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Adding a life-course perspective to cardiovascular-risk communication

Abstract

Current practice in the primary prevention of cardiovascular disease (CVD) involves estimation of the short-term (typically 5–10-year) risk of developing CVD. This risk estimation can serve as the prelude to a conversation between physicians and patients about CVD risk and risk-reducing therapies. However, focusing solely on short-term risk directs these conversations towards individuals who, in all likelihood, have already accrued substantial atherosclerosis during their lifetime. We suggest that estimation of lifetime risk and other novel methods of risk communication, such as risk-adjusted age, should be used as an adjunct to 10-year risk estimation. We believe that these strategies will improve patient understanding of CVD risk, identify new sections of the population who might benefit from preventive therapy, and motivate lifestyle changes and adherence to therapy early in the course of disease progression.

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Figure 1: Sex-specific and age-specific population estimates of risk distribution among US adults aged 20–79 years, without diagnosed cardiovascular disease.
Figure 2: Prevalence of a low-risk profile at 20-year follow-up adjusted for age, sex, and ethnicity according to HLFs among participants in the CARDIA study.23

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References

  1. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 106, 3143–3421 (2002).

  2. Jackson, R. Updated New Zealand cardiovascular disease risk-benefit prediction guide. BMJ 320, 709–710 (2000).

    Article  CAS  PubMed  Google Scholar 

  3. British Cardiac Society et al. JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 91 (Suppl. 5), v1–v52 (2005).

  4. Perk, J. et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur. Heart J. 33, 1635–1701 (2012).

    Article  CAS  Google Scholar 

  5. Genest, J. et al. 2009 Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult—2009 recommendations. Can. J. Cardiol. 25, 567–579 (2009).

    Article  CAS  PubMed  Google Scholar 

  6. Grover, S. A. et al. Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy: the CHECK-UP study: a randomized controlled trial. Arch. Intern. Med. 167, 2296–2303 (2007).

    Article  CAS  PubMed  Google Scholar 

  7. Sheridan, S. L. et al. The effect of giving global coronary risk information to adults: a systematic review. Arch. Intern. Med. 170, 230–239 (2010).

    Article  PubMed  Google Scholar 

  8. Lloyd-Jones, D. M. et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 113, 791–798 (2006).

    Article  PubMed  Google Scholar 

  9. Pignone, M., Phillips, C. J., Elasy, T. A. & Fernandez, A. Physicians' ability to predict the risk of coronary heart disease. BMC Health Serv. Res. 3, 13 (2003).

    Article  PubMed  Google Scholar 

  10. van der Weijden, T., Bos, L. B. & Koelewijn-van Loon, M. S. Primary care patients' recognition of their own risk for cardiovascular disease: implications for risk communication in practice. Curr. Opin. Cardiol. 23, 471–476 (2008).

    Article  PubMed  Google Scholar 

  11. Webster, R. & Heeley, E. Perceptions of risk: understanding cardiovascular disease. Risk Manag. Healthc. Policy 3, 49–60 (2010).

    Article  PubMed  Google Scholar 

  12. Jackson, R. Cardiovascular risk prediction: are we there yet? Heart 94, 1–3 (2008).

    Article  PubMed  Google Scholar 

  13. Cavanaugh-Hussey, M. W., Berry, J. D. & Lloyd-Jones, D. M. Who exceeds ATP-III risk thresholds? Systematic examination of the effect of varying age and risk factor levels in the ATP-III risk assessment tool. Prev. Med. 47, 619–623 (2008).

    Article  PubMed  Google Scholar 

  14. Marma, A. K. & Lloyd-Jones, D. M. Systematic examination of the updated Framingham Heart Study general cardiovascular risk profile. Circulation 120, 384–390 (2009).

    Article  PubMed  Google Scholar 

  15. Berry, J. D. et al. Prevalence and progression of subclinical atherosclerosis in younger adults with low short-term but high lifetime estimated risk for cardiovascular disease: the coronary artery risk development in young adults study and multi-ethnic study of atherosclerosis. Circulation 119, 382–389 (2009).

    Article  PubMed  Google Scholar 

  16. Marma, A. K., Berry, J. D., Ning, H., Persell, S. D. & Lloyd-Jones, D. M. Distribution of 10-year and lifetime predicted risks for cardiovascular disease in US adults: findings from the National Health and Nutrition Examination Survey 2003 to 2006. Circ. Cardiovasc. Qual. Outcomes 3, 8–14 (2010).

    Article  PubMed  Google Scholar 

  17. Enos, W. F., Holmes, R. H. & Beyer, J. Coronary disease among United States soldiers killed in action in Korea; preliminary report. JAMA 152, 1090–1093 (1953).

    Article  CAS  Google Scholar 

  18. McGill, H. C. Jr & McMahan, C. A. Determinants of atherosclerosis in the young: Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Am. J. Cardiol. 82, 30T–36T (1998).

    Article  PubMed  Google Scholar 

  19. Berenson, G. S. et al. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: the Bogalusa Heart Study. N. Engl. J. Med. 338, 1650–1656 (1998).

    Article  CAS  PubMed  Google Scholar 

  20. Juonala, M. et al. Influence of age on associations between childhood risk factors and carotid intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study, the Childhood Determinants of Adult Health Study, the Bogalusa Heart Study, and the Muscatine Study for the International Childhood Cardiovascular Cohort (i3C) Consortium. Circulation 122, 2514–2520 (2010).

    Article  PubMed  Google Scholar 

  21. Loria, C. M. et al. Early adult risk factor levels and subsequent coronary artery calcification: the CARDIA study. J. Am. Coll. Cardiol. 49, 2013–2020 (2007).

    Article  PubMed  Google Scholar 

  22. Morrison, J. A., Glueck, C. J. & Wang, P. Childhood risk factors predict cardiovascular disease, impaired fasting glucose plus type 2 diabetes mellitus, and high blood pressure 26 years later at a mean age of 38 years: the Princeton-lipid research clinics follow-up study. Metabolism 61, 531–541 (2012).

    Article  CAS  PubMed  Google Scholar 

  23. Liu, K. et al. Healthy lifestyle through young adulthood and the presence of low cardiovascular disease risk profile in middle age: the Coronary Artery Risk Development in (Young) Adults (CARDIA) study. Circulation 125, 996–1004 (2012).

    Article  PubMed  Google Scholar 

  24. Wilkins, J. T. et al. Lifetime risk and years lived free of total cardiovascular disease. JAMA 308, 1795–1801 (2012).

    Article  CAS  PubMed  Google Scholar 

  25. Mihaylova, B. et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 380, 581–590 (2012).

    Article  CAS  PubMed  Google Scholar 

  26. Ford, I. et al. Long-term follow-up of the West of Scotland Coronary Prevention Study. N. Engl. J. Med. 357, 1477–1486 (2007).

    Article  CAS  PubMed  Google Scholar 

  27. Heart Protection Study Collaborative Group. Statin cost-effectiveness in the United States for people at different vascular risk levels. Circ. Cardiovasc. Qual. Outcomes 2, 65–72 (2009).

  28. Mitchell, A. P. & Simpson, R. J. Statin cost effectiveness in primary prevention: a systematic review of the recent cost-effectiveness literature in the United States. BMC Res. Notes 5, 373 (2012).

    Article  PubMed  Google Scholar 

  29. Lloyd-Jones, D. M. Short-term versus long-term risk for coronary artery disease: implications for lipid guidelines. Curr. Opin. Lipidol. 17, 619–625 (2006).

    Article  CAS  PubMed  Google Scholar 

  30. Edwards, A., Elwyn, G., Covey, J., Matthews, E. & Pill, R. Presenting risk information—a review of the effects of “framing” and other manipulations on patient outcomes. J. Health Commun. 6, 61–82 (2001).

    Article  CAS  PubMed  Google Scholar 

  31. Frileux, S., Munoz Sastre, M. T., Mullet, E. & Sorum, P. C. The impact of the preventive medical message on intention to change behavior. Patient Educ. Couns. 52, 79–88 (2004).

    Article  PubMed  Google Scholar 

  32. Brewer, N. T. et al. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol. 26, 136–145 (2007).

    Article  PubMed  Google Scholar 

  33. Pencina, M. J., D'Agostino, R. B. Sr, Larson, M. G., Massaro, J. M. & Vasan, R. S. Predicting the 30-year risk of cardiovascular disease: the Framingham Heart Study. Circulation 119, 3078–3084 (2009).

    Article  PubMed  Google Scholar 

  34. Hippisley-Cox, J., Coupland, C., Robson, J. & Brindle, P. Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ 341, c6624 (2010).

    Article  PubMed  Google Scholar 

  35. D'Agostino, R. B. Sr et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 117, 743–753 (2008).

    Article  Google Scholar 

  36. Wells, S., Kerr, A., Eadie, S., Wiltshire, C. & Jackson, R. 'Your Heart Forecast': a new approach for describing and communicating cardiovascular risk? Heart 96, 708–713 (2010).

    Article  PubMed  Google Scholar 

  37. Goldman, R. E. et al. Patients' perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies. Ann. Fam. Med. 4, 205–212 (2006).

    Article  PubMed  Google Scholar 

  38. Mason, D., Prevost, A. T. & Sutton, S. Perceptions of absolute versus relative differences between personal and comparison health risk. Health Psychol. 27, 87–92 (2008).

    Article  PubMed  Google Scholar 

  39. Soureti, A., Hurling, R., Murray, P., van Mechelen, W. & Cobain, M. Evaluation of a cardiovascular disease risk assessment tool for the promotion of healthier lifestyles. Eur. J. Cardiovasc. Prev. Rehabil. 17, 519–523 (2010).

    Article  PubMed  Google Scholar 

  40. Waldron, C. A., van der Weijden, T., Ludt, S., Gallacher, J. & Elwyn, G. What are effective strategies to communicate cardiovascular risk information to patients? A systematic review. Patient Educ. Couns. 82, 169–181 (2011).

    Article  PubMed  Google Scholar 

  41. Persell, S. D., Zei, C., Cameron, K. A., Zielinski, M. & Lloyd-Jones, D. M. Potential use of 10-year and lifetime coronary risk information for preventive cardiology prescribing decisions: a primary care physician survey. Arch. Intern. Med. 170, 470–477 (2010).

    Article  PubMed  Google Scholar 

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Both authors researched data for the article, contributed substantially to discussion of its content, and wrote, reviewed, and edited the manuscript before submission.

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Correspondence to Donald M. Lloyd-Jones.

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The authors declare no competing financial interests.

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Karmali, K., Lloyd-Jones, D. Adding a life-course perspective to cardiovascular-risk communication. Nat Rev Cardiol 10, 111–115 (2013). https://doi.org/10.1038/nrcardio.2012.185

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