There are basically two paradigms when we’re thinking of cardiovascular disease prevention. One is to assess risk over the next 10 years using something like the Framingham risk score or similar scoring system (SCORE system in Europe) but whist this is a perfectly valid approach, it is an incomplete way to represent risk to our patients.
The other paradigm is to assess LIFETIME risk for a cardiovascular event. The results from the Cardiovascular Lifetime Risk Pooling Project, published in the January 26, 2012 issue of the New England Journal of Medicine, show that risk in people in their 40s or 50s with one or two risk factors such as hypertension or high atherogenic lipoproteins ramps up sharply over their lifetime. There is a very important disconnect between the short-term risk information that we routinely calculate and what we know, especially with this paper, are long-term risks that are dramatically higher.
Lifetime atherosclerotic vascular disease (ASCVD) risk at 50% compared to say 1.9% 10 year risk in a 42 yr man tends to grab people’s attention more. If I can tell you that, sure your 10-year risk may be low and not too different from the “God-given” ideal, but based on your profile right now, your lifetime risk is really high and 10 times higher risk of having a major heart attack or stroke (compared to 5% risk if no risk/ optimal risk factors). . . . I hope that’s a little more of a motivating message.
The above study analysed 18 cohort studies with 257 384 patients, including black and white men and women across a 50-year range of birth cohorts. The studies measured important cardiovascular risk factors at ages 45, 55, 65, and 75. The risk factors measured in the study included smoking, cholesterol levels, diabetes, and blood pressure. Calculation of lifetime risks of cardiovascular events shows that the presence of even one risk factor in middle age can dramatically increase one’s lifetime risk of cardiovascular disease compared with no risk factors (optimally managed risks to target goals), and the risk goes up exponentially with each additional risk factor.
Across the whole meta-analysis, participants with no risk factors at age 55 (total cholesterol level: < 180 mg/dL or 4.5 mmol/dL; blood pressure: <120 mm Hg systolic and 80 mm Hg diastolic; non-smoking; non-diabetic) had drastically better odds of avoiding death from cardiovascular disease through the age of 80 than participants with two or more major risk factors (4.7% vs. 29.6% among men and 6.4% vs. 20.5% among women).
People with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal myocardial infarction (3.6% vs. 37.5% among men, <1% vs. 18.3% among women) and fatal or nonfatal stroke (2.3% vs. 8.3% among men, 5.3% vs. 10.7% among women), compared with those with two or more risk factors.
The lifetime risk of death from cardiovascular disease and coronary heart disease or of nonfatal myocardial infarction were generally about twice as high among men than among women, but the lifetime risks of fatal and nonfatal stroke were similar for men and women.
It is Time to Address Risk Factors at an early Age
Our goal as preventative cardiologists is to get young adults living healthier lifestyles and more of them into middle age with optimum risk-factor levels which will transpose into an optimal lifetime risk of about 5% for men and 8% for women. On the flip side, if you are middle-aged and you do have a risk factor or two or more, it’s really time to address those and risk stratify to understand where your risk is coming from. It’s almost certainly going to require expert help to control those risk factors, but just as important is partnering lifestyle changes and perhaps pharmacology to get control of those risks. It’s a critically important partnership, but you can do a lot to mitigate those risks if you get serious about it.
If we can enable adults to avoid conventional cardiovascular risk factors in the first place vascular disease is entirely a preventable disease. We need to be more aggressive at fostering healthy lifestyles in young people. This paper indicates targeting young people should pay off in the long run, not just in less cardiovascular disease, but, by extrapolation, also in reduced overall health costs.
- Berry J, Dyer A, Cai X, et al. Lifetime risks of cardiovascular disease. N Engl J Med 2012 366:321-329.