New UK CV Prevention Recommendations Take the Longer View

Shelley Wood

March 25, 2014

LONDON, UK — Cardiovascular-disease prevention efforts should extend to people with low short-term risk but high lifetime risk of cardiovascular events, according to new CV prevention recommendations released today by the Joint British Societies[1].

The Joint British Societies' Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) puts particular emphasis on lifetime risk and is being launched with an online tool designed to boost the adoption of lifestyle changes early on, thereby reducing CV events down the road. Understanding the "continuum of risk," the authors argue, is particularly important in young people and in women whose 10-year CVD risk is very low but whose lifetime risk is much higher.

JBS3 is published today in Heart.

Recent National Heart, Lung, and Blood Institute–sponsored ACC/AHA guidelines and an accompanying CV risk calculator have drawn fire for their emphasis on older subjects. In particular, critics say, the guidelines would see too many people on statins just because of their advanced age, and not enough younger people whose risk factors or family history warrant more aggressive interventions.

The ACC/AHA cholesterol guidelines include recommendations to initiate statin therapy in individuals who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease of >7.5%.

The JBS3 recommendations, by contrast, use a higher 10-year risk of CVD—"threshold to be defined by [National Institute for Health and Care Excellence] NICE guidance." The draft NICE guidance currently under review (to be finalized this summer) uses a cut point of 10%, down from 20% in the last NICE document, but higher than the 7.5% in the ACC/AHA guidelines, Dr Iain Simpson (Wessex Cardiac Unit, University Hospital Southampton, UK), president of the British Cardiovascular Society and a member of the editorial group for JBS3, explained to heartwire . JBS3 also states that drug therapy can be considered in individuals with high lifetime CVD risk estimated from "heart age and other JBS3 metrics" in whom lifestyle changes alone are considered insufficient by the physician and person concerned.

"Heart age" can be estimated using an online JBS3 calculator that draws on individual age and risk factors. The tool can then also be used to estimate what benefits specific interventions, including lifestyle changes, would have on modifying lifetime risk.

"The 10-year risk tends to depend very much on age and gender, neither of which are modifiable," Simpson said. "It seems slightly illogical to use that as a basis for your cardiovascular risk. It also discriminates against younger people and particularly females who may be at low 10-year risk but at very legitimate risk of cardiovascular events long term. We know that atherosclerosis develops early, so it seems logical that earlier intervention, whether that's lifestyle or drug treatment, is likely to have a greater impact on CV disease in the longer term."

A Lifelong Healthy Heart

Asked why the ACC/AHA guidelines didn't address longer-term risk, Simpson pointed out that the ACC/AHA process, like the NICE guidelines, "are very constrained" by the quality and nature of evidence they are permitted to consider. "One of the differences with JBS3 is that we have produced this as consensus recommendations, rather than formal guidelines. . . . So it's a much more integrated approach, and it allows people to interpret and give expert views on the evidence. There is less [clinical-trial] evidence for using lifetime risk, which is probably why some of the other guidelines have tried to keep away from it on the basis that it may be intuitive; there isn't strong evidence to back up its utility, but it seems to us to be the obvious direction of travel."

The 68-page document tackles lifestyle, childhood and adult obesity, blood pressure, and lipids in primary prevention and in the presence of existing CVD, peripheral arterial disease, diabetes, and other disease settings. All of the recommendations incorporate separate society recommendations for each risk factor, and the specific recommendations will be available on an open-access basis following publication of the paper, Simpson said.

Giving Choices to Patients

In the interview, Simpson stressed the pivotal role of the JBS3 calculator, which he called "a very creative approach to trying to communicate cardiovascular risk."

Currently the calculator is freely accessible to the public but has not been "sufficiently developed" in terms of help screens and interpretation such that it can be "entirely patient-facing." Instead, the idea is that people use the tool in conjunction with a healthcare provider.

The idea is not that the tool will give the user a specific number or arbitrary threshold at which a certain drug therapy or action should be taken, Simpson explained. "What it's doing is giving the choice back to the individual about how they manage their risk, and it's emphasizing the importance of lifestyle intervention and particularly the importance of lifestyle interventions at a young age to invest for future CV health."

After calculating health age, the tool allows for users to change their risk-factor levels—what would happen if they lowered their systolic BP or stopped smoking, for example. "If you make adjustments to your risk factors by lifestyle changes, you may well find that the long-term benefit of doing that will be the equivalent of or potentially greater than intensive drug therapy at a time in the future when you've reached a high short-term CV risk. So it's giving the choice back to the individuals."

This works both ways, Simpson stressed. It could mean that a young woman at very high long-term risk might, after discussing with her physician, decide she wants to take a statin. But by the same token, an older patient in whom a statin is recommended by current guidelines on the basis of age but who otherwise may have optimal risk factors may decide that he doesn't want to start drug therapy—the benefits being too incremental over the short term.

"This is about giving the individual the information to make an informed decision."

The plan currently under discussion with health authorities in the UK is to have the JBS3 tool integrated into the primary-care IT system, such that healthcare providers can use test results already in the patient's record to calculate lifetime risk and heart age, so as to start the discussion on CV prevention.

The authors of JBS3 disclosed having no competing interests.

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