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Statin and Antihypertensive Therapy Changes With PREVENT Risk Equations
Quick Takes
- Substituting the novel AHA PREVENT equation results in assigning lower ASCVD risk predictions, which could reduce eligibility for statin and antihypertensive therapy among 15.8 million US adults.
- It was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories and very few US adults to higher-risk categories.
- PREVENT is a rigid proposal as presented and does not allow for physician and patient discussion about potential value of treating persons at a younger age who have familial lipid disorders, elevated Lp(a), and utilization of the coronary calcium score.
Study Questions:
What is the estimated number of US adults who would experience changes in risk categorization, treatment eligibility, or clinical outcomes when applying the American Heart Association (AHA) Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations to existing American College of Cardiology (ACC) and AHA guidelines?
Methods:
The primary outcomes evaluated were the differences in predicted 10-year atherosclerotic cardiovascular disease (ASCVD) risk, ACC and AHA risk categorization, eligibility for statin or antihypertensive therapy, and projected occurrences of myocardial infarction (MI) or stroke. Data were obtained from a nationally representative cross-sectional sample of 7,765 US adults aged 30-79 years who participated in National Health and Nutrition Examination Surveys of 2011 to March 2020, with response rates ranging from 47% to 70%.
Results:
In the sample with median age of 53 years and 51.3% women, when compared to the pooled cohort equations (PCEs) with ACC and AHA additional risk-based guidelines for primary prevention with high-intensity statins and antihypertensive drugs, it was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories and very few US adults to higher-risk categories (0.41% [95% confidence interval, 0.25%-0.62%]). The number of US adults receiving or recommended for preventive treatment would decrease by an estimated 14.3 million for statin therapy and 2.62 million for antihypertensive therapy. Over 10 years, reduction in treatment eligibility could result in an estimated 107,000 additional occurrences of MI or stroke with 57,800 fewer new-onset diabetes. Eligibility changes would affect twice as many men as women and a greater proportion of Black adults than White adults.
Conclusions:
By assigning lower ASCVD risk predictions, application of the PREVENT equations to existing treatment thresholds could reduce eligibility for statin and antihypertensive therapy among 15.8 million US adults.
Perspective:
Reducing the number of persons treated to prevent MI and stroke should not be an objective. In this era of available generics, cost-benefit of statins and antihypertensive medication is no longer an issue. And while statins increase the risk of diabetes, the benefit outweighs risk, and using low-dose high-intensity statins with ezetimibe would reduce risk of diabetes with further lowering of low-density lipoprotein cholesterol (LDL-C) and event rates.
Should PREVENT substitute for PCEs and be incorporated in the ACC/AHA prevention guideline? After survey adjustment, the mean 10-year ASCVD risk calculated using PREVENT was 50% lower than the mean risk calculated using the PCEs (4.6% and 9.0%, respectively). What is not addressed in the argument is the extension of PCEs in primary prevention by the ACC and AHA with strategies based on absolute risk that expands use of high-intensity statins and more liberal use of statins in patients with ‘risk enhancers’ assigned to low-risk and high-intensity statins in moderate-risk groups.
While the PREVENT equation expands to persons 30-39 years, when considering use of statins and LDL-C targets, almost none would be assigned above low risk and not allow for physician discretion to discuss variables with patients including family history of premature coronary heart disease, lipoprotein(a) [Lp(a)], and coronary calcium score. Finally, the authors point out that not using race in PREVENT is concerning given longstanding disparities in CVD treatment and outcomes, particularly the impact in Black persons of hypertension and diabetes, stroke, heart failure, and end-stage renal disease and hemodialysis.
Clinical Topics: Prevention
Keywords: Antihypertensive Agents, Heart Disease Risk Factors, Statins
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