Cardiovascular Risk Assessment in Primary Prevention (Contemporary Cardiology) 3030988236, 9783030988234

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Contemporary Cardiology Series Editor: Peter P. Toth

Michael D. Shapiro  Editor

Cardiovascular Risk Assessment in Primary Prevention

Contemporary Cardiology Series Editor Peter P. Toth Ciccarone Center for the Prevention of Cardiovascular Disease Johns Hopkins University School of Medicine Baltimore, MD, USA

For more than a decade, cardiologists have relied on the Contemporary Cardiology series to provide them with forefront medical references on all aspects of cardiology. Each title is carefully crafted by world-renown cardiologists who comprehensively cover the most important topics in this rapidly advancing field. With more than 75 titles in print covering everything from diabetes and cardiovascular disease to the management of acute coronary syndromes, the Contemporary Cardiology series has become the leading reference source for the practice of cardiac care. More information about this series at https://link.springer.com/bookseries/7677

Michael D. Shapiro Editor

Cardiovascular Risk Assessment in Primary Prevention

Editor Michael D. Shapiro Section on Cardiovascular Disease Wake Forest University School of Medicine Winston Salem, NC, USA

ISSN 2196-8969     ISSN 2196-8977 (electronic) Contemporary Cardiology ISBN 978-3-030-98823-4    ISBN 978-3-030-98824-1 (eBook) https://doi.org/10.1007/978-3-030-98824-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Humana imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Although management of established atherosclerotic cardiovascular disease has improved dramatically, less has been achieved with regard to early detection and risk mitigation in primary prevention. The life trajectory of the average person (with stress, poor diet, excess body weight, inactivity, smoking, exposure to pollutants, and poor management of metabolic comorbidities) still leads straight to the development of this disease. Therefore, we have an unprecedented opportunity to focus on the prevention of atherosclerosis before cardiovascular events occur, an endeavor that starts with expert cardiovascular risk assessment. This is the first comprehensive text dedicated to risk assessment in the primary prevention of atherosclerotic cardiovascular disease, the number one cause of death and disability in the world. It provides a summary of current evidence regarding approaches to risk assessment, traditional and emerging risk factors, and atherosclerosis imaging for refinement of risk estimation. This book will empower readers to perform state-of-the-art risk assessment to facilitate the prevention of cardiovascular disease. In addition, this volume provides a glimpse into the future of the field with in-depth discussion regarding the latest advances and exciting developments in the pipeline. Multiple tables, figures, and illustrations complement the text. It is my sincere hope that Cardiovascular Risk Assessment in Primary Prevention will become a valuable resource for physicians, residents, fellows, and medical students in cardiology, endocrinology, primary care, and health promotion and disease prevention. May science lead the way to a healthier future. Winston Salem, NC, USA 1/31/2022

Michael D. Shapiro

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Contents

Part I Global Approaches to Risk Assessment 1 Cardiovascular Risk Assessment in Primary Prevention��������������������    3 Aliza Hussain, Mahmoud Al Rifai, Umair Khalid, and Salim S. Virani 2 Global Approaches to Risk Assessment: The US Guidelines ��������������   21 Anurag Mehta, Devinder S. Dhindsa, and Laurence S. Sperling 3 European Guidelines for Risk Assessment in the Primary Prevention of Cardiovascular Disease��������������������������   35 Christian Cawley and John W. McEvoy Part II Traditional Risk Factors 4 Hypercholesterolemia������������������������������������������������������������������������������   61 Ali Agha and Christie M. Ballantyne 5 Blood Pressure Control in Primary Care����������������������������������������������   73 LaShanda Brown, Jeff D. Williamson, and C. Barrett Bowling 6 Cardiovascular Risk Assessment in Metabolic Syndrome and Diabetes ��������������������������������������������������������������������������������������������   89 Nathan D. Wong 7 Primary Prevention: Smoking����������������������������������������������������������������  107 Donna Polk 8 At the Heart of the Matter: Obesity and Its Interplay with Preventive Cardiology��������������������������������������������������������������������  123 Jessica Bartfield, Alex Bonnecaze, and Jamy Ard

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Part III Risk Enhancers 9 Family History of Premature Atherosclerotic Cardiovascular Disease���������������������������������������������������������������������������  149 Amit Khera and Ezimamaka Ajufo 10 Primary Prevention and Cardiovascular Risk Assessment in Women ��������������������������������������������������������������������  177 Lori-Ann Peterson, Priya M. Freaney, and Martha Gulati 11 Ethnic Factors in the Assessment of Cardiovascular Risk for Primary Prevention������������������������������������������������������������������  199 Harpreet S. Bhatia, Irvin Xu, Pam R. Taub, and Michael J. Wilkinson 12 Triglyceride-Rich Lipoproteins��������������������������������������������������������������  227 Najdat Bazarbashi and Michael Miller 13 Inflammatory Diseases and Risk of Atherosclerotic Cardiovascular Disease: A New Focus on Prevention��������������������������  247 Renato Quispe, Bibin Varghese, and Erin D. Michos 14 Chronic Kidney Disease Is a Risk Enhancer for Cardiovascular Diseases��������������������������������������������������������������������  271 Kishan Padalia and Salim S. Hayek 15 Peripheral Arterial Disease and the Ankle–Brachial Index ����������������  307 Peter P. Toth Part IV Novel Risk Factors 16 Lipoprotein(a)������������������������������������������������������������������������������������������  327 Anne Langsted and Børge G. Nordestgaard 17 High-Sensitivity C-Reactive Protein������������������������������������������������������  347 David I. Feldman, Roger S. Blumenthal, and Ty J. Gluckman 18 Apolipoprotein B in Primary Prevention: Ready for Time Prime? ��������������������������������������������������������������������������������������  377 Renato Quispe, Bibin Varghese, and Seth S. Martin 19 Social Determinants of Cardiovascular Health������������������������������������  391 Melvin R. Echols, Rachel M. Bond, and Keith C. Ferdinand 20 Stress and Cardiovascular Disease��������������������������������������������������������  413 B. S. Rishab Revankar, Koushik R. Reddy, and Kavitha M. Chinnaiyan 21 Polygenic Risk Scores������������������������������������������������������������������������������  429 Mette Christoffersen and Anne Tybjærg-Hansen

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Part V Atherosclerosis Imaging as a Tool to Refine Risk Estimates 22 Coronary Artery Calcium ����������������������������������������������������������������������  449 Mohamad B. Taha, Dhruv Ahuja, Kershaw V. Patel, Miguel Cainzos-Achirica, and Khurram Nasir 23 Cardiac Computed Tomography Angiography for Prevention of Cardiovascular Events����������������������������������������������������  469 Rhanderson Cardoso and Ron Blankstein 24 Carotid Intima-Media Thickness and Plaque Assessment ������������������  487 Matthew C. Tattersall and James H. Stein Index�������������������������������������������������������������������������������������������������������������������� 505

Contributors

Ali  Agha  Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX, USA Dhruv  Ahuja  Maulana Azad Medical College, University of Delhi, New Delhi, India Ezimamaka  Ajufo  Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA Mahmoud  Al Rifai  Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Jamy Ard  Department of Epidemiology and Prevention, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Greensboro, NC, USA Christie  M.  Ballantyne  Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX, USA Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Jessica Bartfield  Department of Surgery, Department of Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center Weight Management Center, Greensboro, NC, USA Najdat  Bazarbashi  Department of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA Harpreet  S.  Bhatia  Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, CA, USA Ron  Blankstein  Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

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Roger  S.  Blumenthal  Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, The Johns Hopkins Hospital, Baltimore, MD, USA Rachel  M.  Bond  Division of Cardiology (RMB), Chandler Regional Medical Center, Dignity Health, Chandler, AZ, USA Alex Bonnecaze  Obesity Medicine Fellow, Department of Surgery, Department of Endocrinology, Wake Forest Baptist Medical Center, Greensboro, NC, USA C.  Barrett  Bowling  Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, NC, USA LaShanda  Brown  Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA Miguel  Cainzos-Achirica  Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA Rhanderson Cardoso  Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA Christian  Cawley  University Hospital Galway and SAOLTA University Health Care Group, Galway, Ireland National University of Ireland Galway, Galway, Ireland Kavitha  M.  Chinnaiyan  Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI, USA Oakland University William Beaumont School of Medicine, Rochester, MI, USA Mette Christoffersen  Department of Clinical Biochemistry, Section for Molecular Genetics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Devinder  S.  Dhindsa  Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA Melvin  R.  Echols  Division of Cardiology (MRE), Department of Medicine, Morehouse School of Medicine, Atlanta, GA, USA David I. Feldman  Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA Keith  C.  Ferdinand  Division of Cardiology (KCF), Department of Medicine, Tulane University Medical School, Tulane University, New Orleans, LA, USA Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA Priya M. Freaney  Northwestern University, Chicago, IL, USA

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Ty J. Gluckman  Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, OR, USA Martha Gulati  Cedars Sinai Heart Institute, Los Angeles, CA, USA Salim  S.  Hayek  University of Michigan, Department of Internal Medicine, Division of Cardiology, Ann Arbor, MI, USA Aliza Hussain  Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Umair Khalid  Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Department of Medicine, Michael E.  DeBakey VA Medical Center, Section of Cardiology, Houston, TX, USA Amit Khera  Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA Anne  Langsted  Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark Seth  S.  Martin  Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA Welch Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA John  W.  McEvoy  University Hospital Galway and SAOLTA University Health Care Group, Galway, Ireland National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Galway, Ireland Anurag  Mehta  Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA Erin  D.  Michos  Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA Michael Miller  Department of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA

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Contributors

Khurram Nasir  Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA Børge  G.  Nordestgaard  Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark Kishan  Padalia  University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA Kershaw V. Patel  Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA Lori-Ann Peterson  Mayo Clinic, Phoenix, AZ, USA Donna  Polk  Division of Cardiology, Brigham and Women’s Hospital, Boston, MA, USA Renato  Quispe  Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA Koushik R. Reddy  Division of Cardiology, James A Haley VA Medical Center, Tampa, FL, USA B.  S.  Rishab  Revankar  The Icahn School of Medicine at Mount Sinai, New York, NY, USA Laurence  S.  Sperling  Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA James  H.  Stein  Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA Mohamad  B.  Taha  Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA Matthew  C.  Tattersall  Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA Pam  R.  Taub  Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, CA, USA CGH Medical Center, Sterling, IL, USA

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Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA Anne  Tybjærg-Hansen  Department of Clinical Biochemistry, Section for Molecular Genetics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Bibin  Varghese  Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA Salim S. Virani  Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Department of Medicine, Michael E.  DeBakey VA Medical Center, Section of Cardiology, Houston, TX, USA Section of Cardiology Health Services Research and Development, Michael E.  DeBakey Veterans Affairs Medical Center, Section of Cardiology, Houston, TX, USA Michael  J.  Wilkinson  Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, CA, USA Jeff  D.  Williamson  Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA Nathan  D.  Wong  Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, CA, USA Irvin Xu  School of Medicine, University of California, San Diego, CA, USA

Part I

Global Approaches to Risk Assessment

Chapter 1

Cardiovascular Risk Assessment in Primary Prevention Aliza Hussain, Mahmoud Al Rifai, Umair Khalid, and Salim S. Virani

Introduction Cardiovascular disease (CVD) is the leading cause of mortality in the United States, accounting for over 840,000 deaths annually (Benjamin et  al. 2019). There have been significant advancements in therapies targeting cardiovascular risk factors with a resulting reduction in the incidence of CVD and cardiovascular death. Between 2006 and 2016, the overall cardiovascular mortality decreased by 18.6% in the United States (Benjamin et al. 2019). However, a significant proportion of high-­ risk populations are still not receiving therapies with proven benefits in

A. Hussain · M. Al Rifai Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]; [email protected] U. Khalid Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Department of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, TX, USA e-mail: [email protected] S. S. Virani (*) Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA Department of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, TX, USA Section of Cardiology Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, Section of Cardiology, Houston, TX, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 M. D. Shapiro (ed.), Cardiovascular Risk Assessment in Primary Prevention, Contemporary Cardiology, https://doi.org/10.1007/978-3-030-98824-1_1

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cardiovascular risk reduction (Pokharel et al. 2016; Virani et al. 2015; Cutler et al. 2008; Thorndike et  al. 2007), which may lead to disease progression and CVD events. On the other hand, pharmacological treatment options do not come without side effects, financial burden, and concern regarding medication compliance. In order to find the right balance, one approach to improve health-care delivery in regard to primary prevention of CVD is to accurately estimate a patient’s absolute risk for CVD and identify those who will derive the greatest absolute benefit from therapy with minimal risk. By using risk assessment models, matching treatment intensity with CVD risk constitutes one of the fundamental tenets of preventive cardiovascular medicine. Global cardiovascular risk assessment is crucial to inform clinical decision-­ making regarding initiation and intensification of cardiovascular risk-reducing therapies for primary prevention of CVD. Simply put, it is a calculation of the absolute risk of having a cardiovascular disease event, such as myocardial infarction, ischemic stroke, or incident heart failure, over a specified period of time. Traditionally, risk assessment has been based on empirical equations such as the pooled cohort equations (PCEs) (Goff Jr et al. 2014), which combine cardiovascular risk-­modifying variables such as blood pressure, diabetes, and cholesterol levels. In some cases, such as the use of PCE, these risk assessment tools are also sex- and race-specific. Although risk assessment tools like PCE work well at a population level, they have limitations when applied to individual patients and can over- or underestimate risk in certain populations, including contemporary cohorts, racially diverse non-US populations, and chronic inflammatory conditions [e.g., lupus, rheumatoid arthritis, human immunodeficiency virus (HIV)] (Andersson et  al. 2015; Chia et  al. 2014; DeFilippis et al. 2015). As a result, there is growing focus on the identification of novel risk-enhancing conditions and use of biomarkers and cardiovascular imaging to further improve risk stratification and risk reclassification. In this chapter, we aim to provide the rationale behind global CVD risk assessment, highlight major concepts related to risk assessment based on traditional risk factors, and summarize use of novel biomarkers and cardiovascular imaging, either currently under research or used in clinical practice that may help personalize cardiovascular risk assessment.

Importance of Global Cardiovascular Risk Assessment One of the fundamental principles of preventive cardiovascular medicine is to identify patients that are most likely to benefit from risk-reducing therapies. Although relative risk reduction from blood pressure lowering (e.g., 10 mmHg lower systolic blood pressure) or lowering of LDL-C (e.g., 40 mg/dL) may be the same for two individuals, the absolute risk reduction will still be higher for the individual with a baseline risk that is higher. Moreover, in reverse, this may also help identify patients that are more likely to be harmed than helped from therapies such as aspirin, intensive lipid lowering, and/or antihypertensive medications. The reality is that

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health-­care resources are finite, so allocation of health-care resources to match treatment intensity with CVD risk is imperative. Moreover, preventive therapies are more cost-effective when used in those with higher absolute risk. Therefore, assessment of global cardiovascular risk is important to identify those who are most likely to benefit from them. Several factors determine the individual cardiovascular risk for each patient. While earlier models of risk assessment utilized the presence or absence of risk factors for atherosclerotic CVD (including age, gender, family history of premature coronary heart disease, smoking status, hypertension), multiple epidemiological studies have indicated that all risk factors do not contribute equally (Wilson et al. 1998) and the risk is altered by the presence of other nontraditional risk determinants. As a result, several validated population-based risk calculators or tools were developed to accurately define risk by assigning weightage to individual factors. Some of these risk calculators have been adopted by multinational guidelines. The American Heart Association (AHA)/American College of Cardiology (ACC) cholesterol (Grundy et al. 2019) and hypertension (Whelton et al. 2018) guidelines, US Preventive Task Force guideline for aspirin, and European Society of Cardiology/ European Atherosclerosis Society (ESC/EAS) guidelines for the management of dyslipidemia (Mach et al. 2020) recommend the use of global CVD risk to guide primary prevention of CVD.

Global CVD Risk Assessment in Clinical Practice The 2013 AHA/ACC cholesterol guideline (Goff Jr et al. 2014) recommended that clinicians focus on 10-year absolute atherosclerotic cardiovascular disease (ASCVD) risk. While two different individuals may derive the same relative risk reduction from a particular statin medication, the absolute risk reduction will naturally be higher in the individual with higher absolute ASCVD risk. It is for this reason that the intensity of statin therapy was intended to match the absolute risk of CVD with high-risk individuals recommended high-intensity statin and low- to moderate-risk individuals targeted with less intensive therapy. With removal of LDL-C cutoffs in the 2013 guideline, some have mistakenly believed that it is no longer necessary to measure a lipid profile. However, cholesterol measurements continue to remain necessary not only for monitoring response to statin therapy (≥ 50% LDL-C lowering with high-intensity statin and 30–50% with moderate-­ intensity statin) but also for assessing medication adherence. Absolute ASCVD risk is estimated using the pooled cohort equations (PCEs), the risk score introduced by the 2013 AHA/ACC guidelines. The PCEs are sex- and race-specific equations for four groups: white men, white women, black men, and black women. The PCE includes the same risk factors as its predecessor, the Framingham Risk Score (FRS), with two differences: (1) inclusion of stroke as an end point in addition to coronary heart disease (CHD) making ASCVD event as the primary outcome of interest and (2) separate equations for blacks and whites. The

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PCE was derived using several NHLBI-funded population-based cohorts, which included large samples of blacks and whites, unlike FRS, which included only whites. The PCE is therefore better calibrated than the FRS, but in general can overestimate ASCVD risk because the populations included in these cohorts were enrolled a few decades ago when ASCVD event rates were higher compared to contemporary populations. Using the PCE risk cutoff of ≥7.5%, a larger sample of adults now became eligible for statin therapy and there is a concern for overtreatment. This cutoff was chosen as the threshold above which benefits of statin therapy outweigh risks, that is, when the net clinical benefit favors statin therapy. Along with the use of PCE for risk estimation, the 2013 AHA/ACC cholesterol guidelines identified four major statin benefit groups that the 2018 cholesterol guideline (Grundy et  al. 2019) continued to endorse: (1) clinical ASCVD, (2) LDL-C ≥ 190 mg/dL, (3) diabetes mellitus and LDL-C 70–189 mg/dL, and (4) no diabetes, LDL-C 70–189 mg/dL, and ASCVD risk ≥7.5% (Table 1.1). Central to both the 2013 and 2018 guidelines was the clinician–patient risk discussion (CPRD) that incorporates patient preferences and values and the risks and benefits of statin. Patients belonging to these statin benefit groups are not automatically assigned to a statin, but rather in the context of a CPRD, initiation of statin therapy is a shared decision-making process. Importantly, lifestyle recommendations of diet and exercise should be discussed and emphasized among all patients regardless of risk, and statin therapy should be decided together with therapeutic lifestyle changes. A similar shift in clinical practice was also seen in hypertension management, whereby the 2017 ACC/AHA blood pressure (BP) guideline moved away from recommending antihypertensive therapies based solely on absolute BP values to one based on both BP and underlying CVD risk. Specifically, in adults with BP between 130–139/80–89 mmHg and without clinical ASCVD, DM, or CKD, the guideline Table 1.1  Absolute risk thresholds for intervention for primary prevention of ASCVD Intervention Lifestyle modificationsa Antihypertensive therapy (if BP ≥ 140/90 mmHg) Antihypertensive therapy (if BP ≥ 130/80 mmHg) Statin therapy

Absolute risk of ASCVD event over 10 years