Assessing Personal Risk of Heart Attack and Heart Disease
New cholesterol guidelines from the American Heart Association and the American College of Cardiology (AHA/ACC) emphasize a personalized approach to determining an individual’s risk of cardiovascular disease (CVD) and tailoring treatment options. The guidelines have been endorsed by over 10 other medical societies. They offer improved risk-assessment scores and calculators and more individualized recommendations on lifestyle interventions as well as statin and non-statin drug therapies.
Having high cholesterol at any age significantly increases a person’s risk for cardiovascular disease. Extra cholesterol in the blood can be deposited in blood vessel walls, forming plaques and narrowing blood vessels. This is why the AHA/ACC guideline panel underlines the importance of educating people about adopting heart-healthy lifestyles to achieve and maintain healthy cholesterol levels. The emphasis on shared decision-making between patients and their healthcare practitioners is a major shift from the 2013 AHA/ACC guidelines, as is the focus on identifying and addressing lifetime risks for cardiovascular disease and the importance of lowering low density lipoprotein (LDL, “bad” cholesterol) levels in the blood.
Cardiovascular disease, which includes heart disease, heart attacks and strokes, is a serious health problem for Americans. It kills over 836,000 people in the U.S. every year—more than all forms of cancer and chronic lung disease combined. While coronary heart disease claims about 366,000 lives each year, heart attacks account for about 114,000 deaths, with 720,000 new and 335,000 recurrent heart attacks per year.
The new AHA/ACC guidelines include an updated risk calculator to estimate a person’s risk for having a major cardiovascular event (e.g., heart attack, stroke) in the next 10 years. The new calculator retains the 2013 risk factors (e.g., unhealthy lipid levels, smoking, diabetes, high blood pressure) and adds questions about statin treatment and aspirin therapy. And while the risk calculator can be used as a base-line assessment of risk, it has been expanded to include data from previous health exams to track a person’s risk over time.
The AHA/ACC guideline panel also recommends that healthcare practitioners discuss other factors with their patients that can contribute to their personal CVD risk. These include:
- Family history of early heart disease (male relative younger than age 55 years with CVD or female relative younger than age 65 years with CVD)
- Asian ancestry
- Metabolic syndrome
- Chronic kidney disease
- Chronic inflammatory conditions (e.g., rheumatoid arthritis, psoriasis, HIV)
- For women, history of pre-eclampsia or early menopause
- Persistently high cholesterol (LDL, 160 milligrams per deciliter (mg/dL) or higher; non-high density lipoprotein cholesterol (non-HDL) 190 mg/dL or higher)
- Persistently high triglycerides at or over 175 mg/dL
For select individuals, additional testing may be done to further refine their CVD risk. (Not all patients will have these tests performed.) Increased CVD risk is associated with:
- High-sensitivity C-reactive protein (hs-CRP) at or over 2.0 mg/dL
- Lipoprotein (a) at or over 50 mg/dL, or at or over 125 nmol/L
- Apolipoprotein B at or over 130 mg/dL
- Ankle-brachial index over 0.9 (compares blood pressure measured at the ankle with blood pressure measured at the arm)
Worthy of noting, the new AHA/ACC guidelines restore the importance of lowering LDL levels to less than 70 mg/dL in the blood for high-risk patients—a recommendation that was controversially removed in the 2013 guidelines. The new guidelines also include the recommendation to use coronary artery calcium score (as assessed by a cardiac CT scan) to determine whether or not to prescribe statins to patients with an intermediate CVD risk. The guidelines continue to stress that patients should try to reduce their risk of cardiovascular disease by first adopting a healthy lifestyle—including a healthy diet, regular exercise, and avoiding smoking.
By combining risk-assessment tools with doctor-patient communication for shared decision-making, the new AHA/ACC guidelines aim to provide a way for healthcare practitioners to collaborate with their patients on a personalized treatment plan based on individual risk, medications, and lifestyle.
Statins remain the “gold standard” for lowering blood lipid levels and are recommended at different treatment intensities depending on individual patient need. New non-statin medications, like ezetimibe and PCSK9 inhibitors, are recommended for high-risk patients when statins fail to lower LDL-cholesterol to desired levels.
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(January 31, 2018) American Heart Association. At-a-Glance: Heart Disease and Stroke Statistics. Available online at https://www.heart.org/-/media/data-import/downloadables/heart-disease-and-stroke-statistics-2018—at-a-glance-ucm_498848.pdf. Accessed on November 30, 2018.
(November 30, 2018) American Heart Association. 2018 Prevention Guidelines Tool CV Risk Calculator. Available online at https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Accessed on November 30, 2018.
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