GRUNDY
ET AL., Assessment of Cardiovascular Risk
J Am Coll Cardiol 1999;34:1348--59
AHA/ACC
Scientific Statement: Assessment of Cardiovascular Risk
by Use of Multiple-Risk-Factor Assessment Equations
A
Statement for Healthcare Professionals From the American
Heart Association and the American College of Cardiology
VIII.
Absolute Short-Term Risk
Estimates
of short-term risk (absolute risk in the next 10 years)
are potentially useful for the identification of patients
who need aggressive risk reduction in the clinical setting.
Patients at high short-term risk may need pharmacological
agents to control risk factors. The precise level of absolute
risk that defines a patient at high short-term risk has
been an issue of some uncertainty and involves a value
judgment. Theoretically, this level of risk justifies
aggressive risk-reduction intervention and is set through
an appropriate balancing of efficacy, costs, and safety
of therapy. Over time and depending on economic considerations,
the thinking about this critical cutpoint of risk may
change. Furthermore, little dialogue has occurred in the
United States regarding the process of choosing a single
absolute risk cutpoint for high short-term risk. The NCEP
has taken the lead in adjusting the aggressiveness of
cholesterol-lowering therapy to the absolute risk of patients.
The NCEP identified patients having established CHD and
other atherosclerotic disease as being at very high risk
and deserving of aggressive therapy. For primary prevention,
LDL-C goals were established by counting risk factors,
but they did not define absolute risk in precise, quantitative
terms. Future guidelines for risk reduction in the United
States likely will put greater emphasis on quantitative
global risk assessment.
Recently,
guidelines of the joint European Societies9
have identified high short-term risk as an absolute
risk that imparts a >20% probability of developing
CHD in the next 10 years. Once a patient reaches this
threshold of risk, guidelines similar to those for secondary
prevention are triggered. This threshold may be reasonable,
but several comments must be made about how the European
guidelines were derived. The authors9
made use of older Framingham risk equations,29
but their own risk estimates were based only on age,
cigarette smoking, blood pressure, and total cholesterol.
HDL-C levels were not included. Framingham risk equations2,
29
consistently include HDL-C, which is a powerful independent
risk factor. The absence of HDL-C as a risk factor in
European guidelines must be considered a limitation.
As previously mentioned, European guidelines9
used Framingham's total CHD as the coronary end point,
which is a liberal coronary outcome and lowers the barrier
to initiation of secondary-prevention guidelines. Irrespective
of these details, there appears to be considerable consensus
in the European cardiovascular community that a 10-year
risk for clinical coronary end points of >20% justifies
the category of high short-term risk. One concern about
European guidelines is that although they creatively
bridge the gap between primary and secondary prevention,
they seemingly deemphasize the need for long-term primary
prevention in the clinical setting.
Copyright
© 2000 by The American Heart Association, Inc.
and
The American College of Cardiology
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