EDITOR’S CORNER
Alfred A. Bove, MD, PhD
Editor-in-Chief, CardioSource WorldNews
Educating Patients About
Cardiovascular Risk
S
ince my practice is focused on ambulatory
cardiology for patients with chronic cardiac
conditions, I find myself spending considerable time with them explaining their health status
based on measures that identify high risk for coronary heart disease. Most patients will ask about their
risk for coronary heart disease in the context of their
own measurements. So, I am asked, for example,
about how much added risk is created when LDL is
125 instead of 100, or when A1c is 7.0 versus 6.0.
These questions often arise during discussion of how
they can reduce their risk.
Similar questions surface regarding target blood
pressure, particularly in light of the recent findings
from the SPRINT hypertension trial. To answer the
patient’s questions, we need data from large studies
that encompass a variety of factors that can include
family history, patient age, sex, ethnicity, and
behaviors such as smoking, excess alcohol intake,
use of recreational drugs, social background, and
lifestyle.
To provide our patients with an intelligent assessment of their cardiovascular risk, we have seen
the development of risk scores that provide population-based estimates of coronary heart disease risk
derived from longitudinal studies where observations can be made over many years, allowing us to
craft and expand a concept of how these various
risk factors influence the health outcomes of our
patients at risk for heart disease.
We have risk scores for a number of cardiovascular and other diagnoses. Risk scores for stroke
risk in atrial fibrillation (AF), for bleeding risk on
anticoagulant therapy, for heart failure outcome,
and a number of risk scores for cancer. In our
cardiology world, the Framingham Risk Score held
sway for many years. This risk score incorporated
the measures we use in managing patients with
heart disease, and became an important means of
assessing patient risk for coronary heart disease.
However, it was limited by its measures from a
single population.
Despite this limitation, the Framingham score
became ingrained in our practices as a tool to
assess cardiovascular risk. Both physicians and
patients could understand the origin of the data,
the value of a follow-up period of 12 to 15 years,
ACC.org/CSWN
and the conversion of the risk into numerical values
that could be followed over time to determine if
risk reduction therapies were effective. In 2013,
the Framingham-based risk score was updated to
include Caucasian and African-American patients,
stroke risk, and a larger population base that
supplemented the Framingham data with data
from several other large databases. The ACC/AHA
atherosclerotic cardiovascular disease (ASCVD)
risk estimator is similar to the Framingham risk
estimator but covers a larger population base. After
much debate on the accuracy of the new risk score,
the cardiology community has accepted this risk
calculator for assessing CVD risk.
Newer risk scores like GRACE provide an assessment of risk in patients with documented coronary
disease. Besides the ASCVD composite score for
coronary risk, we have improved on scores as
more data became available: CHADS2 evolved into
CHA2DS2-VASc in assessing stroke risk in atrial fibrillation, for example, and HAS-BLED has become
more of a go-to score than HEMORR2HAGES for
bleeding risk in these patients. How can a risk score
help us in our day-to-day practice of cardiology?
From the provider perspective, useful information
on patient management comes from assessing a
SYNTAX score prior to proposing a method of
revascularization. With the CHA2DS2-VASc score,
we can make decisions regarding the use of an
anticoagulant in patients with AF based on easily
determined variables, and assess their bleeding risk
as well with HAS-BLED.
But most patients don’t look at risk scores. They
are focused on target values that they can change
with medications and lifestyle changes. So a change
in LDL toward a stated goal is better understood by
the patient even though it may not have the same
significance as a reduction in composite risk score.
As clinicians, our goal should be to both understand the impact of changes in patient status
on overall cardiovascular risk, and to point out
improvements in individual measures that encourage patient motivation to improve their risk. It is
important to remind patients that the scores are
estimates of risk based on population statistics; a
personal discussion tailored to each patient is still
needed to encourage healthy behaviors that lower
cardiovascular disease risk. ■
Alfred A. Bove, MD, PhD, is professor emeritus of
medicine at Temple University School of Medicine in
Philadelphia, and former president of the ACC.
CardioSource WorldNews
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