BLOG: Speakers highlight, debate approaches to CV risk assessment

DALLAS — With all the excitement over risk prediction related to the new American College of Cardiology/American Heart Association 2013 Guideline on the Assessment of Cardiovascular Risk — the so-called “calculator-gate” — it was apropos that I spent the afternoon and evening of Nov. 19 in two sessions at AHA 2013 about CV risk prediction.

2 p.m.

In conference room D167, I attended a session focused on CV risk prediction and multimarker approaches. It was moderated by Matthew A. Allison, MD, MPH, from the University of California, San Diego, School of Medicine, and Joseph Yeboah, MD, MS, from Wake Forest Baptist Health.

A highlight of the session was Jonathan Rubin, MD, from Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, speaking about the interaction of the Framingham Risk Score and exercise capacity for the prediction of all-cause mortality. Rubin presented findings from the FIT project showing that fitness is strongly associated with mortality across Framingham Risk Score categories. These results were nicely complemented by several other presentations from well-known cohorts such as Atherosclerosis Risk in Communities (ARIC), the Cardiovascular Health Study, the Dallas Heart Study and Framingham suggesting that multimarker approaches may improve classification. The research findings suggested that different approaches may need to be taken, depending on the disease or endpoint of interest.

Seth S. Martin

During the question and answer sessions, many questions were raised by David C. Goff, Jr., MD, dean of the Colorado School of Public Health and co-chair of the ACC/AHA risk assessment guidelines, who asked presenters whether he or she agreed that risk assessment should remain a key element of guidelines to guide treatment decisions. The presenters unanimously said yes, but when asked more difficult questions like how to best incorporate novel multimarker approaches to risk prediction in practice the answer became less clear.

5:30 p.m.

Leading into the evening, a second session debated whether we can agree on approaches to risk assessment. The session was moderated by Vera A. Bittner, MD, of the University of Alabama at Birmingham and a Cardiology Today Editorial Board member.

A series of leading experts stepped up to the podium. Daniel Steinberg, MD, PhD, of the University of California, San Diego, made a compelling case to shirt our paradigm of statin allocation to focus more on younger individuals at risk, rather than the “geriatric approach” that we currently gravitate to with our risk calculators driven by age. Michael Blaha, MD, MPH, of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, showed how an imaging-based screening strategy could help implement the strategy discussed by Dr. Steinberg. We could use imaging to identify those with measurable atherosclerosis in whom we could then treat early and aggressively. Dr. Blaha supported the argument with strong data on coronary artery calcium in risk assessment through a careful and insightful discussion of recent studies. Is seeing believing?

Michael H. Davidson, MD, a Cardiology Today Editorial Board member from the University of Chicago Medicine, shifted the discussion to nonimaging-based approaches using novel biomarker-based risk assessment. Such strategies could be complementary to imaging-based strategies. He discussed granular lipid and lipoprotein measures, as well as high-sensitivity C-reactive protein and the omega-3 index. He demonstrated how a multimarker approach can reveal multiple underlying mechanisms/pathologies, and how such information could help inform treatment decisions.

Finally, Jennifer Robinson, MD, MPH, from the University of Iowa College of Public Health, discussed a benefit-based approach starting with a discussion of the Institute of Medicine approach to guideline development. Unlike the other presenters, she made a point to emphasize what we don’t know, rather than what we do know.

Overall, with so many great minds in one room it was an intellectually stimulating afternoon and early evening in D167 at AHA 2013.

Seth S. Martin, MD, is a clinical fellow at The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. He can be reached at The Johns Hopkins Division of Cardiology, 600 N. Wolfe St./Carnegie 568, Baltimore, MD 21287; email: smart100@jhmi.edu.

Disclosure: Martin reports no relevant financial disclosures.