Clinical Prediction Guide

ACC/AHA, Adult Treatment Panel III, and ESC guidelines overestimated risk for CVD in older adults

Kavousi M, Leening MJ, Nanchen D, et al. Comparison of application of the ACC/AHA guidelines, Adult Treatment Panel III guidelines, and European Society of Cardiology guidelines for cardiovascular disease prevention in a European cohort. JAMA. 2014;311:1416-23.

Clinical impact ratings: F ★★★★★★✩ C ★★★★★✩✩ Question

Conclusion

In adults aged ≥ 55 years, how do the American College of Cardiology/American Heart Association (ACC/AHA), Adult Treatment Panel III (ATP-III), and European Society of Cardiology (ESC) guidelines compare for predicting cardiovascular disease (CVD)?

In adults aged ≥ 55 years, the American College of Cardiology/ American Heart Association, Adult Treatment Panel III, and European Society of Cardiology guidelines overestimated risk for cardiovascular disease and had discrimination C statistics ranging from 0.67 to 0.77. Sources of funding (Rotterdam Study): Erasmus MC and Erasmus University; The Netherlands Organisation for Scientific Research (NOW); The Netherlands Organisation for Health Research and Development (ZonMw); Research Institute for Diseases in the Elderly (RIDE); Ministry of Education, Culture, and Science; Ministry for Health, Welfare, and Sports; European Commission (DG XII); Municipality of Rotterdam. For correspondence: Dr. M. Kavousi, Erasmus University Medical Center, Rotterdam, The Netherlands. E-mail m.kavousi@ erasmusmc.nl. ■

Methods Design: Prospective cohort study (Rotterdam Study), with 10 years of follow-up. Setting: Population-based study in Rotterdam, The Netherlands. Participants: Adults aged ≥ 55 years who did not use statins at baseline. Assessment with the ACC/AHA guideline included 3433 participants (56% women) who had low-density lipoprotein cholesterol (LDL-C) ≤ 190 mg/dL (4.91 mmol/L) and no CVD. Assessment with the ATP-III guideline included 3407 participants (58% women) who did not have CVD or diabetes mellitus (DM). Assessment with the ESC guideline included 3182 participants (57% women) who did not have CVD, DM, or chronic kidney disease. Description of prediction guides: ACC/AHA included age, systolic blood pressure, treatment of hypertension, total and highdensity lipoprotein (HDL) cholesterol levels, current smoking, and history of diabetes mellitus; cutpoints were 5% for “treatment considered” and 7.5% for “treatment recommended” for 10-year risk for hard atherosclerotic CVD (ASCVD). ATP-III included age, systolic blood pressure, treatment of hypertension, total and HDL cholesterol levels, and current smoking; cutpoints were 10% for intermediate risk and 20% for high 10-year risk for hard coronary heart disease. ESC included age, systolic blood pressure, total cholesterol levels, and current smoking; cutpoints were 1% for moderate risk, 5% for high risk, and 10% for very high risk for 10-year CVD mortality. Outcomes: ASCVD (myocardial infarction, other coronary heart disease [CHD] mortality, or stroke), hard CHD (myocardial infarction or CHD mortality), and CVD mortality.

Main results C statistics and predicted and observed incidence rates for men and women are in the Table. Guidelines for predicting 10-y CVD risk in adults ≥ 55 y of age* Guidelines (outcomes)

ACC/AHA (hard ASCVD†) ATP-III (hard CHD‡) ESC (CVD mortality)

Population

C statistic (95% CI)

Mean cumulative incidence of events Predicted Observed risk (CI) risk (CI)

Men

0.67 (0.63 to 0.71)

22% (21 to 22) 13% (11 to 15)

Women

0.68 (0.64 to 0.73)

12% (11 to 12)

8% (7 to 9)

Men

0.67 (0.62 to 0.72)

16% (16 to 17)

7% (6 to 8)

Women

0.69 (0.63 to 0.75)

5% (5 to 6)

3% (2 to 4)

Men

0.76 (0.70 to 0.82)

7% (6.5 to 7.1) 4% (3 to 5)

Women

0.77 (0.71 to 0.83)

4% (3.7 to 4.0) 2% (1 to 3)

*ACC/AHA = American College of Cardiology/American Heart Association; ASCVD = atherosclerotic cardiovascular disease; ATP-III = Adult Treatment Panel III; CHD = coronary heart disease; CVD = cardiovascular disease; ESC = European Society of Cardiology; other abbreviations defined in Glossary. †Myocardial infarction, other CHD mortality, or stroke. ‡Myocardial infarction or CHD mortality.

19 August 2014 | ACP Journal Club | Volume 161 • Number 4

Commentary Publication of the 2013 ACC/AHA guidelines on assessment of CV risk and management of blood cholesterol introduced several new ideas and challenged decades of established clinical practices. The guidelines have shifted the emphasis away from treatment to specific LDL-C targets and use of nonstatin therapies, made explicit recommendations about the use of high- or moderateintensity statin therapy in appropriately selected patients, and encouraged use of the Pooled Cohort Risk Equations for assessment of CV risk to inform primary prevention with statin therapy. The guidelines recommend statin therapy in patients without clinical ASCVD or diabetes but with LDL-C levels of 70 to 189 mg/dL and estimated 10-year ASCVD risk ≥ 7.5% as estimated by the Pooled Cohort Equations. Changes to firmly established practice patterns may be challenging in some settings, particularly when such studies as that of Kavousi and colleagues draw attention to the limitations of the guidelines used in practice. The study by Kavousi and colleagues showed that the risk equations overestimated risk for ASCVD events and would have recommended statins for nearly all men and two thirds of women. This is an important reminder that guidelines are a framework for delivering care and should not supplant clinical judgment. The Pooled Cohort Risk Equations may not be generalizable to nonAmerican populations, given the substantial number of Europeans who would qualify for statin therapy. The new guidelines can instead be seen as an opportunity for shared decision-making. As noted by Montori and colleagues, the 10-year risk threshold of 7.5% for ASCVD events is a value judgment. Not all patients may find a 7.5% 10-year risk important enough to justify treatment, even though randomized trials have shown a reduction in ASCVD events at this risk threshold (1). Recognizing that collaboratively integrating individual patient preferences into decision-making is imperative, Montori and colleagues suggest the use of shared decision-making tools to translate new guidelines into practice. Such an approach may advance patient-centered care while assimilating the latest evidence into decision-making, paving the way for an acceptance of new guidelines and their limitations. Prashant Vaishnava, MD Kim A. Eagle, MD University of Michigan Health System Ann Arbor, Michigan, USA Reference 1. Montori VM, Brito JP, Ting HH. JAMA. 2014;311:465-6. © 2014 American College of Physicians

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AHA, Adult Treatment Panel III, and ESC guidelines overestimated risk for CVD in older adults.

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