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-
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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