Editor’s Corner: Educating Patients About Cardiovascular Risk | Alfred A. Bove, MD, PhD Editor-in-Chief, CardioSource WorldNews
CardioSource WorldNews | Since my practice is focused on ambulatory cardiology for patients with chronic cardiac conditions, I find myself spending considerable time with them explaining their health status based on measures that identify high risk for coronary heart disease. Most patients will ask about their risk for coronary heart disease in the context of their own measurements. So, I am asked, for example, about how much added risk is created when LDL is 125 instead of 100, or when A1c is 7.0 versus 6.0. These questions often arise during discussion of how they can reduce their risk.
Similar questions surface regarding target blood pressure, particularly in light of the recent findings from the SPRINT hypertension trial. To answer the patient’s questions, we need data from large studies that encompass a variety of factors that can include family history, patient age, sex, ethnicity, and behaviors such as smoking, excess alcohol intake, use of recreational drugs, social background, and lifestyle.
To provide our patients with an intelligent assessment of their cardiovascular risk, we have seen the development of risk scores that provide population-based estimates of coronary heart disease risk derived from longitudinal studies where observations can be made over many years, allowing us to craft and expand a concept of how these various risk factors influence the health outcomes of our patients at risk for heart disease.
We have risk scores for a number of cardiovascular and other diagnoses. Risk scores for stroke risk in atrial fibrillation (AF), for bleeding risk on anticoagulant therapy, for heart failure outcome, and a number of risk scores for cancer. In our cardiology world, the Framingham Risk Score held sway for many years. This risk score incorporated the measures we use in managing patients with heart disease, and became an important means of assessing patient risk for coronary heart disease. However, it was limited by its measures from a single population.
Despite this limitation, the Framingham score became ingrained in our practices as a tool to assess cardiovascular risk. Both physicians and patients could understand the origin of the data, the value of a follow-up period of 12 to 15 years, and the conversion of the risk into numerical values that could be followed over time to determine if risk reduction therapies were effective. In 2013, the Framingham-based risk score was updated to include Caucasian and African-American patients, stroke risk, and a larger population base that supplemented the Framingham data with data from several other large databases. The ACC/AHA atherosclerotic cardiovascular disease (ASCVD) risk estimator is similar to the Framingham risk estimator but covers a larger population base. After much debate on the accuracy of the new risk score, the cardiology community has accepted this risk calculator for assessing CVD risk.
Newer risk scores like GRACE provide an assessment of risk in patients with documented coronary disease. Besides the ASCVD composite score for coronary risk, we have improved on scores as more data became available: CHADS2 evolved into CHA2DS2-VASc in assessing stroke risk in atrial fibrillation, for example, and HAS-BLED has become more of a go-to score than HEMORR2HAGES for bleeding risk in these patients. How can a risk score help us in our day-to-day practice of cardiology? From the provider perspective, useful information on patient management comes from assessing a SYNTAX score prior to proposing a method of revascularization. With the CHA2DS2-VASc score, we can make decisions regarding the use of an anticoagulant in patients with AF based on easily determined variables, and assess their bleeding risk as well with HAS-BLED.
But most patients don’t look at risk scores. They are focused on target values that they can change with medications and lifestyle changes. So a change in LDL toward a stated goal is better understood by the patient even though it may not have the same significance as a reduction in composite risk score.
As clinicians, our goal should be to both understand the impact of changes in patient status on overall cardiovascular risk, and to point out improvements in individual measures that encourage patient motivation to improve their risk. It is important to remind patients that the scores are estimates of risk based on population statistics; a personal discussion tailored to each patient is still needed to encourage healthy behaviors that lower cardiovascular disease risk.
Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.
|Read the full September issue of CardioSource WorldNews at ACC.org/CSWN|
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