Just over a year ago, the PREVENT calculator to predict cardiovascular risk was released by American Heart Association. It was praised for being an improvement over a 2013 model that did not take into account accompanying conditions such as kidney disease or type 2 diabetes, or include people from more diverse backgrounds.
PREVENT quickly attracted attention for its potential to reduce the number of Americans eligible to receive commonly prescribed cholesterol-lowering statins, as predicted in two analyzes published in June and July.
A less noticeable change was the addition of heart failure to the risk calculator’s estimated conditions, in addition to the traditional targets of heart attack and stroke. Heart failure is a serious disease, meaning the heart can no longer pump blood around the body as well as it should. It is different from diseases that narrow the blood vessels that supply the heart or brain.
There is no cure for heart failure, making it more urgent to identify who is at risk. PREVENT allows that risk to be estimated using information typically collected during a regular primary care visit.
“There have been previous approaches to assessing risk for heart failure, but they always required more expensive or intensive testing,” Timothy Anderson, a family physician at the University of Pittsburgh Medical Center, told STAT. “We can assess your risk, but we need to do an ultrasound of your heart or ECGs first.”
Anderson and colleagues reported Monday that they used PREVENT to model the risk of heart failure versus other types of cardiovascular disease and found that there is a substantial group of people who are at risk for heart failure but are not at risk for the more common condition of arteries clogged by plaque. which can cause angina pectoris, heart attacks and strokes. More than half of the participants at risk for heart failure had high blood pressure; half were overweight or obese.
“That’s a new high-risk population,” Anderson said. “Early detection of risk is so important because once it’s present, it’s not like a heart attack where we can stent and fix it. We are often quite limited in undoing damage. This is actually about slowing down or preventing heart failure.
The jury is still out on how the PREVENT model will shape new guidelines to be reached jointly by AHA and the American College of Cardiology on statin use. (These guidelines, which will affect the standard of care in primary and specialty care, are not expected until 2026.) But they already provide new insights into cardiovascular disease, the number one cause of death in the United States.
The newly updated calculator estimates that 15 million American adults are at high risk for heart failure. Most of them are also at high risk of heart attacks and strokes, which can be caused by plaque-clogged arteries. But it seems unlikely that 4.3 million of those at high risk for heart failure will develop these other forms of cardiovascular disease, known as atherosclerotic cardiovascular disease, or ASCVD.
To arrive at these estimates, researchers applied the PREVENT calculator to data from 4,872 adults ages 30 to 79 who had no known cardiovascular disease and responded to national surveys from 2017 through 2020. The goal was to determine the PREVENT equations to model the risk of heart failure and cardiovascular disease over ten years for the 143.2 million Americans in this age range.
Their conclusion: the average estimated ten-year risk of heart failure was 3.7%, while 15 million adults had a risk of more than 10%. Most of these people also had a high risk of atherosclerotic cardiovascular disease. An estimated 4.3 million adults had a low risk of atherosclerotic cardiovascular disease, but a greater than 10% risk of heart failure. Among that group, most (62%) were 70 to 79 years old and 14% were black adults.
Sadiya Khan, a cardiologist at Northwestern Medicine and lead chair of the AHA writing group that produced the PREVENT risk model, cited two factors that influenced the addition of heart failure: a recognition of the increasing burden of heart failure hospitalizations and deaths, as well as a growing body of evidence on therapies to reduce heart failure.
“Overall, this is very useful data to quantify the distribution of risk for each type of cardiovascular disease,” she told STAT. She was not involved in the investigation. “I think it really highlights and emphasizes the importance of the PREVENT model, which allows you to not just calculate total CVD, or just ASCVD, or just heart failure, but do it at the same time.”
Although not surprising, she said, it is important to identify factors such as obesity or a high BMI in the risk of heart failure and cholesterol in atherosclerotic cardiovascular disease.
Until PREVENT, there was no paradigm to estimate the risk of heart failure. Anderson envisions the risk calculator being used to determine who could benefit from more testing. Future avenues to explore include learning which blood pressure medications may be best, not only for people with heart failure, but perhaps also to prevent them from developing it.
“There’s a lot to consider when it comes to thinking about how therapies reduce the risk of cardiovascular disease, whether that’s ASCVD or heart failure, and which therapies might more differentially benefit someone at higher risk for heart failure than ASCVD risk, or vice versa,” says Khan. said. “I think this is very important work that needs to be done.”
But don’t forget statins.
“We don’t think of statins as something that’s particularly helpful in heart failure, but we do know that heart attacks can lead to heart failure, and statins are certainly helpful in preventing heart attacks,” Anderson said. “There is probably a lot more to be done to better tailor the risk assessment for people.”
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