Transcript
Speaker: You are listening to the What's the Proof podcast, where we seek to help doctors and other clinicians incorporate the best available evidence into their everyday clinical decision making. The content of this podcast is meant for educational purposes only and should not be construed as personalized medical advice. The views and opinions expressed are those of the host and guest, and no content on this podcast has been approved or sanctioned by Atrium Health.
Speaker: Last fall, the AHA announced the development of a new cardiovascular risk calculator that would replace the ASCVD risk calculator based on the pooled cohort equations. Well, it's finally here and we're going to break down all the details for you on today's episode of What's the Proof?
Speaker: Welcome to What's The Proof, the family medicine podcast that seeks to help family physicians and other clinicians incorporate the best available evidence into their everyday clinical decision making. My name is Bobby Scott and with me as always is Sandy Robertson. Welcome Sandy. I hope you're doing well today. Hey, good morning. Doing well. I hope you are. I'm doing well. Did you get a chance to view the eclipse?
Speaker: I did. I actually viewed it safely momentarily. How about you? I did not. I'm such an idiot sometimes. I was working at home and was really getting a lot done. I was being super productive. It was probably one of the most productive days I've had in a long time. Kids were off at their community day for school.
Speaker: So I had the house to myself and I was working and I had gone upstairs to I think go to the bathroom or something like that. And I came back downstairs, the room that I was working in, it was about three in the afternoon. And for those that are listening, if you're from not in this area, we had about 84 % coverage. We weren't in the totality zone, but I came down and walked into the room and I noticed like this is visibly darker in here.
Speaker: I couldn't figure out why. I totally forgot there was eclipse. I even went over to the window and I looked outside and looked up at the sky. I can't believe you're admitting this. Yeah, it's embarrassing. This audience doesn't know you all that well, Bobby. He really is very smart. He was just so into his work. Yeah, but I looked up at the sky out the window and I was like, it's not even cloudy. That's weird.
Speaker: Yeah, it wasn't until I was walking, probably two hours later, I was walking through my neighborhood and my neighbor walked past me and he's like, that eclipse was pretty cool, wasn't it? I was like, yeah, it was. Did it actually hit me? Okay, that's why it was so dark around three o 'clock.
Speaker: Oh man. Oh, that's funny. That's funny. It's not as fun when you don't have school age kids, they make a big deal out of it, but I did take a moment. And I learned that a welding helmet is satisfactory for protection of your eyes. So my husband was like, here's this hat from here. She just happened to have one of those at home, right? Oh yeah. I bet everybody has those at home. Master welder, I know. So I got to put the cool welding helmet on and look up. It's pretty cool. Yeah.
Speaker: Well, I know it's been a while since our last episode and so much so there's been a solar eclipse that has happened since then and hopefully it'll be before the next one. The next one. We have our next episode come out, but we're going to get started on today's topic. Today, we're going to break down in detail the new AHA prevent calculator.
Speaker: and the scientific statement that was released alongside of it. I'm so very excited to talk about this today because I really think this is going to reflect a massive sea change in the way we approach cardiovascular disease prevention going forward.
Speaker: I am very, very excited about it too. I've been anticipating it for quite a while. And there's one thing I know about family medicine doctors is that we just really enjoy change. We just embrace it. I mean, don't you think? Yeah, yeah. We all love change. Everybody does. I can't wait to tell everyone that ASCVD calculator on your, you know, that app on your phone, just, you know, we're going to replace it and have to recalculate and re -talk to our patients. Not different than aspirin, all the other things.
Speaker: Here we go. Speaking of change, before we really get into the new calculator, Sandy, can you walk our audience through some of the history of cardiovascular disease risk assessment that's kind of occurred up to this point? I will try to do my best. Very briefly, the Framingham 10 -Year Risk Score, I think we all remember Framingham. I had to Google it and just fun fact, Framingham started in Framingham, Massachusetts with 5 ,200 participants in 1948.
Speaker: So they are on their third generation now of data. Over 3 ,000 studies have been published based on the Framingham data. So we have a lot to give credit to the Framingham investigators and the NIH for that. So we started really looking at it with a calculator in 2008. The problem with the Framingham was the population was exclusively white.
Speaker: It predicted only coronary disease, and it did not include diabetes. So while it was a good starter, we really had to progress to something else. So luckily in 2013, we moved on to these pool cohort equations. We're going to refer to them as the PCEs. That's what the AHA always talks about. And this was developed from five large community -based cohorts. It was released in 2013.
Speaker: Lots of benefits to that. It included stroke as part of the ASCVD outcome. So it was no longer just a coronary outcome, but an ASCVD. It included black adults in the population and diabetes as a risk factor. So the clinical management guidelines were also released with this to make the recommendations about managing traditional blood cholesterol levels and subsequent updates and new guidelines have all referenced these, the gold standard.
Speaker: However, it became apparent with time that these pooled control, excuse me, pooled cohort equations, that's why I'm gonna call it PCEs, were actually overestimating the ASCVD risk, especially in women, and a new risk assessment tool was needed. So, this overestimation was thought to be multifactorial. So, you know, why are we deliberately doing this? Like, what's going on?
Speaker: And they think in part it's due to the changing prevalence of risk factors. So tobacco use has gone down, which is a great thing. Also the population trends in risk factor levels and changes in care patterns, you know, better cholesterol management, different things that have kind of progressed luckily as we've learned more about ASCVD. So the AHA set out to develop new risk assessment tools that would address all these shortcomings with our PCEs or pooled cohort equations.
Speaker: Yeah, speaking of loving change, when I was in residency is when these came out. So I had learned initially how to assess cardiovascular risk on the Framingham risk score. And then these came out and I remember everybody was just kind of like, what do we do with this? This is crazy.
Speaker: I know. We got used to it. I think one of the arguments at the time is like, everybody's on statin now. I know. We did realize over time that things did need to change with that. Here we are now today with the new calculator. One of the interesting things that the AHA did was that they recently defined a new disease state.
Speaker: which they have labeled cardiovascular kidney metabolic syndrome or CKM syndrome. And this recognizes that there is an interconnected nature of heart disease, kidney disease, obesity, and diabetes. And with that, they've developed an entire framework of risk -based prevention
Speaker: that integrates CKM staging and cardiovascular risk assessment using this new prevent tool. And in this framework, they recommended screening for CKM risk by assessing health behaviors and health factors, what they call life's essential eight, which is another trademark of the AHA. But this is basically, it includes eight different things, including diet, exercise, sleep, tobacco use, BMI, blood pressure, lipids, and blood glucose.
Speaker: And so when you screen for risk based on those behaviors and factors, they then recommend using the prevent calculator to assess the CVD risk in adults age 30 to 79. Then using this information, you can then place your patient in one of four CKM stages, which will then guide your management plan for reducing the CKM risk going forward. So they've given
Speaker: CKM four stages, not including stage zero, which basically means that you have no CKM risk factors. But stage one means that your patient has excessive or dysfunctional adiposity.
Speaker: Patients in stage two are those with established CKM risk factors. These would be things like hypertriglyceridemia, hypertension, diabetes, or CKD. Stage three patients have subclinical CVD and features of CKM. So this is a little more complex as this includes those with subclinical atherosclerosis, such as having an elevated coronary artery calcium score,
Speaker: you might have subclinical heart failure, which means like having a reduced ejection fraction or elevated cardio biomarkers without signs and symptoms. This would be like someone that has, you know, elevated baseline BMP, but they've really never had any signs or symptoms of heart failure. Or if they have CVD risk equivalents, which what they define as, you know, patients with a high 10 year CVD risk, meaning
Speaker: greater than or equal to 20 % or those with very high or very high risk CKD, meaning stage G4, G5, or very high risk according to the KDGO classification. And stage four patients are those that just have clinical CBD. So they've have coronary artery disease, they've had heart failure, they've had a stroke, peripheral arterial disease, and they actually include atrial fibrillation in that category as well.
Speaker: It looks like there's a lot of patients that will be in stage three. That's what I'm hearing. Okay. Stage three is a big stage. Yeah. Okay. One thing that's important to note is that the staging is dynamic, so patients can progress along this or they may potentially even regress along the stages.
Speaker: So, you can go down from a stage two to stage one. Yeah, it's a real positive. And in patients, recognizing that obesity is not always a factor in this syndrome, the patients that have conditions like diabetes can be classified as being stage two, for example, even if they don't have the adiposity that is characteristic of stage one.
Speaker: Okay, okay. So perhaps it would be helpful to illustrate this with a case example. How does that sound? Yeah, this is a good idea. All right. This is someone I think most of us see in a weekly basis. So let's call our patient John.
Speaker: 48 -year -old with hypertension and newly diagnosed type 2 diabetes. John is overweight and has a family history of heart disease. His recent lab tests have shown elevated triglycerides as well as another concern, albinuria. Bobby, walk us through the risk -based prevention strategies for CKM outlined by the AHA.
Speaker: Well, yeah, this is a classic example of the CKM syndrome where his metabolic issues having type 2 diabetes and elevated triglycerides alongside a diagnosis of hypertension are not only contributing to a heightened risk of developing cardiovascular disease, but are also beginning to impact his kidney health as evidenced by the presence of abuminuria.
Speaker: And this condition, where albumin is found in the urine, is an early sign of kidney damage and is particularly concerning in patients with diabetes, suggesting diabetic kidney disease. So, in short, John's health trajectory is very concerning. The discovery of albuminuria underscores the interconnected nature of these conditions, so it points to the urgent need for a comprehensive and integrated approach to his care.
Speaker: Now, because of his diabetes, hypertension, and now evidence of kidney disease, he would be classified as stage two CKM syndrome. And managing John's diabetes and hypertension more aggressively becomes crucial now, not just for his metabolic health, but also to help safeguard his kidney function and cardiovascular health going forward. So, depending on the levels of his abuminuria, you certainly would want him on an ACE inhibitor or an ARB.
Speaker: and likely an SGLT2 inhibitor. And for those listeners who may need a refresher on the use of SGLT2 inhibitors in CKD treatment, you can go back and listen to Episode 6 with Dr. Austin Bush, who discusses this in great detail and does a fabulous job.
Speaker: Yes, he does. So let's go back to John, though. An effective treatment plan for him involves obtaining metabolic control through medication and lifestyle modifications aimed at managing his weight, his blood pressure, his blood glucose levels. And additionally, we need to address the albuminuria, as I just mentioned. So these steps are vital to slowing the progression of kidney disease and curtailing the risk of cardiovascular complications.
Speaker: I was really struck by the comment in the AHA scientific statement that individuals with CKD are actually more likely to die of a cardiovascular event than they are to progress to kidney failure, which was really amazing to me.
Speaker: I think that's something we need to share with patients more. Yeah. I mean, it's a hard fact, but yeah, I agree. So really we need to do all that we can to help John and of course patients like John lower his risk for cardiovascular disease going forward. And this is where the prevent calculator comes in. Right. So this would be a good time, Sandy, I think would you explain how to use the prevent calculator? I will do my best. Okay.
Speaker: So at the time of this recording, there's not a smartphone app for this quite yet, but the Prevent Calculator can be found online on the AHA website, and we will include a link to it in the episode description. So the Prevent Calculator is based on regression models that were derived and validated in a total of 46 observational cohort studies and EMR data sets, leading to an N of, you ready?
Speaker: 6 .6 million adults aged 30 to 79 years of age. I know. A lot of patients. I know. A lot of data crunching. I know. I'm so glad that's not... Apologies to anybody who lives in Framingham, Massachusetts. I know. I know. So the model is sex -specific, but in a change from the PCEs, it's race -free and it's broadly generalizable. External validation studies have shown that the model performs with exceptional accuracy and precision.
Speaker: The calculator has a group of standard health factors that you must input, including sex, age, total cholesterol, HDL, systolic VP, BMI, estimated GFR, and from that you want to use the CKD -EPI equation.
Speaker: diabetes, current smoking, and whether the patient is taking antihypertensive medications and or lipid lowering medications. So a lot of these, this is common, this is not unusual for us, but I guess including the estimated GFR, that's something that's very different. They've also added three variables including the urine albumin creatinine ratio,
Speaker: hemoglobin A1C and the patient's home zip code. Now these are not absolute, they don't have to include that, but it's something that just gives you added information. And this last piece, this zip code, is an attempt to acknowledge the contribution of social determinants of health in cardiovascular risk assessment by using the zip code to estimate the social deprivation index, which is very intriguing. I would admit to you that I haven't read all the background on that, but
Speaker: just in the presentations that I've seen so far. This is really next level, right? Yeah, it's very cool. Yeah. So you put your patient -specific data into the calculator, and this part is really interesting. It not only gives you a risk estimate for atherosclerotic cardiovascular disease, but it also gives you a risk estimate for heart failure and a composite outcome of CVD, which includes both ASCVD and heart failure.
Speaker: Now, depending on the age of your patient, it will give you both a 10 -year estimated risk as well as a 30 -year estimated risk. So we are looking way in the future, which is a bit more useful than the lifetime risk previously given by the PCEs. The AHA gives the following guidance for interpretation of risk.
Speaker: So if a patient's 10 -year risk is less than 5%, they're in the low risk category. 5 % to 7 .4 % is considered borderline. If the risk is 7 .5 to 19 .9%, it is considered intermediate. And the patient with a 10 -year risk of 20 % or higher is considered high risk.
Speaker: It's interesting that they've added the heart failure component. Yes. There's a much greater emphasis on heart failure prevention in the scientific statement where they cite a greater relative increase in mortality from heart failure than ASCVD in recent years.
Speaker: Interestingly, heart failure is now the leading cause of hospitalization for people 65 years and older and is actually increasing in all age groups. They cite estimates that the lifetime risk for developing heart failure at age 45, which is an age that I'm getting uncomfortably close to, is now between 20 and 45%, which is astonishing to me. So in light of those statistics, I guess it really makes sense that we as family physicians
Speaker: will need to dedicate more energy to heart failure prevention. Absolutely. So getting back to our example patient, John, we would enter his numbers into the Prevent Calculator for an absolute risk assessment of CVD that would be integrated into the CKM staging framework to be used in risk management discussions going forward.
Speaker: So right now, that means applying previous ASCVD prevention and lipid management guidelines to this assessed risk until we have new management guidelines, of course, which you know will be coming out based on this new CKM framework. So I know that's a little bit confusing, but what are your thoughts on that, Bobby? Have you been, how do you see this being used, I guess, clinically right now where we are?
Speaker: Yeah, I think new guidelines will certainly be coming down the road. But until then, we're just going to have to figure out how to act on this new risk assessment in an individualized fashion in the best way possible. And this is me editorializing a bit here. But I do think a new approach to CBD prevention is long overdue.
Speaker: For a disease that is still the number one cause of death in America, we have what I think is a very underdeveloped evidence -based approach for prevention. I think the 30 -year risk estimate has the potential to be very helpful yet difficult at the same time.
Speaker: For example, consider those patients who are estimated to be borderline risk, and that's the 5 % to 7 .4 % 10 -year CVD risk. Now, when someone is borderline risk and they have risk factors, it's not really clear cut how aggressive you should be, and that's what we've been used to with the ACVD risk calculator as well. But cardiovascular disease is one that we know that develops over the course of decades.
Speaker: So, the historical focus on tenure risk seems a bit short -sighted, but this is where we have all the data on interventions such as statins. The scientific statement discussed how the group considered including other predictive markers such as ApoB or BNP, which is the B -type, natriuretic peptide, but for various reasons decided against that.
Speaker: And one thing I learned about from this statement was that the AHA had previously released a scientific statement to suggest for patients with a high LpA, which is another marker that has been identified as a risk -enhancing factor for ASCVD. You actually could multiply the 10 -year ASCVD risk from the PCEs. You can multiply that by a factor of 1 .1 for every 50 nanomoles per liter higher of LpA greater than 50.
Speaker: And you could use that to get an adjusted 10 -year predicted risk. I'd never seen that before, and I'm going to have to look at that a little more closely. But they did mention that these additional markers could be considered for use in sequential diagnostic testing to reclassify someone's risk. So perhaps identifying someone with subclinical disease that would put them in CKM Stage 3.
Speaker: This might be the patient you consider getting coronary artery calcium scoring to help you decide how aggressive you really want to be with lipid lowering. Perhaps you obtain a screening BNP level or an echocardiogram in the patient who has a high risk of developing heart failure based on this.
Speaker: We've had all of these different markers out there for a long time and it's just never been perfectly clear what to do with them in framing your patient's cardiovascular risk. We're still not there, but I think we're moving in that direction. There actually are medications that are coming out that
Speaker: Likely you're gonna specifically lower lp. Little a which we've never had medications that do that before So I anticipate that in the future if they do if doing that actually is shown to improve cardiovascular outcomes And that may be something we're treating in the near future
Speaker: We've all understood for a long time that patients that have this chronic disease, trifecta of metabolic disease, cardiovascular disease, kidney disease, and now it's actually being called something called CKM syndrome. They've developed this over time and we knew that they were all connected.
Speaker: But now it seems that we actually have a useful tool that incorporates a lot of these considerations and we might be able to have better risk prevention discussions with our patients in the future.
Speaker: Yes, the authors of the scientific statement acknowledge that there are still some key gaps to fill in in terms of risk -based prevention, including better evidence for deciding when and for whom to obtain these additional predictive markers or diagnostic imaging to identify subclinical CVD. So like, for example, CT imaging or echocardiography.
Speaker: They acknowledge that additional research is needed to refine the contributions of social determinants of health, and a notable limitation in the prevent equations is that the number of Hispanic and Asian patients included is relatively lower than national estimates in the population.
Speaker: I agree that now that we have a more accurate and comprehensive risk estimator, we need much better data to guide us on these treatment decisions. So everyone comes to me as the pharmacist, how do we treat all these numbers and they'll rattle off these percentages.
Speaker: They want a one sentence answer and I always struggle with that like it's not that easy I can't just tell you based on the number what to do, right? Yeah, hopefully in the future We'll be able to so you need to be able to quantify the benefit of treatment more easily for these patients You need to be able to say your estimated 30 year risk for CBD is this and if we start this medication it will decrease to this and
Speaker: Right? I would love to be able to say that. But the calculator now at least includes statin treatment as a predictor that influences the overall risk estimate. And additionally, although diabetes is included as one of the key components of CKM syndrome, it is important to note that the authors emphasize the point that diabetes is not automatically associated with a high CVD risk.
Speaker: I think that's gonna take a moment for some of our listeners here. It used to be called a cardiovascular disease equivalent, right? A cardiovascular equivalent and that's now, it's like been downgraded a little bit. So I don't wanna overemphasize that, but we need to be careful with our words. It's a change. Yup. Prevent will potentially allow us to give a much more tailored approach to CVD risk for our patients with diabetes. For example, their estimated CVD risk may now play a much greater role
Speaker: in determining diabetic medication choices, particularly when it comes to GLP1s and SGLT2s and their known effects on cardiovascular outcomes, which we know is in general positive. The current guidelines still recommend statins for all diabetics, regardless of their estimated risk, based on the current evidence, but perhaps this will change in the future. I don't know.
Speaker: Yeah, we'll have to see. I think one of the things is noticeably different. I went in and took a female patient of mine that is not on a statin yet, but previously had estimates based on the PCEs. I think I shared this one with you. I think it was about 14 %
Speaker: Right. And for a 10 year CVD risk, and then plugging into this calculator, I think it was like four to 6%. And so I think there's going to be a lot of need to reevaluate our women patients especially, potentially
Speaker: even maybe taking them off of statin for a while, see what their baseline... Well, I mean, I guess you include statin, so maybe you can make an assessment based on that, but maybe you have to see what they're like without the statin again and just start over with assessing their risk. So maybe there's going to be a lot of people coming off statins in the near future. I don't know. We'll see.
Speaker: I don't know. One of the more fascinating aspects to me is how AHA is really leading a paradigm shift to begin with CVD risk assessment and prevention at a much earlier age. They suggest a life course approach that begins with screening and staging for CKM syndrome in childhood.
Speaker: as many of the modifiable drivers of CKM syndrome are established in early life, and we all see this. Risk factors develop in adolescence and early adulthood, typically resulting in subclinical or even clinical CVD in the 30s and onward. I really like this approach. It seems to mesh well with what we do as family physicians, and I think that there's a concrete clinical label for preclinical disease
Speaker: CKM stages one and two, and that might give our prevention conversations a bit more momentum for patients.
Speaker: Yeah, I agree. I feel like just trying to look at the entire life cycle, you know, we all have been there where when you finally had the first discussion about lifestyle when someone who is 60, it's very difficult to change those lifestyles when you've, you know, replicated that your whole life. So talking about that very early on and having some more concrete data, I think would be very, very helpful.
Speaker: So, to summarize what we've talked about today, I know it's a lot. Yeah. More to come on this topic, I'm sure. I know. Oh, I know. So, we believe the introduction of the AHA's Prevent Calculator represents a significant step forward in our approach to cardiovascular risk assessment.
Speaker: With this comprehensive framework that encompasses the new cardiovascular kidney metabolic syndrome, it offers a more nuanced understanding of the interconnectedness of various risk factors. The inclusion of a broader set of variables, including social determinants of health, allows for a more individualized assessment moving beyond the limitations of previous models.
Speaker: The challenge ahead really lies in integrating this tool into clinical practice effectively, ensuring that we use these enhanced risk assessment to guide more precise and impactful prevention strategies. That is no small task for sure.
Speaker: So, as we await further guidelines on the management based on this new model, it's crucial for us as clinicians to stay informed and adaptable, adaptability, ready to incorporate these advancements into our patient care, but being patient, we're not great at that.
Speaker: The journey towards more personalized and preemptive cardiovascular care is evolving, and tools like Prevent are paving the way for a future where we can offer our patients more targeted, effective interventions to reduce the risk and improve their overall health. Now, this is my question for you, Bobby. Are you already using the Prevent calculator?
Speaker: Yes, yeah. You're an early adapter? I'm an early adapter on this one. Not usually the adaptable, but this one I am. Yeah, I've used it in clinic a few times already. I've started to assign CCAM stages to my patients. Early returns suggest that it's going to be very helpful in these discussions going forward.
Speaker: The change is hard and we still face some of the same challenges and motivating behavioral changes as we've always had. However, it's encouraging because I think we're finally moving away from what I think is a very simplistic numbers -focused view of good cholesterol and bad cholesterol and towards a more holistic understanding of our patients' lives and guiding them towards healthy futures.
Speaker: So as we adapt to this new model, I encourage our listeners to explore the PREVENT tool, familiarize themselves with the CCAM staging, and just start integrating these into your risk prevention discussions. Patients seem to understand it. I think so. I think they've responded well. Good. So we'll put links to the PREVENT calculator and then the AHA scientific statement
Speaker: in the episode description for further reading on the topic. I hope people will start using it more going forward. Me too. I'm looking forward to seeing all the data and the newest guidelines are going to
Speaker: be tweaked and changed a little bit. And I agree. If at the end of the day we have better patient care and more accurate, I think our patients are really going to appreciate that. So all in all, it's a good thing. Change is good. Change is good. That's right. Well, as we wrap up today's episode, we'd like to thank all of you for listening. We are all still growing and improving as healthcare professionals, and we appreciate that you take the time to listen and engage with the evidence.
Speaker: So we encourage you to share this podcast with your colleagues, friends, and even your patients. We also invite you to share your experience, thoughts, and questions about the Prevent Calculator and CKM Syndrome with us. You can reach out to us at whatstheproofpodcast .gmail .com or through X, formerly known as Twitter, at The Proof Podcast. We'd love to hear from you. Until next time, this is What's The Proof? Have a great day.
