Majority of US Adults Have High Long-term Risk of CVD: NHANES

One in five US adults are at an increased risk of atherosclerotic cardiovascular disease (ASCVD) over the next decade and the majority are at a heightened risk over the next 30 years, according to a new analysis.

The findings highlight the need for “intensive public health efforts” to improve the cardiometabolic risk profile of Americans and to prevent future CVD, according to investigators.

“The long-term perspective is important here because what we would like to do ideally is prevent cardiovascular disease and prevent development of risk factors for cardiovascular disease,” lead investigator Kamil F. Faridi, MD (Yale School of Medicine, New Haven, CT), told TCTMD. “So, either preventing the disease itself from manifesting or delaying it as long as possible. When you look at the US population, when you calculate their 30-year risk, we see that the vast majority of people will have high risks and that‘s really the time to act by controlling or managing these risk factors.”

The study, published this week in JACC, includes 14,184 participants ages 30 to 79 years, representing more than 160 million US adults, enrolled in the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2020. Estimated risks were calculated using the PREVENT equations, which were developed as an update to the pooled-cohort equations recommended by current guidelines to aid in clinical decision-making for primary prevention.

PREVENT includes a spectrum of cardiovascular, kidney, and metabolic risk factors and can estimate both the 10- and 30-year risks of MI, stroke, and heart failure (HF) in patients as young as 30 years old.

“We felt this was a great opportunity to take these equations, which are based on commonly measured metrics in the clinic—common risk factors—and look at the US population as a whole and predict the risk of cardiovascular disease, both in 10-year and 30-year time horizons for the entire population,” said Faridi.

CVD Risk Increases with Age

The 10-year risks of total CVD, ASCVD, and HF were 5.6%, 3.5%, and 3.3%, respectively. A little more than 20% of US adults ages 30 to 79 years had a 10-year risk of total CVD (ASCVD and HF) of 7.5% or higher, the threshold to define elevated risk. Coupled with those with existing disease, which was 9.6%, roughly 30% of US adults either have CVD or are at high risk for developing it.  

In men and women, the prevalence of elevated risk was 23.1% and 17.1%, respectively, and 11.2% and 8.2% of men and women had existing CVD. More than 24% of non-Hispanic Black participants had an elevated risk of CVD, a prevalence that was similarly high in Hispanic individuals (23.3%). In the oldest cohort (65 to 79 years), 66.2% of all adults had an increased risk of CVD over the next 10 years while 26.8% had existing CVD. Less than 7.0% of this older cohort had a 10-year risk of total CVD less than 7.5%.  

“One of the most notable things is how risk increases with age,” said Faridi. “This is something we already know. For any risk calculator, age predominantly drives the risk because age is the single biggest risk factor for cardiovascular disease, in general, but we do see the risks change in different age groups.”

Over the longer term, 66.7% of adults ages 30 to 59 years had an elevated 30-year risk of total CVD. In men, more than three-quarters were considered to have a heightened risk of disease over 30 years compared with 56.2% of women. Roughly two-thirds of non-Hispanic Black participants in NHANES had a 30-year risk of 7.5% or higher and 8.0% had preexisting CVD.

In younger adults (30 to 44 years), 42.5% were estimated to be at increased risk of CVD over 30 years, with the prevalence of elevated risk much higher in younger men than women (59.9% vs 23.2%). In those ages 45 to 59 years, nearly 90% of NHANES participants were estimated to be at high risk of CVD over 30 years.    

To TCTMD, Faridi said that most adults younger than 60 years would have a low 10-year risk of CVD, but the reverse is true when looking over the 30-year horizon. “If you look at adults under 60, two-thirds have an elevated 30-year risk.”

Racial Disparities

Focusing on the 30-year timeline is critical so that physicians can get patients to make lifestyle changes early in life to prevent CVD developing (or delay its onset), said Faridi. The promotion and adoption of Life’s Essential 8, which was put forward by the American Heart Association to promote a healthy lifestyle and awareness around risk factors, is one way to stem the rising prevalence of CVD. This program could be taught in schools from a young age, Faridi suggested.

Like in other studies, the researchers also found significant racial disparities in risk. Black adults had higher rates of preexisting CVD and both Black and Hispanic adults had higher 10-year risks for CVD, ASCVD, and HF, and higher risks for ASCVD over 30 years, compared with white participants. Black adults were at a particularly increased risk for HF over 10 and 30 years, say researchers, a risk likely attributable to the high burden of hypertension, obesity, and chronic kidney disease in this population.

The disparities are important because the PREVENT equations do not include race/ethnicity as a predictor of risk, meaning the increased risk seen in Black and Hispanic adults is attributable to modifiable CVD risk factors. In these groups, there are many barriers to accessing care or addressing risk factors and strategies are needed to “help break through to these communities so that we can identify and manage these risk factors as early in life as we can,” said Faridi.

In an editorial, Sadiya Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who led the development of the PREVENT risk equations, said the introduction of 30-year risk estimates raises some important issues. For one, what threshold should be considered for “increased” CVD risks? And which prevention efforts—lifestyle or pharmacotherapy—should be recommended for those at increased risk? Additionally, do prevention efforts vary for those with increased risk of ASCVD versus those with HF? Finally, there are questions about how to best incorporate information about lipoprotein(a) and polygenic risk scores into estimates of lifetime risk.

“To affect long-term population health, a road map for the prevention of CVD across the life course is needed with an emphasis on primordial and primary prevention in young adults,” Khan writes. “Ultimately, clinicians, patients, and policymakers should consider this long-term view for optimizing prevention of CVD with use of the accurate and precise long-term risk tools we now have available.”