Cardiovascular risk prediction – are we missing something?
Published May 22, 2020 · J. Gallagher, C. Watson, M. Ledwidge
European Journal of Heart Failure
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Abstract
The prediction of total cardiovascular risk is gaining increasing importance in international guidelines as we seek to identify those people most at risk of cardiovascular disease in the general population, i.e. those without established cardiovascular disease.1,2 Guidelines also recommend the use of risk scores to identify those who would most benefit from treatment for conditions such as hypertension3 and hyperlipidaemia,2 and risk estimates are being used to inform policymakers as they plan health services for the future. However, there has been a proliferation of cardiovascular risk scores. A recent systematic review identified 363 prediction models for estimating cardiovascular risk in the general population.4 It noted that there is an excess of models predicting incident cardiovascular disease in the general population with methodological shortcomings and a lack of external validation and model impact studies. However, a point not identified is that the vast majority of models used atherosclerotic cardiovascular disease alone as the outcome. Only one score out of 363 involved heart failure as an outcome measure. For example, scores recommended to decide who should be treated for hypertension do not include heart failure as an outcome whereas the greatest benefit of blood pressure lowering is the prevention of heart failure.5 Although there have been efforts to develop scores for heart failure they have not been externally validated or undergone clinical impact studies.6,7 We are in a changing world of cardiovascular disease. Although ischaemic heart disease is the leading cause of cardiovascular health lost globally, as well as in each world region8 heart failure is a growing burden. The estimated absolute number of individuals with newly diagnosed heart failure in the UK is estimated to have increased by 12% largely due to an increase in population size and age.9 Also recent data from an observational cohort suggested a relatively small burden of residual atherosclerotic risk after aggressive risk factor modification in diabetes.10 However, there was a persistent increased risk of heart failure despite optimal risk factor control. This suggests an alternate strategy is required to identify the risk of, and curtail the threat of heart failure. This is not addressed in current cardiovascular prediction models or prevention guidelines.