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Current Heart Attack Screening Tools Are Not Optimal and Fail to Identify Half the People Who Are at Risk

Current cardiac screening tools used to prevent heart attacks fail to identify nearly half of the people who are actually at risk of having one, according to a new study led by Mount Sinai researchers. The results, published in a brief report on November 21, in the Journal of the American College of Cardiology: Advances, expose a major flaw in patient care: that following current screening guidelines may cause missed opportunities for early detection of heart attacks and prevention. The researchers assessed the accuracy of a widely used tool, the atherosclerotic cardiovascular disease (ASCVD) risk score, and of a newer measure, called PREVENT, which adds variables and is intended to provide a…

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 The Legacy of MESA – Providing Evidence for Subclinical Cardiovascular Disease in Risk Assessment

MESA was designed to study the prognostic value of subclinical atherosclerosis and other risk markers in a multi-ethnic population. In a series of landmark publications, MESA demonstrated that measures of subclinical cardiovascular disease add significant prognostic value to the traditional Framingham risk variables. In head-to-head studies comparing these markers, MESA established that the coronary artery calcium (CAC) score may be the single best predictor of CHD risk

 What Will the New Cardiovascular Risk Calculator Mean for Patients?

In November 2023, the American Heart Association unveiled the updated calculator, called PREVENT... A recently unveiled cardiovascular disease risk calculator that measures a patient’s risk for heart attack and stroke is better calibrated and more precise than its previous version, but if current treatment guidelines for cholesterol and blood pressure therapy remain unchanged, the new calculator may have unintended consequences, according to research from Harvard Medical School.

Articles of Interest

Cardiovascular risk assessment in daily clinical practice: when and how to use a risk score

Cardiovascular diseases (CVDs) remain a major cause of morbidity and mortality worldwide. The European Society of Cardiology Guidelines encourage the use of risk prediction models to enhance an adequate management of cardiovascular risk factors and the implementation of healthy behaviours.

Cardiovascular Risk Calculators – Use or Lose?

Clinical practitioners have used calculators such as the Framingham Risk Score to assess the probability that a patient will develop coronary heart disease (CHD) and to guide primary prevention therapy for decades.1 In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released an updated risk calculator which has been widely criticized and may lead to over-prescribing of cholesterol-lowering agents (namely statins), aspirin, and antihypertensive drugs.2,3 Over-use of preventative therapies is not without risk: statins increase the risk for type 2 diabetes and aspirin can cause gastrointestinal bleeding.4,5 While many of these risk calculators have been validated in multiple cohorts, questions still remain. Do these widely used tools potentially over-expose patients to preventative therapies by over-estimating risk?

How Accurate are Cardiac Risk Calculators?

The process of optimizing risk scores is akin to the classic dilemma of “picking your poison.” There does not appear to be a good solution as of now and efforts to better understand the mechanics underlying our current risk stratification models are certainly necessary. Equally as vital is a clearer picture of what the treatment goals should be for CVD prevention. Should we lower our threshold for treatment at the cost of exposing healthy people to medications or reserve therapy — and its associated harms – for only those with definite disease?

Major Limitations of Cardiovascular Risk Scores

Approximately half of all cardiovascular diseases (CVDs) stem from preventable risk factors, offering a promising avenue to curtail cardiovascular morbidity and mortality. Numerous cardiovascular risk scores are currently employed for predicting cardiovascular risk. However, many of these possess numerous limitations that can impact their effectiveness. Some scores lack validation in external cohorts, and others have demonstrated a tendency to miscalculate risk when applied to populations different from their origin relying on classical risk factors, which limit their sensitivity and do not explain all observed cardiovascular events.

A new tool to predict heart disease risk

The PREVENT equation — which takes kidney and metabolic health into account — estimates a person's risk of heart disease over the next 30 years.

Calculating risks for heart disease

Multiple factors can influence cardiovascular risk – and they can start to have an effect as early as in childhood or adolescence, said Vasan S. Ramachandran, M.D., a principal investigator and director of the Framingham Heart Study and chief of preventive medicine and epidemiology at Boston University’s Schools of Medicine and Public Health. “Cardiovascular disease is a life course disease,” he explained.

Fewer people may need statins to prevent heart disease, new study suggests

The researchers found that among the participants, the 10-year risk of developing heart disease determined with the new tool was about half that estimated with the previous one, according to the report published Monday in JAMA Internal Medicine. Using PREVENT to calculate the 10-year risk for developing heart disease, the researchers determined that some 40% fewer people would have met the criteria for a statin prescription. In other words, as many as 4 million people in the U.S. who currently take statins for primary prevention — meaning they have not had a cardiovascular event such as a stroke or heart attack — may not need them, said Anderson, lead author of the new study.

Framingham Risk Score might be outdated to assess CV disease risk

The Framingham Risk Score system for assessing the risk of cardiovascular disease among older people should be replaced with something more accurate, according to a study published Jan. 8 in the British Medical Journal (BMJ).

Framingham score adapted: a valid alternative for estimating cardiovascular risk in epidemiological studies

Framingham risk score (FRS) is an important cardiovascular risk assessment tool, based on objective measurements of blood pressure and lipid profile, among other factors. However, in large population surveys, these measures are not always available, which limits their use.

Major Limitations of Cardiovascular Risk Scores

Scientists have made significant advancements in improving cardiovascular risk models, tailoring them to accommodate a wide range of populations and devising scales for estimating cardiovascular risks that can account for all prevailing restrictions. Better understanding these limitations could improve the cardiovascular risk stratification.

Most Clinical ‘Calculators’ Overestimate Heart Attack Risk

Most “risk calculators” used by clinicians to gauge a patient’s chances of suffering a heart attack and guide treatment decisions appear to significantly overestimate the likelihood of a heart attack, according to results of a study by investigators at Johns Hopkins and other institutions. Physicians commonly use standardized risk assessment systems, or algorithms, to decide whether someone needs care with daily aspirin and cholesterol-lowering drugs or just watchful waiting and follow-up exams. These algorithms calculate heart attack probability using a combination of factors, such as gender, age, smoking history, cholesterol levels, blood pressure and diabetes, among others.

PREVENT Risk Score vs the Pooled Cohort Equations in MESA

PREVENT-ASCVD equations demonstrated a more accurate ASCVD risk-prediction stratification than the PCE. PREVENT performs best in women, nonsmokers, those with a greater degree of renal dysfunction, social deprivation, and Black individuals. PREVENT-HF overestimates risk of incident HF in a Multi-Ethnic Study of Atherosclerosis.

Risk assessment gone mad: the rise of risk evaluation and mass public deception

New risk scoring systems have been proposed, each claiming to predict, with greater accuracy than Framingham, the risk of a future cardiovascular event, at least in the population in which each was developed. Will ‘better’ scoring systems help us manage our patients better?

What a Polygenic Risk Score Can and Can’t Tell You

Scientists have made great strides in predicting the genetic risk of common diseases. Figuring out what to do with that information may be just as hard.

What are the features of calculators used to estimate cardiovascular risk?

To estimate risk, components incorporated into the risk calculator include the specific outcome for which the risk is being assessed, the proven independent factors that increase risk, the extent to which that risk is increased, and the timeframe over which the risk occurs.5 These components are determined by the population dataset that is used to create the risk calculator and known risk factors as defined by available guidelines.

What to Know About PREVENT, the AHA’s New Cardiovascular Disease Risk Calculator

After 10 years, the American Heart Association (AHA) has updated its cardiovascular disease risk calculator for all adults aged 30 to 79 years without known cardiovascular disease. The Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator is based on newer data from a larger, more diverse sample than the existing tool, the commonly used Pooled Cohort Equations (PCEs), released in 2013 for non-Black Hispanic and White adults aged 40 to 79 years. The PREVENT equations also take into account other health conditions, such as kidney and metabolic diseases, for determining the 10- and 30-year chances of both atherosclerotic cardiovascular disease and heart failure.

Resources

CVD Risk Estimator Plus

CVD Risk Estimator Plus is a clinical decision‑support app that unifies two cardiovascular prevention tools: the 2013 ACC/AHA Pooled Cohort Equations (previously known as the ASCVD Risk Estimator) and the American Heart Association's PREVENT™ Calculator*. Combining traditional ASCVD risk modeling with modern cardiovascular‑kidney‑metabolic (CKM)–inclusive risk equations, CVD Risk Estimator Plus provides clinicians with a comprehensive, personalized cardiovascular disease (CVD) risk assessment.

MESA Risk Score

An accurate estimate of 10-year CHD risk (MI, cardiac arrest, confirmed angina requiring revascularization, CHD death) can be obtained using traditional risk factors and coronary artery calcium (CAC). The MESA CHD Risk Score, which enables calculation of risk both before and after inclusion of an individual’s CAC score, can be used to aid clinicians in the communication of risk to patients and when determining risk-based treatment strategies.

PREVENT™ Online Calculator

The PREVENT equations estimate absolute 10-year risk for total cardiovascular disease (PREVENT-CVD), atherosclerotic cardiovascular disease (PREVENT-ASCVD) and heart failure (PREVENT-HF) for adults aged 30–79 years, and and 30-year risk for the same outcomes among adults aged 30–59 years.

ASCVD Risk Calculator (PCE 2013)

Pooled Cohort Equations (PCE) risk predicts 10-year risk for a first atherosclerotic cardiovascular disease (ASCVD) event.

Framingham Risk Score

There are several distinct Framingham risk models. MDCalc uses the 'Hard' coronary Framingham outcomes model, which is intended for use in non-diabetic patients age 30-79 years with no prior history of coronary heart disease or intermittent claudication. This version was selected because it is the most widely applicable to patients without previous cardiac events.

Cardiac Risk Calculator

A cardiac risk calculator uses your personal health information to gauge your future risk of cardiovascular disease (heart disease). The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.

CardioCal

This FREE application is a tool for estimating the risk of cardiovascular disease and offers therapeutic recommendations by the guidelines of the HEARTS in the Americas Initiative. It was developed using the risk charts published in 2019 by the World Health Organization (WHO)...

Heart Age Calculator

This calculator is intended for people aged 35–75 who do not have heart disease. If you or someone you care for has a heart condition,

My Heart Risk

The My Heart Risk™ is a mobile app that helps to track physical activity and predict health status including risks of cardiovascular disease.

Risk calculators

Health professionals often use risk calculators to assess their patients' 10 year cardiovascular risk to help them identifying the need for lifestyle changes and medication.