Projected Changes in Statin and Antihypertensive Therapy Eligibility With the AHA PREVENT Cardiovascular Risk Equations

Abstract

Importance: Since 2013, the American College of Cardiology (ACC) and American Heart Association (AHA) have recommended the pooled cohort equations (PCEs) for estimating the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). An AHA scientific advisory group recently developed the Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations, which incorporated kidney measures, removed race as an input, and improved calibration in contemporary populations. PREVENT is known to produce ASCVD risk predictions that are lower than those produced by the PCEs, but the potential clinical implications have not been quantified.

Objective: To estimate the number of US adults who would experience changes in risk categorization, treatment eligibility, or clinical outcomes when applying PREVENT equations to existing ACC and AHA guidelines.

Design, setting, and participants: Nationally representative cross-sectional sample of 7765 US adults aged 30 to 79 years who participated in the National Health and Nutrition Examination Surveys of 2011 to March 2020, which had response rates ranging from 47% to 70%.

Main outcomes and measures: Differences in predicted 10-year ASCVD risk, ACC and AHA risk categorization, eligibility for statin or antihypertensive therapy, and projected occurrences of myocardial infarction or stroke.

Results: In a nationally representative sample of 7765 US adults aged 30 to 79 years (median age, 53 years; 51.3% women), it was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories (53.0% [95% CI, 51.2%-54.8%]) and very few US adults to higher risk categories (0.41% [95% CI, 0.25%-0.62%]). The number of US adults receiving or recommended for preventive treatment would decrease by an estimated 14.3 million (95% CI, 12.6 million-15.9 million) for statin therapy and 2.62 million (95% CI, 2.02 million-3.21 million) for antihypertensive therapy. The study estimated that, over 10 years, these decreases in treatment eligibility could result in 107 000 additional occurrences of myocardial infarction or stroke. Eligibility changes would affect twice as many men as women and a greater proportion of Black adults than White adults.

Conclusion and relevance: 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.

Figure 1.. Marginal Distributions for Predicted 10-Year ASCVD Risk by Gender, Age, and Race and Ethnicity Among US Adults Aged 40-79 Years With No History of Myocardial Infarction, Stroke, or Heart Failure

A, Probability density distributions for 10-year atherosclerotic cardiovascular disease (ASCVD) risk as calculated using the pooled cohort equations (PCEs) and Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations among men and women aged 40-79 years with no history of myocardial infarction, stroke, or heart failure. Data from National Health and Nutrition Examination Survey 2011-2020 were survey adjusted to represent the 2020 US population. B, Same as A, but stratified by age group. C, Same as A, but stratified by race and ethnicity. Categories for race and ethnicity are mutually exclusive and were derived from self-reported survey responses. Respondents who self-identified as Hispanic were categorized as Hispanic American. The remaining participants were categorized as non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, or other race, including multiracial. The non-Hispanic descriptor was omitted for brevity.

Figure 2.. Joint Distribution of Predicted 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk and Discordance in ACC/AHA Treatment Recommendations for Primary Prevention Among US Adults Aged 40-79 Years With No History of Myocardial Infarction, Stroke, or Heart Failure

A, Cross-tabulation of US adults according to 10-year predicted ASCVD risk as calculated using the pooled cohort equations (PCEs) or Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations among US adults aged 40-79 years with no history of myocardial infarction, stroke, or heart failure. Cells are shaded according to total projected population count. The dotted blue line represents concordance between the 2 equations. B, Same as A, but only showing US adults with discordant recommendations for statin therapy between the PCEs and PREVENT equations. Recommendations from the American College of Cardiology (ACC) and American Heart Association (AHA) were determined based on prior myocardial infarction (MI) or stroke, low-density lipoprotein (LDL) cholesterol levels ≥190 mg/dL, diabetes among adults aged 40-75 years with LDL cholesterol levels between 70 and 189 mg/dL, or predicted ASCVD risk ≥7.5% among adults aged 40-75 years with LDL cholesterol levels between 70 and 189 mg/dL. Dashed lines indicate treatment thresholds of ≥7.5%. Cholesterol values were adjusted among participants receiving lipid-lowering therapies to model baseline untreated values. C, Same as B, but showing US adults with discordant ACC/AHA recommendations for blood pressure (BP)–lowering medication based on stage 2 hypertension (≥140/90 mm Hg) or stage 1 hypertension (≥130/80 mm Hg) with either prior MI or stroke or predicted risk ≥10%. Dashed lines indicate treatment thresholds of ≥10%. BP values were adjusted among participants receiving antihypertensive therapy to model baseline untreated values. D, Same as B, but showing US adults with discordant ACC/AHA recommendations for high-intensity statin therapy based on prior MI or stroke, LDL cholesterol ≥190 mg/dL, or predicted ASCVD risk ≥20% among adults aged 40-75 years with LDL cholesterol levels between 70 and 189 mg/dL. Dashed lines indicate treatment thresholds of ≥20%. Cholesterol values were adjusted among participants receiving lipid-lowering therapies to model baseline untreated values.

Figure 3.. Projected Differences in Number and Proportion of US Adults Receiving or Recommended for Statin or Antihypertensive Therapies

A, Estimated number, proportion, absolute difference, and proportion difference in US adults receiving or recommended for statin therapy when 10-year atherosclerotic cardiovascular disease (ASCVD) risk is calculated using the Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations as compared with the pooled cohort equations (PCEs). Data from National Health and Nutrition Examination Survey 2011-2020 were survey adjusted to represent the 2020 US population. B, Same as A, but for US adults receiving or recommended for antihypertensive therapy. Data showing differences for high-intensity statin therapy, with exclusion of out-of-range laboratory values or with adjustments for treated persons, are shown in eFigures 5-7 in Supplement 1.

Figure 4.. Estimated Number of US Adults Eligible for Statin or Antihypertensive Therapy by Choice of Risk Threshold

A, y-Axis shows number of US adults receiving or recommended for statin therapy when evaluated using ACC/AHA criteria, including predicted 10-year ASCVD risk higher than the corresponding risk threshold on the x-axis when calculated using the PCEs or PREVENT. Shading represents 95% CIs. Data from NHANES 2011-2020 were survey adjusted to represent the 2020 US population. B, Same as A, but for US adults receiving or recommended for antihypertensive therapy based on ACC/AHA criteria, including predicted 10-year ASCVD risk. C, Same as A, but for US adults recommended for statin therapy. Cholesterol values were adjusted among participants receiving lipid-lowering therapies to model baseline untreated measurements. D, Same as B, but for US adults recommended for antihypertensive therapy. BP values were adjusted among participants receiving antihypertensive therapies to model baseline untreated measurements.