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CLINICAL NEWS American College of Cardiology Extended Learning on target organ damage and triggering of events, in the context of life expectancy and patient goals. RECALCULATING HOW RISK GETS CALCULATED Without calculating a risk score, Dr. Lloyd-Jones says the average 75-year-old has a 10-year ASCVD risk of at least 30%. How does he figure that? Easy, life expectancy at age 75 is a little more than a decade for men (10.7 years to be precise) and slightly longer for women (12.6 years). There is no math necessary to know the epidemiology: CHD and stroke together account for 30% of deaths at this age and that’s just the fatal events. As noted above, competing risks must be taken into account for proper risk estimation. Dr. Lloyd-Jones and colleagues published on this concept of assessing patients within a competing risks framework.3 They put it this way: “Competing risk models estimate which specific events are more likely to occur first for various populations; this ability to understand risks for multiple different outcomes at a given point in time may be clinically useful, because it affords patients and clinicians a more accurate sense of real-lif e risks for first events.” As for risk factors that are losing steam at this point in life, Dr. LloydJones looks at it this way: “By older age, you have been marinating your arteries in plenty of apolipoprotein Bcontaining particles, regardless of your LDL-cholesterol level.” With older age, he said, there is no “normal” LDL level; hence, you see an MI in a person with “normal” cholesterol. Given the high prevalence of ASCVD, Dr. Lloyd-Jones said we no longer care so much about risk factors in patients after age 75. It is more about disease burden, he said, and triggering events. Granted, he said, triggering is tough to predict. At this age, one issue is “instantaneous risk.” For example, will it snow tomorrow and your patient have to shovel? Will there be something else to make their blood To listen to an pressure spike? interview with Donald M. LloydIn the near Jones, MD, on future, he said, the topic of risk he can envision a prediction at age 75, scan the code. risk score that is competing-riskadjusted, age-specific, and inclusive of appropriate risk factors and biomarkers of 26 CardioSource WorldNews target organ damage or disease burden. In any event, he predicts that patient-clinician discussion will still be crucial. Finally, a new paper leaves us with reason for optimism. As this issue of CSWN was going to press, a paper was published identifying a group of “adapter” older adults who were more vigorous than expected, based on their disease burden.4 Compared to a refer- PEOPLE ARE COUNTING ON THIS MIDDLE-AGED FATHER OF 3... EFFIENT® (PRASUGREL) CAN HELP PROTECT HIM AFTER STEMI-PCI Learn more at EffientHCP.com ence group of “expected agers,” these adapters did significantly better in terms of years of able life and years of self-reported healthy life. They also lived longer than expected based on their disease burden. This four-city U.S. study suggests that we need to learn a lot more about these “adapters,” who could have unique characteristics or perhaps some undefined coping mechanism. Studying these