Atherosclerotic Cardiovascular Disease Risk Calculation in Primary Care

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After reading the 2019 ACC/AHA CLINICAL PRACTICE GUIDELINE on the Primary Prevention of Cardiovascular Disease I decided to share the important bits I have learned. I also encourage anyone reading this article to read the guideline for themselves as there is a lot to learn for improvement of their practice.

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INTRODUCTION

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality globally (ACC/AHA, 2019).

According to WHF (World Heart Foundation) report on Tanzania premature deaths attributable to Cardiovascular Disease (CVD) (age 30–70 years) matched those of Kenya and Mozambique at 8% in 2012. In 2017, the age-standardized total CVD death rate was almost 13% which is higher than most of the other African countries. Global data for total percentage of deaths caused by CVD is 31.8%. Mortality caused by hypertensive heart disease was 1.43%, which was slightly lower compared to the 1.65% of the global data (Mvungi et al, 2020).

In the same report it was found that the prevalence of tobacco use in adult men and women (15 years and older) was 27.5% and 3.8% respectively. In 2016, Tanzania had more women (35.5%) than men (19.6%) who were overweight and similarly, far more women (12.7%) were found to be obese than the men (4%). The prevalence of age-adjusted (20–79 years) diabetes in 2019 was 5.7%, which is lower than the global estimate of 9.3% (Mvungi et al, 2020).

The percentage of men and women with raised blood pressure (BP) (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) in 2015 was 26.6 and 27.7%, respectively (Mvungi et al, 2020).

Much of this burden is attributable to suboptimal implementation of prevention strategies and uncontrolled ASCVD risk factors in many adults (ACC/AHA, 2019).

Equipped with this knowledge we can see that its important to be aware on calculating the risk of our patients in developing cardiovascular disease in the future.

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CALCULATING ASCVD RISK

From Heart Health Now Initiative we learn the following 4 steps in using risk calculation in our practices:

Different number of guidelines recommend identifying and treating individuals’ overall risk of cardiovascular disease events instead of treating individual risk factors. As a result, providers need to develop a thorough understanding of the risk-based approach including why, when, and how to do it.

How does your practice approach cardiovascular disease risk? Do you, as a group, routinely calculate cardiovascular risks? If so, what risks? And with what calculator? Do you have a system for monitoring and tracking cardiovascular disease risk, communicating risks to patients? If not, why not?

Why the risk approach?

·????????It places the focus on the right goal: Reducing cardiovascular disease events.

·????????It predicts events better than counting of risk factors.

·????????It allows targeting of therapy to those most in need of prevention, those who are at highest risk.

·????????It is more cost-effective than other approaches such as using electron beam CT for coronary artery calcium.

·????????When communicated to providers and patients, it improves outcomes.

Reducing risks by a relative 10 percent across a general population of patients over 10 years has been estimated to prevent 250,000 new cases of cardiovascular disease to result in 35,000 fewer deaths and to save $2.7 billion. Further, overestimating risks causes patients harm. Most notably, excess bleeding in the 25-percent of patients inappropriately started on aspirin. Ignoring risks also propagates disparities. All of these reasons make a compelling case for considering cardiovascular risk estimation as a strategy for cardiovascular disease prevention.

Either way we can not ignore risk calculation because if we do it is on our own peril starting from the health care provider, health care system and the patient.

When should risk be calculated?

For all patients age 40 to 79 without prior cardiovascular disease to determine the need for risk-reducing medicine including aspirin and statins which are prescribed on a purely risk-based approach.

How should you calculate risk?

1.??????Risk calculation exists on a continuum to impact on cardiovascular events. The pathway starts with risk calculation, continues on through communication of risks and risk-based recommendations, and then it continues with shared decision making so that we can determine whether a risk-based recommendation aligns with patient’s preferences and values. And, finally, it continues through initiation and adherence to prescribe medicines on to risk reduction of risk factors, cardiovascular risks; and, finally, events.

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2.??????Use a risk calculator, not an estimate. Multiple studies show that physicians are inaccurate in the risk estimates and that calculators improve risk estimation.

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One of the recommended calculator is the ASCVD calculator developed by American College of Cardiology in 2013. The ASCVD, or Atherosclerotic Cardiovascular Disease calculator. It predicts 10-year risks of Atherosclerotic Cardiovascular or ASCVD events including heart attacks, stroke, and cardiovascular death. And it uses various risk factors for calculation including age, gender, systolic blood pressure, hypertension treatment, total and HDL cholesterol, smoking, diabetes, and race.

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You can find this calculator in the internet via: https://www.CVRiskCalculator.com.

Or you can use Medscape app which has inbuilt calculator.

·????????A 0 to 4.9 percent risk is considered low.

·????????A 5 to 7.4 percent risk is considered borderline.

·????????A 7.5 to 20 percent risk is considered intermediate.

·????????A greater than 20 percent risk is considered high.

Other risk calculators include Framingham Risk score which has several cons including; it included a homogenous group mostly white people in USA, underestimates risk in women, overestimates risk in population with a low incidence of CAD, provides risk only over 10 years. Another risk calculator is the Reynolds Risk Score developed at first to address the overestimation of risk in women by other calculators. The ASCVD risk calculator is recommended because it includes race and multiple populations.

There is a lack of similar calculators available to be used in Sub Saharan Africa specific population hence a need for such development as we have seen there is an increase in cardiovascular disease incidence in our setting (Wagner et al, 2021). Overall the clinician should be aware of the existing different calculators and use the most appropriate calculator representing the population he/she is serving.

In our setting we can also use the WHO CVD risk calculator which has addressed contextual differences by recalibrating its models using nationally representative data from diverse settings. It has also categorized risk factors in using both laboratory based (age, sex, smoking, systolic blood pressure, presence or absence of diabetes, total cholesterol) and non-laboratory based ( age, Sex, smoking, systolic blood pressure, BMI) in resource limited settings.

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The following is reference from HEARTS: Risk-based CVD management guidelines 2020 by WHO:

3.??????Integrate risk calculations into your practice routine. Clinicians report that major barriers to risk communication are time and having an available calculator. To make risk calculation more successful, you should integrate it into your Electronic Health Record. Consider Web, and phone apps, and decision aids to help.

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4.??????Communicate risks to patients. Optimal risk communication includes a statement of risks such as, “your chances of future heart attack, stroke, or cardiovascular-related death over 10 years is X percent.” Notice a few things about this statement. First, the word chances instead of risks. This is more understandable to patients. Second, a statement of outcomes: heart attack, stroke, or cardiovascular-related death. And, third, a statement of time: over the next 10 years. All of these things make risks more understandable to patients.

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Optimal risk communication also includes an indication of how much risk can be lowered with one, or multiple, preventive treatments. There is evidence that patients pay more attention to how much the risk can be lowered than where they start with the risks. And, finally, optimal risk communication includes shared decision making and supportive counseling for risk reduction. This ensures that risk-based recommendations align with patient’s preferences and values. And that information is provided so patients can circumvent their barriers to risk reduction.

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NUGGETS:

Be sure to include the following in the discussion:

a. Why it is important to control risk factors and minimize risk

b. How drug therapy can provide a net benefit

c. Risk associated with drug therapy

d. His or her therapy preferences

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Highlights from ACC/AHA 2019 guidelines: after looking on how to calculate the ASCVD risk I would now share some of the highlights from the recent ACC/AHA guideline.

ASPIRIN USE

In clinical practice I meet several patients who are on aspirin just because they have hypertension with no background history of compelling risk factors indicated for aspirin intake. The ACC/AHA guideline recommends the following for aspirin intake:

·????????Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk.

·????????Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.

·????????Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.

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TOBACCO USE

·????????In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.

Sometimes it may be difficult identifying patient who smoke and thus the guidkenies advice on this strategies: …using multiple questions to assess tobacco use status may improve accuracy and disclosure. For example, clinicians should ask, “Have you smoked any tobacco product in the past 30 days, even a puff?” “Have you vaped or ‘juuled’ in the past 30 days, even a puff?” “Have you used any other tobacco product in the past 30 days?” If these questions are answered with “yes,” the patient is considered a current smoker. Clinicians should avoid asking “Are you a smoker?” or “Do you smoke?” because people are less likely to report tobacco use when asked in this way.

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·????????In adults who use tobacco, tobacco abstinence is recommended to reduce ASCVD risk.

To help patients quit, it is critically important to use language that is clear and strong, yet compassionate, nonjudgmental, and personalized, to urge every tobacco user to quit.

·????????To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare system.

·????????All adults and adolescents should avoid secondhand smoke exposure to reduce ASCVD risk.

It is recommended that clinicians advise patients to take precautions against exposure to second-hand smoke and aerosol from all tobacco products, such as by instituting smoking restrictions ?inside all homes and vehicles and within 25 feet from all entryways, windows, and building vents.

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ADULTS WITH OVERWEIGHT AND OBESITY

·????????In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile. It is recommended to reduce about 5% of current weight.

·????????Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity.

·????????Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations.

·????????It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk.

Increased waist circumference has been associated with increased cardiometabolic and ASCVD risk. Central adiposity, captured by using waist circumference, has been associated with ASCVD risk and may be missed when BMI is used as the only measure of obesity. Definitions of elevated waist circumference as ≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women.

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NUGGETS from ACC/AHA guidelines:

·????????Short sleep duration (<6 h) and poor-quality sleep are associated with high blood pressure and should be addressed in hypertensive patients.

·????????Potential barriers to adhering to a heart-healthy diet should be assessed, including food access and economic factors; these factors may be particularly relevant to persons from vulnerable populations, such as individuals residing in either inner-city or rural environments, those at socioeconomic disadvantage, and those of advanced age.

·????????Adults should be routinely assessed for psychosocial stressors and provided with appropriate counseling.

·????????Health literacy should be assessed every 4 to 6 y to maximize recommendation effectiveness.

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CONCLUSION

It is a high time for the primary care workforce to start using available risk stratification tools to manage effectively the risks for atherosclerotic cardiovascular disease (ASCVD). ?

Prevention strategies occur at the population level but must also engage individual adults to slow the development of ASCVD. The most important way to prevent ASCVD is to promote a healthy lifestyle throughout life. Prevention strategies must include a strong focus on lifestyle optimization (improvements in diet, physical activity, and avoidance of tobacco use and exposure to secondhand smoke) to minimize the risk of future ASCVD events (ACC/AHA, 2019).

We end the article with the key messages from the 2019 ACC/AHA guideline:

TOP 10 TAKE-HOME MESSAGES FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin.

4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations, are crucial.

7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

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REFERENCES

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678

HEARTS technical package for cardiovascular disease management in primary health care: risk based CVD management. WHO 2020.

https://www.HeartHealthNow.org.

Heart Health Now. 2015. Calculating Risk for Primary Prevention of Cardiovascular Disease (CVD)

Robert Mvungi, Jean M Fourie, Oana Scarlatescu, George Nel, Wihan Scholtz. 2020. Tanzania Country Report. PASCAR and WHF Cardiovascular Diseases Scorecard project. Cardiovascular Journal of Africa ? Volume 31, No 4. DOI: 10.5830/CVJA-2020-036

Wagner Ryan G, Nigel J Crowther, Lisa K Micklesfield , Palwende Romauld Boua , Engelbert A Nonterah,6 Felistas Mashinya , Shukri F Mohamed , Gershim Asiki, Stephen Tollman ?Michèle Ramsay, Justine Davies1. 2021. BMJ Global Health;6:e003499. doi:10.1136/bmjgh-2020-003499

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