Moving Toward the Next Paradigm for Cardiovascular Prevention

Robinson, Jennifer G.; Ray, Kausik K.

doi:10.1161/circulationaha.116.022134

Cited by 25 publications

(11 citation statements)

References 19 publications

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“…A personalized approach in choosing therapies that provide the greatest risk reduction may indeed be the coming paradigm shift in clinical practice [21]. In this study, we demonstrated that in asymptomatic individuals with low/intermediate ASCVD risk, a benefit threshold of ARR 10 ≥2.3% identified 40% more individuals for primary prevention when compared with a risk-based approach, and that these individuals also had higher coronary plaque burden.…”

Section: Discussionmentioning

confidence: 71%

Personalized Statin Therapy and Coronary Atherosclerotic Plaque Burden in Asymptomatic Low/Intermediate-Risk Individuals

et al. 2018

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Background: Current guidelines for the primary prevention of atherosclerotic cardiovascular disease are based on the estimation of a predicted 10-year cardiovascular disease risk and the average relative risk reduction estimates from statin trials. In the clinical setting, however, decision-making is better informed by the expected benefit for the individual patient, which is typically lacking. Consequently, a personalized statin benefit approach based on absolute risk reduction over 10 years (ARR₁₀ benefit threshold ≥2.3%) has been proposed as a novel approach. However, how this benefit threshold relates with coronary plaque burden in asymptomatic individuals with low/intermediate cardiovascular disease risk is unknown. Aims: In this study, we compared the predicted ARR₁₀ obtained in each individual with plaque burden detected by coronary computed tomography angiography. Methods and Results: Plaque burden (segment volume score, segment stenosis score, and segment involvement score) was assessed in prospectively recruited asymptomatic subjects (n = 70; 52% male; median age 56 years [interquartile range 51–64 years]) with low/intermediate Framingham risk score (< 20%). The expected ARR₁₀ with statin in the entire cohort was 2.7% (1.5–4.6%) with a corresponding number needed to treat over 10 years of 36 (22–63). In subjects with an ARR₁₀ benefit threshold ≥2.3% (vs. < 2.3%), plaque burden was significantly higher (p = 0.02). Conclusion: These findings suggest that individuals with higher coronary plaque burden are more likely to get greater benefit from statin therapy even among asymptomatic individuals with low cardiovascular risk.

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Section: Discussionmentioning

confidence: 71%

Personalized Statin Therapy and Coronary Atherosclerotic Plaque Burden in Asymptomatic Low/Intermediate-Risk Individuals

et al. 2018

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“…With the current shift in CVD prevention guidelines toward personalized treatment recommendations tailored to the unique benefit-harm assessment of a given patient, both quantitative CVD risk assessment and clinician-patient risk discussions are essential components of optimal CVD prevention (Robinson and Ray, 2016). However, we recently completed a systematic review that identified multiple evidence gaps pertaining to the best strategies for implementing these risk estimates in clinical practice (Karmali et al, 2017).…”

Section: Discussionmentioning

confidence: 99%

“…These guidelines eliminated cholesterol goals and instead identified evidence-based CVD risk thresholds to guide clinician-patient decision-making for statin initiation in primary prevention, a shift that has been recognized as the next paradigm in “personalized” CVD prevention (Robinson and Ray, 2016). This approach requires estimating 10-year CVD risk from multiple traditional risk factors including laboratory values like total cholesterol and high-density lipoprotein cholesterol to guide risk assessment and treatment discussions.…”

Section: Introductionmentioning

confidence: 99%

Point-of-care testing to promote cardiovascular disease risk assessment: A proof of concept study

Karmali

Brown

Sanchez

et al. 2017

Preventive Medicine Reports

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Updated cholesterol guidelines emphasize multivariable cardiovascular disease (CVD) risk estimation to guide treatment decision-making in primary prevention. This study tested the preliminary feasibility, acceptability and efficacy of point-of-care testing (POCT) and quantitative CVD risk assessment in high-risk adults to increase guideline-recommended statin use in primary prevention. Participants were aged 40–75 years, without CVD or diabetes mellitus, and potentially-eligible for consideration of statins based on estimated 10-year CVD risk from last-measured risk factor levels in the electronic health record. We performed POCT to facilitate quantitative CVD risk assessment with the Pooled Cohort Equations immediately before a scheduled primary care provider (PCP) visit. Outcomes were: physician documentation of a CVD risk discussion and statin prescription on the study date. We also assessed acceptability of the intervention through structured questionnaire. We recruited 18 participants (8 from an academic practice and 10 from a federally-qualified health clinic). After the intervention, 83% of participants discussed CVD risk with their PCP, 47% received a statin recommendation from their PCP, and 29% received a new statin prescription during the PCP visit. Participants reported high levels of satisfaction with the intervention. This study demonstrates that in initial testing pre-visit POCT and quantitative CVD risk assessment appears to be a feasible and acceptable intervention that may promote guideline-recommended statin initiation in primary prevention. Future research with an adequately powered trial is warranted to determine the effectiveness of this approach in clinical practice.

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“…Residual LDL-C on statin and incremental, absolute risk reduction, both affecting numbers needed to treat, are key elements of this decision process for add-on medications [22,23]. However, fundamentally improved risk assessment, perhaps through imaging, appears to influence this decision-making process which underscores the need for further research to properly justify these strategies [21].…”

Section: Tablementioning

confidence: 99%

Detection of atherosclerotic cardiovascular disease influences the perceived need for aggressive lipid management

et al. 2017

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Background and aims Overt atherosclerotic cardiovascular disease (ASCVD) warrants aggressive lipid lowering. Imaging for ambiguous symptoms suggesting ischemia or for clarification of CV risk in asymptomatic individuals often uncovers previously unknown ASCVD. Guidelines do not provide clear recommendations for aggressive lipid lowering in such cases. We explored physicians' perception, as influenced by tests that detect ASCVD, regarding appropriateness of getting to lipid goals and for theoretically accessing proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i). Methods A questionnaire was developed including cases of low to high CV risk, chronic kidney disease (CKD) or type 2 diabetes mellitus (T2DM). Each case was considered with or without angina symptoms and, in turn, whether testing identified previously unknown advanced, early/subclinical or no ASCVD. Synthesis of responses was facilitated by using a scale for perceived appropriateness from 1 (lowest) to 9 (highest). Results Getting to goal and, if not achieved by statins and/or ezetimibe, accessing PCSK9i was considered appropriate in patients with T2DM with preclinical or advanced ASCVD, patients with moderate or high CV risk and advanced ASCVD, patients with CKD or low CV risk with angina symptoms and advanced ASCVD. For most of the remaining cases adding PCSK9i was considered only possibly appropriate. Conclusions Physicians' perception of appropriateness for achieving lipid goals, including access to PCSK9i, is markedly influenced by detection of previously unknown ASCVD. Since these commonly encountered scenarios do not clearly meet current indications for PCSK9i, our data identify pressing areas requiring further research

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Moving Toward the Next Paradigm for Cardiovascular Prevention

Cited by 25 publications

References 19 publications

Personalized Statin Therapy and Coronary Atherosclerotic Plaque Burden in Asymptomatic Low/Intermediate-Risk Individuals

Personalized Statin Therapy and Coronary Atherosclerotic Plaque Burden in Asymptomatic Low/Intermediate-Risk Individuals

Point-of-care testing to promote cardiovascular disease risk assessment: A proof of concept study

Detection of atherosclerotic cardiovascular disease influences the perceived need for aggressive lipid management

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