riskThreshold for considering statin
Reclassification of Risk by CAC
Nasir et al., MESA Study, JACC 2015
Example: MESA Study
Reclassification of Risk by CAC
Identifies pts with event ratesbelow net statin benefit range
Nasir et al., MESA Study, JACC 2015
Example: MESA Study
Reclassification of Risk by CAC
Approach to Risk Assessment in 1o Prevention: CPREstimate Absolute 10‐year ASCVD Risk
Low Risk0 ‐ <5%
High Risk≥20%
Intermediate Risk 7.5% ‐ <20%
If uncertainty or patient indecision remains, consider CAC score
and revise decision based on results
Lifestyleand drug therapy
Lifestylemodification
Borderline Risk 5% ‐ <7.5%
Clinician‐patient discussion considering risk‐enhancing factors and net benefit of therapy
Calculate
Personalize
Reclassify
Perform CPR …Then Treat Accordingly
•Risk‐based and risk‐enhanced algorithm for selecting patients considered for treatment with statins in primary prevention likely to lead to better decisions and greater patient satisfaction/adherence
•This CPR now or that CPR later
Step Resources and Tools
Estimating 10‐year and lifetime
risks for ASCVD
Many EHRs can calculate 10‐y ASCVD risk automatically ACC ASCVD Risk Estimator Plus AHA ASCVD Risk Calculator
Clinician‐patient discussion
ACC ASCVD Risk Estimator Plus
Mayo Clinic Shared Decision Making Cardiovascular Primary Prevention Choice
After the clinician‐patient discussion, the patient is hesitant to initiate statin therapy based on the information discussed.
According to the 2018 ACC/AHA cholesterol guideline, what else may be done to assess this patient’s risk and aid in decision making?
2018 ACC/AHA cholesterol guideline
Summary• 10‐year and lifetime risk estimates can assist with decision making regarding intensity of prevention efforts
• These data start the discussion, they do not prescribe a drug• When applying risk scores to individual patients, in the context of a clinician‐patient discussion, consider personalized risk‐enhancing factors
• If clinical uncertainty or patient indecision remain, consider CAC measurement in intermediate risk and selected borderline risk patients
• CAC=0 can meaningfully down‐classify risk; statin avoidance reasonable
• CAC 1‐99 and <75th %ile for age/sex/race does not meaningfully reclassify risk; use clinical judgment
• CAC ≥100 or ≥75th %ile for age/sex/race can meaningfully up‐classify risk; confirms likely statin benefit
Take Home Points
•Treatment strategy should match ASCVD risk•With primary prevention + 10‐yr ASCVD risk 5 ‐ <20%, consider ASCVD risk enhancers
•Use clinician‐patient shared decision making to determine treatment strategy
•With uncertain treatment decision for 10‐yr ASCVD risk ≥7.5 ‐ <20%, may use a CAC score in the risk assessment and treatment decision