New CVD Risk Tool Can Spur Even Earlier Talk About Prevention

A new risk calculator encompassing the full spectrum of cardiovascular, kidney, and metabolic risk factors can estimate both the 10- and 30-year risks of MI, stroke, and heart failure for a broad spectrum of patients even earlier than current tools allow.

The PREVENT equations, which can be used in patients as young as 30, modernize the American College of Cardiology (ACC)/American Heart Association (AHA) pooled cohort equations (PCE) for atherosclerotic cardiovascular disease (ASCVD) that are recommended by current guidelines to aid in the clinical decision-making process for primary prevention.

“The goal was to update the pooled cohort equations and actually expand upon that framework and be able to more comprehensively estimate risk,” Sadiya S. Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who presented the new tool at AHA 2023 Scientific Sessions, told TCTMD. In use for more than a decade now, the PCEs have faced some criticism related to their overestimation of risk in many patients.

Importantly, the new scientific statement, published in Circulation along with a methods paper, is not a guideline document. “We completely endorse the current guidelines in terms of their approach to risk assessment but feel like this could be something that future guidelines may consider,” said Khan.

Explaining CKM

Chiadi E. Ndumele, MD, PhD (Johns Hopkins University School of Medicine, Baltimore, MD), who spoke during AHA 2023 about the organization’s Cardiovascular-Kidney-Metabolic (CKM) health initiative, explained what CKM encompasses.

The newly coined term “reflects the fact that there are close connections among obesity, diabetes, chronic kidney disease, and the cardiovascular system,” he said during a press conference. “This construct involves those individuals both who are at risk for developing cardiovascular disease as well as those with existing cardiovascular disease where there are some unique treatment implications in the context of these conditions.”

Poor CKM health is strongly linked to premature mortality and often worsened by fragmented patient care, said Ndumele. It also disproportionately affects people who face more adverse social determinants of health.

To better address these issues, as well as the increasing burden of CKM syndrome, especially in younger adults, Khan said the PREVENT equations were developed with a different tack than before. First, she explained, they included heart failure because it is associated with significant morbidity and mortality and has seen “the most reversal of progress” of all the cardiovascular disease subtypes. They also added kidney function as a variable to the clinical calculator. 

But they removed race, which “is a social construct and not a biological predictor,” and added a social deprivation index, said Khan.

Another major change is PREVENT allows for risk assessment to begin when a patient is as young as 30 years old, 10 years earlier than the PCEs do. “They enable 10- and 30-year risk estimation to begin these conversations early and expand the time horizon with which we are discussing with our patients’ options for prevention,” Khan highlighted. “And importantly, this serves as a launching path to optimize CKM health across the life course.”

Generalizable, More Equitable

Khan and colleagues designed the PREVENT equations, which were derived and externally validated in 6,612,004 adults (mean age 53 years; 56% female) from almost 50 data sets, to be more generalizable to contemporary patients than the PCEs.

Over a mean follow-up period of 4.8 years, there were 211,515 incident total CVD events. The PREVENT equations were validated in both females and males, with C-statistics of 0.794 and 0.757, respectively. When the researchers limited their analysis to ASCVD- and heart failure-specific models, they saw similar estimates in discrimination and calibration.

An online calculator for PREVENT is in development, according to Khan, but the exact release date is unclear.

She hopes these risk equations will especially be valuable in calculating the expected benefit for therapies based on risk. “The amount of benefit of a specific therapy is directly related to that predicted risk,” Khan said. “This will really help us guide if and which therapies should be considered and allow us to move beyond statins as a solo approach for prevention. It's not a question of replacing statins, but 'statins and' when indicated.”

Khan sees the PREVENT equations as a bridge toward “prioritizing equity in CVD prevention.” Over time, she said, upstream social determinants drive disease burden. “As we think and move forward, . . . we can optimize CKM health for everyone in the US population.”

Most importantly, she said, the CVD prevention conversation needs to start earlier. “We have to focus on the lifestyle behaviors at the individual level that we can control,” Khan advised, plus keep in mind “measures at the structural and community and policy level that we need to modify to ensure that there are healthy environments for everyone to be able to make those behavior changes as well.”