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Raging Controversies in CVD
Risk Assessment and
Cholesterol Management
Roger S. Blumenthal, MD
The Kenneth Jay Pollin Professor of Cardiology
Director, Johns Hopkins Ciccarone Center for the
Prevention of Heart Disease
Disclosures: None
The Statin Reluctant Patient
May 25, 2017
2
2013 Prevention Guidelines
ASCVD Risk Estimator
ASCVD Risk Calculator: Pooled
Cohort Equations
Risk Factor
Sex
Age
Race
Total Cholesterol
HDL-Cholesterol
Systolic BP
Treatment for High BP
Diabetes
Smoker
Units
M or F
years
AA or WH
mg/dL
mg/dL
mm Hg
Y or N
Y or N
Y or N
Value
Acceptable
range of Optimal
values
values
M or F
20-79
AA or WH
130-320
170
20-100
50
90-200
110
Y or N
Y or N
Y or N
N
N
N
Results of Risk Estimator
May 25, 2017
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The Risk Discussion
1. Potential for ASCVD risk reduction benefit
2. If decision unclear, consider LDL>160; FHx
of premature ASCVD, lifetime ASCVD risk,
abnormal CAC score or ABI, or hs-CRP >2
3. Potential adverse effects and drug-drug
interactions
4. Healthy lifestyle
5. Management of other risk factors
6. Patient preferences
Is Risk Calculator Flawed?
“Dr.
Blaha said the problem might
be due to the calculator using as
reference points data collected more
than a decade ago, when more
people smoked and had strokes and
heart attacks earlier in life.
But people have changed in the past
few decades, Dr. Blaha said..
“The cohorts were from a different
era,” Dr. Blaha said.”
May 25, 2017
8
Overestimation of Predicted Risk
Ridker and Cook. Lancet. 2013;382:1762-5.
Kavousi. JAMA. 2014;311:1416-23.
9
* New Risk Estimator Innovative
and an Improvement
* However, Discrimination Remains
Suboptimal, Concern for
Overestimation in Healthier Groups
May 25, 2017
10
Percent of U.S. Adults Who Would Be Eligible for Statin Therapy for
Primary Prevention, According to Set of Guidelines and Age Group.
Pencina MJ et al. N Engl J Med 2014. DOI: 10.1056/NEJMoa1315665
.5
.4
.3
.2
0
.1
40
50
60
AGE
Framingham Risk Score
70
80
ACC/AHA CVD Risk Score
The Statin Reluctant Patient:
Principles of Therapy in 1o Prevention
•
•
•
•
Preventive therapies are lifelong therapies
All medications have some cost and side effects
Patients in general do not want to take medicines
Patients receive absolute benefit in direct
proportion to absolute risk
• Patients who are not destined to have an event
receive no benefit from treatment
• Risk factor-based approach fails to identify many
high risk, and most truly LOW RISK patients
May 25, 2017
14
~1 mSv
CAC = 0
CHD Event Rates (per 1,000 person-years)
With Increasing CAC scores, by RF Burden
May 25, 2017
Silverman MG, et al. EHJ. 2014.
17
Biologic Age > Chronologic Age
May 25, 2017
Tota-Maharaj, et al. Mayo Clinic Proceedings.
2014
18
30
26.1
28.9
26.1
25.6
25
20
14.0
15
10.5
10
5
10.2
6.7
4.7
≥100
3.5
0
2.6
<1.80
1.80 to 2.57
Martin SS, et al. Circulation. 2013.
1 to 99
3.0
0
2.58 to 3.34
≥3.35
CAC
Rate of CVD per 1,000 person-years
CAC and LDL Cholesterol
MESA JUPITER Population
25%
25.16%
47%
46.74%
28%
28.11%
CAC=0
CAC 1-100
CAC >100
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MESA JUPITER: Estimated 5-year
number needed to treat (NNT)
5-year
NNT CHD
5-year
NNT CVD
 Zero CAC
 CAC present
549
42
124
30
 CAC=0
 CAC 1-100
 CAC >100
549
94
24
124
54
19
JUPITER pop.
NNH:
•Statins/Diabetes: 255
JAMA Case: Coronary Artery
Calcium Guided Statin Use
CAC=0
% of
CHD event rate
population (per 1000 patientyears)
50%
1.8
5-year NNT with
35% event
reduction
282
CAC 1-100
37%
7.2
74
CAC >100
13%
12.4
46
SUMMARY: CAC, When Individualization
of Primary Prevention May Be Useful
1. When Risk/Decision to Treat is Uncertain
–
–
–
–
2.
3.
4.
5.
Family History
Metabolic syndrome
Non-While, non-AA
Rheumatologic Diseases, etc.
Statin Reluctant Patient
Statin Intolerant Patient
Decisions for Non-Statin Therapy
Decisions For Aspirin Therapy
May 25, 2017
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