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Should the first priority in cardiovascular risk management be those with prior cardiovascular disease?
1School of Population Health, University of Auckland, Auckland, New Zealand. a.kerr@auckland.ac.nz
Insights
Patients with prior cardiovascular disease (CVD) have significantly higher CVD event risks than predicted. Intensive preventive management is crucial for these high-risk individuals.
Area of Science:
- Cardiology
- Preventive Medicine
- Public Health
Background:
- Current cardiovascular disease (CVD) prevention guidelines often categorize patients based on prior CVD history.
- This practice assumes individuals with a history of CVD are at high risk, irrespective of other risk factors.
Purpose of the Study:
- To evaluate the clinical appropriateness of dichotomizing patients by prior CVD history.
- To compare CVD event rates in patients with and without prior CVD, beyond standard risk factor predictions.
Main Methods:
- Utilized a web-based Framingham risk prediction algorithm for CVD risk assessments in primary care (2002-2007).
- Linked individual risk profiles to national hospitalization and death records.
- Compared observed CVD risks against Framingham predictions for patients with and without prior CVD.
Main Results:
- Analyzed 35,760 patients, with 10.4% having prior CVD.
- 42% of 1216 first CVD events occurred in patients with prior CVD.
- Observed CVD risk in patients with prior CVD ranged from 21.7% (low Framingham risk) to 49% (high Framingham risk), significantly exceeding predictions.
Conclusions:
- Patients with prior CVD exhibit approximately 20% higher absolute five-year CVD risks than those without, even after accounting for standard risk factors.
- Nearly half of all CVD events occurred in patients with a history of CVD.
- Prioritizing intensive preventive management for patients with prior CVD in primary care is strongly recommended.
Background:
Cardiovascular disease (CVD) prevention guidelines typically dichotomise patients by history of CVD, as patients with prior CVD are assumed to be at high CVD risk, whatever their CVD risk profiles.
Objective:
To assess the appropriateness of this practice by comparing CVD event rates of patients with and without prior CVD, over and above risk predicted by standard CVD risk factors.
Methods:
Between 2002 and 2007 CVD risk assessments were generated using a web-based Framingham risk prediction algorithm in routine primary care. Individual risk profiles were subsequently linked to national hospitalisation and death records. Observed and predicted (Framingham) CVD risk were compared in patients with and without prior CVD.
Results:
35 760 patients were assessed including 10.4% with prior CVD. Of 1216 first CVD events during an average follow-up of 2.05 years, 42% occurred in those with prior CVD. Among those without prior CVD, the predicted Framingham five-year CVD risk was similar to the observed risk extrapolated to five years; in the highest Framingham risk band (>20% five-year risk), observed risk was 25.3%. Among those with prior CVD the observed risk extrapolated to five years rose from 21.7% in the lowest Framingham risk band (<5%) to 49% in the highest (>20%).
Conclusions:
Patients with prior CVD have five-year CVD risks approximately 20% higher, in absolute terms than patients without prior CVD, after accounting for standard risk factors. Almost half the CVD events occurred in those with prior CVD. These patients should be the highest priority for intensive preventive management in primary care.
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