Primary cardiovascular prevention: Rethinking 'high risk'


Who is "high risk" when it comes to primary prevention of cardiovascular disease?

Several risk formulas now exist to calculate a person’s risk level, but maybe the best answer is rooted in clinical practice. Speaking in April at EuroPrevent 2013, cardiologist and preventive-medicine specialist Dr. Donald M. Lloyd-Jones offered this definition: "Assuming that lifestyle intervention is appropriate for everyone, ‘high risk’ may mean being at enough risk for atherosclerotic cardiovascular disease in 10 years to merit drug treatment," in a calculation that takes into account the cost-effectiveness of the treatment and its risk-to-benefit ratio.

Courtesy Orange County Archives

A designation of high risk that comes and goes depending in part on the cost of intervention is wonderfully adaptive to real-world circumstances.

What I like about this definition is that it puts the meaning of high-risk in very practical terms: Is the person at enough risk to warrant a particular treatment after also taking into account its financial and adverse-effect costs?

In other words, a person may be high risk and deserve aggressive primary prevention if treated with a cheap agent, like a generic statin or aspirin, but at lower risk if treatment involves a more expensive drug, for example a brand-name statin like rosuvastatin or ezetimibe, which in the United States are only available as the brand names Crestor and Zetia. A designation of high risk that comes and goes depending in part on the cost of intervention is wonderfully adaptive to real-world circumstances.

Dr. Lloyd-Jones went a little further, elaborating on how this definition of high risk works in today’s era of generic atorvastatin, America’s first high-potency statin marketed as a generic, its status for a little over 1 year.

"In the current era when a high-potency, generic statin is $4 a month, cost is no longer an issue," he said. "All you really have to think about are the adverse events, not the cost; cost doesn’t enter into the equation."

I previously spoke to Dr. Lloyd-Jones a little less than 18 months ago, when genetic atorvastatin was on the verge of first entering the U.S. market, and at the time he excitedly called its pending availability a "game changer" for the management of patients with established cardiovascular disease. It sounds like he sees it the same way for primary prevention.

At EuroPrevent, he also talked about the need to consider a person’s long-term – either 30-year or lifetime – risk for cardiovascular disease rather than exclusively focusing on their 10-year risk calculated with one of the standard risk measurement formulas, like the Framingham Risk Score or the EuroSCORE.

Dr. Lloyd-Jones serves on the U.S. panel that’s writing America’s updated, official cholesterol-treatment guidelines, ATP IV, and he also cochairs another U.S. panel that is preparing revised guidelines on cardiovascular risk reduction. Another cardiovascular-risk expert, Dr. Peter W.F. Wilson from Emory University in Atlanta, also serves on both panels and also spoke at the same meeting session, where he said he fully agreed with Dr. Lloyd-Jones and stressed the need to take into account the net benefit that accrues when putting people on treatment.

It sounds like when the new ATP IV guidelines appear, there is a good chance they will call for more aggressive, generic-statin-based risk reduction for primary prevention than current ATP III recommendations.

On Twitter @mitchelzoler

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