42 Are we overestimating or underestimating cardiovascular events risk? the impact of using the american, british and european guidelines on cardiovascular risk assessment

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Abstract

Objectives

The guidelines of the American College of Cardiology/American Heart Association, the British National Institute for Health and Clinical Excellence and the European Guidelines on cardiovascular disease prevention are worldwide disseminated. They recommend the use of different tables to estimate cardiovascular risk: atherosclerotic cardiovascular disease risk-ASCVD, the QRISK2 and the SCORE. ASCVD and QRISK2 measure risk of cardiovascular morbidity and mortality due to atherosclerosis disease and due to coronary heart disease and stroke, respectively, and SCORE measures risk of cardiovascular death. According to ASCVD a high-risk person is considered when risk is >7.5%, according to QRISK2 >10% and according to SCORE >5%, in the next ten years. The objective was to evaluate and compare the impact of using the American, the British and the European guidelines on the identification of high risk patients and on the percentage of patients requiring statin therapy in a Spanish working population.

Method

Observational study conducted among Spanish workers whose companies had contracted health monitoring services from the Sociedad de Prevencion de Ibermutuamur, who underwent a medical examination between 2004–2007. Cardiovascular risk was calculated for each worker using the SCORE cardiovascular risk tables for low-risk countries, as well as the tables recommended by the American and British guidelines. Diabetic patients were excluded. Following the recommendations of the European Guidelines on Cardiovascular Prevention, treatment targets for patients at high (SCORE 5%–9%) or very high risk (SCORE >10%) are LDL-C concentrations of <100 mg/dL and <70 mg/dL, respectively. NICE and ACC/AHA recommendations do not stipulate therapeutic targets for LDL-C, therefore all patients at high risk are considered candidates for lipid lowering therapy. On top of that, ACC/AHA recommends treatment with lipid lowering therapy when LDL-C is >190 mg/dl, regardless the cardiovascular risk.

Results

A total of 227 371 workers between 40 and 65 years were included (75.54% men; mean age, 47.96 years; 42.62% were smokers; 10.1% were hypertensives; 11.0% had dyslipidemia; 7.2% were treated with antihypertensive drugs; 3.7% were treated with lipid lowering drugs). Individuals at high risk was found in 4.42% of the population according to the SCORE tables and in 17.79% and 26.02% according to the British and American tables, respectively. Lipid lowering treatment would be recommended in these high risk patients, except for the American Guidelines that the percentage would increase up to 33.74% (after including non-high risk patients with LDL-C >190 mg/dl).

Conclusions

We observed marked differences on the percentages of high risk patients when comparing the three different cardiovascular risk charts. The application of the American and British compare to the European guidelines would result in identifying more high risk patients and in treating a larger fraction of the population with lipid lowering drugs and with other intensive preventive pharmacotherapy such as use aspirin and anti-hypertensive agents, which would result in substantially increase costs. Clinicians may need to interpret cardiovascular risk estimates with caution in order to avoid overestimation of risk and overtreatment.

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