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Projected Changes in Statin and Antihypertensive Therapy Eligibility With the AHA PREVENT Cardiovascular Risk
James A Diao1,2, Ivy Shi1,3, Venkatesh L Murthy4
1Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts.
Insights
The new PREVENT equations may lower atherosclerotic cardiovascular disease (ASCVD) risk scores for millions, potentially reducing statin and antihypertensive therapy eligibility. This shift could lead to an estimated 107,000 additional heart attacks or strokes over 10 years.
Area of Science:
- Cardiovascular Medicine
- Public Health
- Epidemiology
Background:
- Current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines use Pooled Cohort Equations (PCEs) for atherosclerotic cardiovascular disease (ASCVD) risk estimation.
- The new Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations offer improved calibration and incorporate kidney measures, removing race as a factor.
- PREVENT equations yield lower ASCVD risk predictions than PCEs, necessitating an evaluation of their clinical impact.
Purpose of the Study:
- To quantify the impact of applying PREVENT equations on US adults' risk categorization and treatment eligibility based on current ACC/AHA guidelines.
- To estimate changes in eligibility for statin and antihypertensive therapies.
- To project potential alterations in clinical outcomes like myocardial infarction and stroke.
Main Methods:
- Analysis of a nationally representative sample of 7765 US adults aged 30-79 from the National Health and Nutrition Examination Surveys (2011-2020).
- Comparison of ASCVD risk predictions, risk categories, and treatment eligibility using both PREVENT and PCE equations.
- Estimation of projected myocardial infarction and stroke occurrences based on treatment eligibility changes.
Main Results:
- The PREVENT equations reclassified 53.0% of adults to lower ASCVD risk categories, with only 0.41% moved to higher categories.
- An estimated 14.3 million fewer adults would be eligible for statin therapy and 2.62 million fewer for antihypertensive therapy.
- These reductions in treatment eligibility could result in approximately 107,000 additional myocardial infarctions or strokes over 10 years, disproportionately affecting men and Black adults.
Conclusions:
- Applying PREVENT equations with existing ACC/AHA treatment thresholds could decrease statin and antihypertensive therapy eligibility for 15.8 million US adults.
- The findings highlight potential significant clinical implications of adopting the PREVENT equations, including an increased risk of major adverse cardiovascular events.
- Further research is warranted to refine risk prediction models and ensure optimal patient care in light of evolving ASCVD risk assessment tools.
Importance:
Since 2013, the American College of Cardiology (ACC) and American Heart Association (AHA) have recommended the pooled cohort equations (PCEs) for estimating the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). An AHA scientific advisory group recently developed the Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations, which incorporated kidney measures, removed race as an input, and improved calibration in contemporary populations. PREVENT is known to produce ASCVD risk predictions that are lower than those produced by the PCEs, but the potential clinical implications have not been quantified.
Objective:
To estimate the number of US adults who would experience changes in risk categorization, treatment eligibility, or clinical outcomes when applying PREVENT equations to existing ACC and AHA guidelines.
Design, Setting, And Participants:
Nationally representative cross-sectional sample of 7765 US adults aged 30 to 79 years who participated in the National Health and Nutrition Examination Surveys of 2011 to March 2020, which had response rates ranging from 47% to 70%.
Main Outcomes And Measures:
Differences in predicted 10-year ASCVD risk, ACC and AHA risk categorization, eligibility for statin or antihypertensive therapy, and projected occurrences of myocardial infarction or stroke.
Results:
In a nationally representative sample of 7765 US adults aged 30 to 79 years (median age, 53 years; 51.3% women), it was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories (53.0% [95% CI, 51.2%-54.8%]) and very few US adults to higher risk categories (0.41% [95% CI, 0.25%-0.62%]). The number of US adults receiving or recommended for preventive treatment would decrease by an estimated 14.3 million (95% CI, 12.6 million-15.9 million) for statin therapy and 2.62 million (95% CI, 2.02 million-3.21 million) for antihypertensive therapy. The study estimated that, over 10 years, these decreases in treatment eligibility could result in 107 000 additional occurrences of myocardial infarction or stroke. Eligibility changes would affect twice as many men as women and a greater proportion of Black adults than White adults.
Conclusion And Relevance:
By assigning lower ASCVD risk predictions, application of the PREVENT equations to existing treatment thresholds could reduce eligibility for statin and antihypertensive therapy among 15.8 million US adults.
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