SNOWMASS, COLO. – The Multi-Ethnic Study of Atherosclerosis–based 10-year coronary heart disease risk calculator offers significant advantages over the far more widely used Atherosclerotic Cardiovascular Disease risk estimator based upon the pooled cohort equations recommended in the American College of Cardiology/American Heart Association guidelines, Robert A. Vogel, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I don’t use the PCE very much. I use the MESA [Multi-Ethnic Study of Atherosclerosis]. I like it because it gives me options I don’t have with the PCE [pooled cohort equations],” Dr. Vogel, a preventive cardiology expert at the University of Colorado at Denver, Aurora, said at the meeting sponsored by the American College of Cardiology.
Those added options include, importantly, the ability to plug in a patient’s coronary artery calcium score. MESA, a landmark longitudinal National Institutes of Health–sponsored study, generated a great deal of the data that established the prognostic value of measuring coronary artery calcium.
“You can do the MESA worksheet with or without coronary artery calcium, either way,” Dr. Vogel noted.
Another big advantage for the MESA risk calculator: It asks a yes/no question about family history of heart attack in first-degree relatives. That’s truly risk-altering information, and yet it’s absent from the ACC/AHA ASCVD (Atherosclerotic Cardiovascular Disease) risk calculator, the cardiologist continued.
Plus, the MESA risk calculator includes four ethnic options: Caucasian, African American, Chinese, or Hispanic, while the ACC/AHA’s PCE-based tool includes only the categories of white, African American, or other.
Dr. Vogel offered a case example for purposes of comparison and contrast of the two risk calculators: a 48-year-old white man with no history or symptoms of cardiovascular disease whose father had an MI at age 52. He wants to know whether he should start taking a statin. The patient is a former smoker who quit 3 years ago. His physical exam is normal. He has a body mass index of 29 kg/m2, an LDL cholesterol of 134 mg/dL, a total cholesterol of 194 mg/dL, a triglyceride level of 92 mg/dL, blood pressure of 128/78 mm Hg, an HDL cholesterol of 42 mg/dL, and a hemoglobin A1c of 5.9%.
Using the PCE-based risk calculator, the man’s 10-year risk of cardiovascular disease is only 3.3%, which falls below the ACC/AHA guideline-recommended threshold for statin therapy for primary prevention. But with the MESA score, as a result of the additional information regarding the family history of premature cardiovascular disease, the patient’s risk jumps to 4.9%, even without including a coronary artery calcium score.
“This shows you how big a factor the family history is. I think it’s unfortunate that the PCE doesn’t put it in,” Dr. Vogel said.
Indeed, in an analysis from MESA, a 60-year-old man with a lipid and blood pressure profile similar to that of Dr. Vogel’s patient would have a 10-year cardiovascular disease risk of 6% with a negative family history and a 9% risk with a positive history, he noted.
In the 48-year-old patient used as an example by Dr. Vogel, plugging into the MESA risk calculator a coronary artery calcium score of, say, 50, 100, or 150 Agatston units would boost the 10-year cardiovascular disease risk to 7.5%, 8.9%, and 9.9%, respectively.
Both the MESA and the ACC/AHA risk calculators incorporate diabetes as a simple yes/no item. It’s either present or absent. This is too crude a dichotomy for Dr. Vogel’s liking in light of data showing that individuals with impaired glucose tolerance have a cumulative risk of cardiovascular mortality that’s intermediate between diabetic and normoglycemic individuals. And of course, the patient in his case example had a HbA1c of 5.9%. So what is a physician to do?
“I fudge the numbers,” he said. “
He also adjusts a former smoker’s estimated 10-year cardiovascular risk based upon how long ago the smoker quit. An ex-smoker’s hazard ratio for coronary heart disease doesn’t drop to that of a never-smoker until 8 years after quitting. And since the patient in this example has been tobacco-free for only 3 years, Dr. Vogel bumps up that individual’s risk level once again. So at this point, even without the additional information that would be provided by a coronary calcium score, the patient’s adjusted MESA 10-year risk is in the 10% range, compared with the 3.3% figure derived using the PCE-based risk calculator.
He reported serving as a paid consultant to the National Football League and the Pritikin Longevity Center, receiving research grants from Sanofi, and serving on speakers bureaus for Regeneron and Sanofi.