New CVD risk calculator could end statin therapy eligibility for millions of heart patients
A new risk calculator for predicting a patient’s long-term risk of heart attack, stroke or heart failure could result in millions of patients no longer being eligible for preventive therapy, according to a new analysis published in JAMA.[1] In fact, researchers estimated that the updated prediction model could result in more than 100,000 additional heart attacks and strokes in the next 10 years alone—if current guidelines for statin and blood pressure therapies are not also adjusted, that is.
The American Heart Association (AHA) introduced its PREVENT calculator in November 2023, describing it as an updated tool for calculating how likely patients are to develop cardiovascular disease (CVD). PREVENT was different from previous risk calculators in multiple ways; it featured an increased focus on sex-specific data, incorporated different variables such as kidney function and left race completely out of the equation. It was also designed to evaluate younger patients than previous risk calculators, covering anyone between the ages of 30 and 79 years old.
However, the AHA and American College of Cardiology (ACC) have not yet updated their own treatment guidelines to match the new risk calculator—and cardiologists who move forward with PREVENT could suddenly find that many patients are no longer eligible for statin therapy or other treatments.
“The takeaway from our study is that updating risk estimation without reconsidering treatment thresholds has the potential to change recommended care for millions of Americans,” said first author James Diao, MD, a resident physician at Brigham and Women’s Hospital, said in a statement.
“At its core, cardiovascular disease prevention has two elements—predicting risk and choosing when to treat in order to prevent a heart attack or a stroke, so I would be concerned if we only change one side of this equation without reexamining the other side, which is the treatment threshold,” added senior author Raj Manrai, PhD, an assistant professor of biomedical informatics in the Blavatnik Institute at Harvard Medical School.
Diao, Manrai, et al. examined data from more than 7,700 U.S. patients between the ages of 30 and 79 years old. All patients participated in the National Health and Nutrition Examination Survey from 2011 to 2020. The researchers used the pooled cohort equations (PCEs) that were previously used to predict long-term CVD risk to evaluate each patient—and then used PREVENT to evaluate those same patients, comparing the different outcomes.
Overall, compared to the PCEs, PREVENT reclassified nearly half of U.S. adults to lower AHA/ACC risk categories. Less than 0.5% of patients, meanwhile, were reclassified with higher AHA/ACC risk categories. This resulted in more than 14 million people who would no longer qualify for statin therapy—and another 2.6 million who would no longer qualify for antihypertensive therapy.
The group noted that these significant changes in eligibility “carry the potential for both benefit and harm.” For example, reduced statin eligibility could potentially lead to worse cholesterol management in a large number of adults—but it could also help avoid overtreatment, which has been linked to an increased diabetes risk. This “trade-off” is seen in the fact that PREVENT could lead to an estimated 107,000 additional heart attacks or strokes in the next decade—but it could also result in nearly 58,000 fewer cases of new-onset diabetes.
Ultimately, the researchers highlighted the importance of physicians sitting down with their patients to make care decisions instead of simply typing figures into an equation.
“The sort of nuanced decision-making that needs to occur at the physician’s office means that after a careful conversation, two people with the same estimated level of risk might end up on different treatment regimens,” Manrai said. “And that’s a good thing.”
Read the full analysis here.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.