Previewing 30-Year ASCVD Risk May Open Door to Earlier Treatment

Taking into account estimated 30-year risk of atherosclerotic cardiovascular disease (ASCVD) enables clinicians to identify which patients may benefit from starting primary-prevention strategies earlier despite having a low 10-year risk of events, according to new data.

Among more than 3,000 adults between 30 and 59 years without known ASCVD, the mean estimated 10-year risk of ASCVD was only 2.0% in the study, whereas the 30-year estimated risk was 9.7% based on the PREVENT equations. Fewer than one-third of those with elevated long-term risk were on statins even though most had high blood pressure, obesity, and high cholesterol.

How receptive patients are to being treated according to their 30-year risk can vary, however.

“Many of us naturally are always thinking about, to some extent, short-term [risk] but also what’s the pressing next step,” lead investigator Timothy Anderson, MD (University of Pittsburgh, PA), told TCTMD. “For folks, for example, who have multimorbidity and multiple active medical issues, that may not be the right mindset because they’re really thinking about how [to] deal with the things that are going on now.”

Generally healthy patients in their thirties and forties who start to notice declines in fitness, though, “are sometimes the folks who are really receptive to thinking about short-term but also long-term risks,” he continued. “Part of that has to do with what we think about doing in response to those risks. There may be different openness to, for example, exercise and dietary suggestions than medications.”

Commenting on the findings for TCTMD, Andrew Foy, MD (Beebe Healthcare, Lewes, DE), said that while some patients might be receptive to learning about their 30-year ASCVD risk, it would likely be the “minority.” Even then, it’s “hard to conceptualize” risk that far ahead, especially because it’s not necessarily fixed, he added. “There’s so much that can happen over 30 years that it’s almost too much for people to really comprehend.”

Some might be inclined to make lifestyle changes, but it’s unlikely to sway many toward medical therapy, Foy said. “I spend every day treating patients in the office. More often than not, the conversations that are being had are: ‘Can I stop medicines?’ and ‘Do I need to be started on them?’”

Differences by Age

For the analysis, published online last week in Circulation: Population Health and Outcomes, the researchers included 3,229 adults without ASCVD (mean age 44.6 years; 49.8% women) from the National Health and Nutrition Examination Survey between 2017 and 2020 who were representative of 101.9 million Americans.

Mean 30-year ASCVD risk according to PREVENT was higher in men compared with women (11.5% vs 7.9%) and increased with age—only 0.4% of those aged 30 to 39 years had a high risk compared with 20.3% of adults aged between 50 and 59 years. While there were no differences observed by race or ethnicity, diabetic patients were more likely to have a higher long-term risk than those without diabetes (21.2% vs 8.4%).

Among the 9% of the total population with high estimated 30-year ASCVD risk, only 32.4% reported taking statins. Additionally, 70.8% reported elevated blood pressure, 59.9% were obese, 31.1% were smokers, 31.4% had elevated hemoglobin A1c, and 56.2% had elevated total cholesterol.

Almost all participants with low 10-year but high 30-year ASCVD risk had at least two uncontrolled modifiable risk factors, including 68.8% with elevated BP, 51.8% with diabetes, and 48.7% with elevated cholesterol.

Researchers estimated that offering statins to all adults aged 30-59 years with a 30-year ASCVD risk of at least 20% would affect 2.5 million people for whom current guidelines don’t currently recommend the drugs, resulting in a number needed to treat of 78.3 to prevent one event over 10 years.

Foy called the estimations used to show the potential impact of expanding statin use in this study “problematic” as events won’t consistently occur over the 30 years but rather at some unknown point down the line.

“When they start to really accumulate, you just don’t know how many of those people would meet criteria to be treated with statins at that time,” he said. “Then you don’t know if just starting statins later when the 10-year risk increases would be enough to essentially reduce all of these events or most of these events. That’s, to me, the assumption that I really don’t think we have an answer to.”

Not a Perfect Tool

Anderson said that while age is a big factor in risk prediction, the data still have implications for younger patients. That said, “the vast majority of people who fall into this ‘low short-term risk, high long-term risk’ [category] are on the older edge of that spectrum,” he added.

This means that for patients in their fifties, tools like PREVENT can help “nudge people who are on the borderline for medication recommendations in terms of preventative therapies and for really pushing people into gear around diet and exercise,” Anderson said. For younger adults, it would be instead helpful to check in with this type of risk prediction every 5 years or so, because it’s not likely to “dramatically shift” clinical thinking unless there’s high cholesterol or blood pressure that needs immediate care.

PREVENT isn’t a perfect tool, according to Anderson. “It’s important for clinicians to really feel comfortable in being able to explain to people that population risk is not their individual risk,” he said. “These are in a way projections and best guesses, and they don’t include every single factor that might help us estimate someone’s risk” including family history, biomarkers, or other chronic conditions.

“They are a starting point for conversations,” Anderson continued. “We’re not just saying: ‘Tell somebody they have a 20% chance of having a heart attack in 20 years.’ [That’s] not a particularly a useful way to phrase things.” On the flip side, he added, “everybody has some risk, you can’t make it be zero.”

At the end of the day, “all of this has to be personalized, both to the biology and also to people’s preferences,” Anderson said.

Even 10-year risk was a tricky concept for clinicians and patients to become comfortable with, so it’ll take time for 30-year risk to become embedded within the realm of primary prevention if studies continue to show its importance, he said. Further research will be needed to see how physicians use the 30-year risk estimate and whether it actually is beneficial for patients.

Both Anderson and Foy said they’d like to see longer-term research on how primary prevention with lipid-lowering therapies might affect outcomes, though these trials would need large populations that might be difficult to enroll.

“We make a lot of extrapolations, frankly, even still based on what we know from clinical trials in secondary prevention and in older patients, and we’re just assuming that it’s all going be good just with maybe a smaller effect size if we apply it to younger people,” Foy said. “There could potentially be problems with that.”