A new way of predicting cardiovascular disease

A new calculator of cardiovascular risk may prove better in predicting who will most benefit from statins.

The new method, called PREVENT, developed by the American Heart Association (AHA), updates a set of calculations issued in 2013 by the American College of Cardiology and the AHA, and incorporates patient data on obesity, chronic kidney disease and diabetes factors. Excess weight, diabetes and kidney disease are associated with cardiovascular disease and death. For example, a person with chronic kidney disease is more apt to die from a cardiovascular event, such as a heart attack or stroke, than kidney failure, according to the AHA.

Falmouth cardiologist John C. Hostetter, MD, FACC, said that while the method is not widely used yet, “I think it’s an improvement.”

Among the changes, as described in a November 2023 article in Circulation, an AHA journal, PREVENT:

• Can be used starting at age 30, instead of 40.
• Can estimate risk 30 years into the future, not just 10.
• Drops race as a factor.
• Is sex-specific.
• Adds risk of heart failure.
• Adds BMI (body mass index, an indicator of excess body fat) and GFR (glomerular filtration rate, an indicator of kidney function).
• Allows additional metabolic measurements to be considered to further tailor results to individual patient concerns.

“The idea is to help us focus on people who really need treatment,” said Dr. Hostetter, who practices at Cape Cod Healthcare Cardiovascular Centers in Falmouth and Sandwich.

Among the options that can be incorporated into the PREVENT calculations are a patient’s A1C (blood sugar level indicator) level and amount of protein in their urine (elevated protein can indicate kidney problems), he said.

Benefits of Statins

Statins decrease blood levels of low-density lipoprotein (LDL or “bad”) cholesterol. Too much of this substance can lead to plaque forming on the inside walls of your arteries. Statins may also work to reduce inflammation in arteries that contribute to vessel blockages, according to the Centers for Disease Control and Prevention.

Dr. Hostetter stressed that the study was not an indictment of statins nor did it conclude that patients are being overtreated with the drug.

“Statins have been proven time and time again to reduce cardiovascular events,” he said.  About 5-7 percent of people do have side effects, which can lead them to be wary of the drug, “but this means that 90+ percent of people do very well with them,” he said.

The main advantage of the newer PREVENT risk score is “it uses a number of risk factors not previously incorporated into risk prediction that helps us fine-tune who may most benefit most from statins,” he added.

Can Lead to Further Treatment

Dr. Hostetter said PREVENT results and a patient’s personal and family health history may lead to further screening in some cases, such as:

• A blood test for biomarker lipoprotein (a), also called lp(a), a genetic heart disease risk factor.
• Calcium score determined by a cardiac artery calcium test (CAC test) done with a CT (computed tomography) scan without contrast. A higher score indicates more deposits and more severe disease.

Widespread adoption of the PREVENT risk calculations could reduce by half, or 14.3 million, the number of adult Americans recommended to take statins to lower cholesterol, by assigning them to lower risk categories, according to a study published July 29, 2024 in JAMA. Another 2.62 million would be considered as not needing medication for high blood pressure (hypertension). A small group would be shifted to higher risk categories.

Double the quantity of men than women, and more Black Americans than white, would be affected by the changes, according to the study, which looked at data from 7,765 adults 30-79 years old. On the downside, cutting who qualifies for medical treatment could lead to an estimated 107,000 extra cases of heart attack or stroke over 10 years, the study authors wrote.

Moderate blood cholesterol levels can be lowered with exercise and a healthy diet, such as the Mediterranean diet, in addition to taking a statin, Dr. Hostetter said.

“We certainly are not just treating with pills,” he said.

People with moderate risk may be treated with lower doses of statins, including Lipitor (atorvastatin), Crestor (rosuvastatin), Zocor (simvastatin) and Pravachol (pravastatin), with the aim of lowering LDL levels 30-50 percent, he said. Those at higher risk may be prescribed higher amounts of stronger statins, such as Crestor and Lipitor, with a goal of reducing LDL levels by half.

Dr. Hostetter reiterated that statins have been used for decades and are safe.

“Probably no class of medicines have been studied as much as statins,” he said. Yet “25-40 percent who should be on statins decline it.”

Usually, patients say they’re worried about possible side effects, most often muscle pain, which can be resolved by switching to another statin or lowering the dose.

Patients cite other possible side effects as reasons to avoid statins (liver damage, increased glucose levels, cognition problems, weight gain) but “the benefits outweigh the risks,” he said.

His answer to patient worries about starting a statin?

“A good discussion.”