A new scientific statement breaks down the rationale behind the recent shift in risk assessment for primary prevention.
With the latest US guidelines for blood pressure management being the first to recommend using the novel PREVENT calculator to assess patient risk, the American Heart Association (AHA) and American College of Cardiology (ACC) are offering practical tips for clinicians.
In a scientific statement published online today in both JACC and Circulation, the groups review the research that led to the new 7.5% threshold of 10-year risk of all cardiovascular disease—not just atherosclerotic cardiovascular disease (ASCVD) but also heart failure—as well as the clinical implications of these revised recommendations on a population level.
PREVENT, which now supplants the pooled cohort equations (PCE) for ASCVD in the guidelines, can be used in patients as young as 30 years old. It encompasses the full spectrum of cardiovascular, kidney, and metabolic risk factors while being able to predict both the 10- and 30-year risks of MI, stroke, and heart failure. Prior research has shown that the patient population who could benefit from statins might shift using the PREVENT risk calculators.
“The most important highlight is that [the statement] tried to address any concerns that fewer people would be treated because of using the PREVENT equations,” Sadiya S. Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who chaired the statement, told TCTMD. “When it came out without having a threshold [for treatment], it was hard to interpret how it could get applied.”
Further, “the yin and yang” of any risk-prediction model is not only understanding the distribution of risk but also how to use it clinically, she continued. “What do you do and when?”
Embracing PREVENT means “we need new thresholds, and we now have that for blood pressure,” Khan said, adding that a fresh round of US cholesterol guidelines are also coming soon. “So, we’re not undertreating people or overtreating people.”
Rather, the guidelines better ensure “the right people” are receiving treatment, Khan explained.
‘Multipronged Approach’
The AHA/ACA statement provides an algorithm for when to initiate treatment based on several factors. For stage 2 hypertension (≥ 140/90 mm Hg), no risk assessment is needed to support treatment, and “people are pretty comfortable with that,” Khan said.
However, for stage 1 hypertension (130-139 or 80-89 mm Hg), a big change in the recent guidelines was support for treatment initiation in those who have diabetes or chronic kidney disease. “We’re not saying: ‘Wait until your risk gets high,’ but honestly, most people in those categories are at higher risk,” she said. “So, [they should] get treated. There’s good clinical trial data for that.”
The third cohort facing change are those with stage 1 hypertension, who the guidelines recommend starting treatment if the 10-year CVD risk is at least 7.5% according to PREVENT.
“We all know and kind of appreciate that if you leave somebody who has 130-139 untreated most of the time, even just with aging, we’ll see it go up,” Khan explained. “So we just don’t want to wait to have that exposure accumulate over time.”
How do we get the risk estimation in clinic and how do we communicate it in a way that resonates with patients and not as a one-size-fits-all approach? Sadiya S. Khan
According to the statement, “optimal implementation” of the latest BP “recommendations by clinicians, health systems, and public health initiatives would generate substantial momentum toward eliminating the increasing population burden and costs of heart disease, stroke, and non-CVD morbidity (eg, dementia) attributable to hypertension.”
Altogether, the guidelines endorse better continuity of care, given that clinicians will need to ensure they are monitoring when to initiate treatment based on PREVENT or if a patient shifts to stage 2 hypertension, Khan said. “What we’re doing when we see someone again is we’re not starting over and then saying: ‘Let’s reassess your risk.’ What we really want to see is, did it get better with lifestyle changes or not?”
Going forward, she’d like to see more work focused on how to better incorporate PREVENT into electronic medical records as well as how artificial intelligence might be able to help with implementation. Another open question relates to how to better conceptualize ways to communicate risk, both to clinicians and to patients.
“The most important things are: how do we get the risk estimation in clinic and how do we communicate it in a way that resonates with patients and not as a one-size-fits-all approach?” Khan said, adding that absolute risk numbers might work for some but not others. PREVENT is “a way to help us figure out how do we identify who are most likely to benefit from treatment. And then we have to help convey that to patients in a way that helps them understand.”