Atherosclerotic Cardiovascular Disease Risk Estimates Using the Predicting Risk of Cardiovascular Disease Events Equations

Abstract

Importance: In 2023, the American Heart Association (AHA) developed the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations to estimate 10-year risk of atherosclerotic cardiovascular disease (ASCVD), as an update to the 2013 pooled cohort equations (PCEs). The PREVENT equations were derived from contemporary cohorts and removed race and added variables for kidney function and statin use.

Objective: To compare national estimates of 10-year ASCVD risk using the PCEs and PREVENT equations and how these equations affect recommendations for primary prevention statin therapy.

Design, setting, and participants: This cross-sectional study included adults aged 40 to 75 years who participated in the National Health and Nutrition Examination Survey from 2017 to March 2020. Adults were defined as eligible for primary prevention statin use based on the 2019 AHA/American College of Cardiology guideline on the primary prevention of cardiovascular disease. Data were weighted to be nationally representative and were analyzed from December 27, 2023, to January 31, 2024.

Main outcomes and measures: The 10-year ASCVD risk and eligibility for primary prevention statin therapy based on PREVENT and PCE calculations.

Results: In the weighted sample of 3785 US adults (mean [SD] age, 55.7 [9.7] years; 52.5% women) without known ASCVD, 20.7% reported current statin use. The mean estimated 10-year ASCVD risk was 8.0% (95% CI, 7.6%-8.4%) using the PCEs and 4.3% (95% CI, 4.1%-4.5%) using the PREVENT equations. Across all age, sex, and racial subgroups, compared with the PCEs, the mean estimated 10-year ASCVD risk was lower using the PREVENT equations, with the largest difference for Black adults (10.9% [95% CI, 10.1%-11.7%] vs 5.1% [95% CI 4.7%-5.4%]) and individuals aged 70 to 75 years (22.8% [95% CI, 21.6%-24.1%] vs 10.2% [95% CI, 9.6%-10.8%]). The use of the PREVENT equations instead of the PCEs could reduce the number of adults meeting criteria for primary prevention statin therapy from 45.4 million (95% CI, 40.3 million-50.4 million) to 28.3 million (95% CI, 25.2 million-31.4 million). In other words, 17.3 million (95% CI, 14.8 million-19.7 million) adults recommended statins based on the PCEs would no longer be recommended statins based on PREVENT equations, including 4.1 million (95% CI, 2.8 million-5.5 million) adults currently taking statins. Based on the PREVENT equations, 44.1% (95% CI, 38.6%-49.5%) of adults eligible for primary prevention statin therapy reported currently taking statins, equating to 15.8 million (95% CI, 13.4 million-18.2 million) individuals eligible for primary prevention statins who reported not taking statins.

Conclusions and relevance: This cross-sectional study found that use of the PREVENT equations was associated with fewer US adults being eligible for primary prevention statin therapy; however, the majority of adults eligible for receiving such therapy based on PREVENT equations did not report statin use.

Figure 1.. Estimated Mean 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk, by Calculator

Error bars represent 95% CIs. Other race includes multiracial. HbA_1c indicates hemoglobin A_1c level; PCE, pooled cohort equation; PREVENT, Predicting Risk of Cardiovascular Disease Events; and UACR, urine albumin-to-creatinine ratio.

Figure 2.. Comparison of Use of the Pooled Cohort Equations (PCEs) and the Predicting Risk of Cardiovascular Disease Events (PREVENT) Equations on Recommendations for Primary Prevention Statin Use

Primary prevention statin use recommendation based on diabetes status and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk greater than 7.5% based on estimated total cholesterol level if patient was not taking a statin. Based on PREVENT equations, 0.2 million (95% CI, 0.0 million-0.4 million) participants (weighted data) would be newly recommended statin use, but all were not currently taking statins; thus, no point estimate or error bars could be calculated for participants currently taking statins. Error bars represent 95% CIs. Other race includes multiracial.

Figure 3.. Estimated Proportion of Population Meeting Primary Prevention Statin Eligibility by Predicting Risk of Cardiovascular Disease Events (PREVENT) Equations Who Reported Current Statin Use

Primary prevention statin recommendation based on diabetes status and estimated 10-year atherosclerotic cardiovascular disease risk greater than 7.5% based on PREVENT equations using estimated total cholesterol levels if patient was not taking a statin. Error bars represent 95% CIs. Other race includes multiracial.