ASCVD risk assessment practices miss opportunity to identify eligible young adults
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Long-term prediction tools can further discriminate a subgroup of young adults with elevated atherosclerotic CVD risk as candidates for preventive therapy despite having low estimated short-term risk, researchers reported.
In 2018, the American Heart Association and the American College of Cardiology issued a cholesterol guideline recommending the use of pooled cohort equations to estimate 10-year ASCVD risk; however, such equations are not directly applicable to young adults because they were developed in and recommended only for adults aged 40 to 75 years, researchers wrote.
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“The study findings suggest that it is important to estimate young adults’ long-term CV in addition to their short-term risk,” Jaejin An, PhD, a research scientist and assistant professor in the department of health systems science at Kaiser Permanente Bernard J. Tyson School of Medicine, told Healio. “The study showed that the 30-year risk prediction tools have an overall better performance compared with the 10-year risk models and may help to further identify subgroups of young adults with elevated ASCVD risk despite low estimated 10-year risk. This is consistent with the 2018 AHA/ACC cholesterol guideline, which recommends the estimation of lifetime or 30-year ASCVD risk for adults younger than age 40 years.”
10-year vs. 30-year predicted risk
An and colleagues compared the performance of 10-year, 30-year and lifetime ASCVD risk prediction tools recommended by the 2018 AHA/ACC cholesterol guideline in a large diverse sample of 414,260 young adults aged 18 to 39 years from 2008 to 2009. The mean age of adults was 30 years and 60.6% were women. Researchers followed the cohort through 2019.
“We evaluated characteristics of young adults with elevated short-term or long-term predicted ASCVD risk and the incidence of ASCVD associated with short-term and long-term predicted risk categories,” the researchers wrote.
The findings were published in the Journal of the American College of Cardiology.
The median 10-year predicted ASCVD risk was 0.6% and median 30-year predicted risk was 3.1%. Within the cohort, 813 adults had an incident ASCVD event during a median of 4 years.
Compared with 10-year predicted risk, 30-year predicted risk improved reclassification (net reclassification index: 16%) despite having similar discrimination (Harrell’s C: 0.749 vs. 0.726).
Overall, 1% of young adults were categorized as having elevated 10-year predicted risk ( 7.5%), 2.2% were categorized as having elevated 30-year predicted risk ( 20%) and 1.6% were classified as having low 10-year risk but an elevated 30-year predicted risk.
The ASCVD incidence rate per 1,000 person-years was 2.6 (95% CI, 1.92-3.52) for those with elevated 10-year predicted risk, 1.87 (95% CI, 1.42-2.46) for those with low 10-year but elevated 30-year predicted risk and 0.32 (95% CI, 0.3-0.35) for those with low 10-year and 30-year predicted risk.
Compared with young adults who had low 10-year and low 30-year predicted risk, the age- and sex-adjusted incidence rate ratio was 3.04 (95% CI, 2.25-4.1) for young adults with a low 10-year predicted risk but elevated 30-year risk, according to researchers.
“Kaiser Permanente Southern California has built population-based care management programs using clinical information systems and decision support tools, including the Kaiser Permanente ASCVD Risk Estimator (10-year risk prediction), for routine patient care,” An told Healio. “Further incorporating a 30-year risk prediction tool into the existing estimator is something we will present to clinical leadership for consideration. The move has the potential to facilitate a discussion between clinicians and patients. We hope other health care systems also consider using the 30-year risk prediction tool to identify young adults as candidates for lipid-lowering therapy and other preventive measures.”
Risk assessment ‘must evolve with age’
In a related editorial, Donald M. Lloyd Jones, MD, ScM, FACC, FAHA, chair of the department of preventive medicine at Northwestern University Feinberg School of Medicine and immediate past president of the AHA, and John T. Wilkins, MD, MS, assistant professor of medicine (cardiology)/preventive medicine at Northwestern University Feinberg School of Medicine, wrote that the findings create the opportunity to review the current status of risk assessment approaches across the life course, noting that diverse issues come to the fore at different life stages.
“Our approach to ASCVD (and heart failure) risk assessment must evolve with the age of the patient, just as our prevention strategies do,” Lloyd-Jones and Wilkins wrote. “Future guidelines should consider such a life course approach to risk assessment to assist decision making and maximize the sensitivity, efficiency, and cost-effectiveness of intensive preventive strategies at each stage of life.”
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Jaejin An, PhD, can be reached at jaejin.x.an@kp.org; Twitter: @jaejin_an1.
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