“Laurie got offended when I used the word ‘puke.’ But to me, that’s what her dinner tasted like.”
-Jack Handey
Many of you have heard me employ terms such as “garbage,” or “trash” or “not quite useless…but close” when discussing 10-year risk calculators for Cardiovascular Disease. But nowadays, there is the PREVENT Risk Calculator, which aims to assess 30 year-risk and be “more preventive” than the old-school Pooled Cohort Equation Risk Calculators.
And I commend the folks who developed PREVENT for some nice additions to this Risk Calculator, including:
- HbA1c (a marker of glucose metabolism that shows your average blood sugar over the last 3 months), a pretty important marker.
- UACR (a marker of protein leakage into your urine, which is a harbinger of an impaired Home Security System. For instance, those in EPIC-NORFOLK who had microalbuminuria (a little pee protein) had 148% increased risk of all-cause mortality and 203% increased risk of cardiovascular death EVEN IF they didn’t have hypertension or hyperlipidemia.
- eGFR (a marker of kidney function), which is also important, particularly given that those with eGFR under 70 have a 68% and 51% of all-cause and cardiovascular mortality, respectively.
- It also includes BMI, which isn’t useless at the population level, but certainly has its limitations (every NFL linebacker is obese, and that guy is almost assuredly healthier and wealthier than you are). Waist circumference is more useful, but a lot of times people resent it when you start wrapping stuff around their ample midsections, so you have to pick your battles.
Additionally, PREVENT looks at zip code (because Big Brother is always watching). Just kidding, this is for a “social deprivation index,” although I’m skeptical this meaningfully contributes to risk stratification beyond what we already have. PREVENT also eliminates race (which is ostensibly “progressive,” but probably overlooks factors that uniquely contribute to CVD risk). For instance, those of African ancestry often have normal triglycerides and normal HDL-C, but are very insulin resistant. So by taking race out of the equation, you might actually miss some important things.
So how does PREVENT stack up versus the 10 year-risk calculators? Should we abandon our “Got Plaque? Get a CAC!” strategy because of this awesome new calculator with a provocative name?
Well, a recent study showed that a whopping 51% of those who were classified as “low-risk” by PREVENT (so people who are told “Keep up the good work!”) had a CAC above ZERO. These people HAVE EXPERIENCED A BREAK-IN and HAVE PLAQUE IN THEIR CORONARY ARTERIES! This was even a little worse than the standard risk calculator, which showed that 45% of low-risk folks had a non-zero CAC. And then 35% of the “borderline” group by PREVENT calculations (so people who are told, “Maybe we should consider doing something about your life”) had a CAC>100, which is pretty extensive atherosclerosis.
PREVENT is sort of like when your kid is learning soccer and has a real nice kick, but it goes in the wrong goal. Good kick, buddy! And it’s arguably better than completely missing the ball, but if you keep doing that, you’re going to lose the game every time. It’s just another crappy risk calculator that you can start using sooner than the other crappy risk calculator.
So instead, let’s identify disease based on our imaging techniques (like CAC), understand the individual utility of our biomarkers, and shift the paradigm to one of PREVENTion by being awesome clinicians. Expecting any risk calculator to tell you an individual’s cardiovascular risk is a good way to keep scoring in the wrong goal, and no one wants you on their team if you insist on being that person.
Link to the Study:
https://www.sciencedirect.com/science/article/pii/S2666667725003769
