Just over a year ago the PREVENT calculator to predict cardiovascular risk was released by the American Heart Association. It was acclaimed for improving on a 2013 model that didn’t take into account companion conditions such as kidney disease or type 2 diabetes, or include people from more diverse backgrounds.
PREVENT soon drew attention for its potential to reduce the number of Americans eligible to receive widely prescribed cholesterol-lowering statins, projected in two analyses published in June and July.
A less noted change was the addition of heart failure to conditions estimated by the risk calculator, alongside the traditional targets of heart attack and stroke. Heart failure is a serious illness that means the heart can no longer pump blood through the body as well as it should. It’s different from diseases that narrow blood vessels that feed the heart or brain.
Heart failure has no cure, making it more urgent to identify who’s at risk. PREVENT allows that risk to be estimated using information typically collected in a regular primary care visit.
“There have been prior risk estimation approaches for heart failure, but they’ve always required more expensive or intensive testing,” Timothy Anderson, a primary care physician at University of Pittsburgh Medical Center, told STAT. “We can estimate your risk, but we have to do an ultrasound of your heart first or EKGs.”
Anderson and colleagues reported Monday that they used PREVENT to model risk of heart failure versus other types of cardiovascular disease and found that there’s a substantial group of people at risk for heart failure but not at risk for the more common condition of plaque-clogged arteries, which can cause angina, heart attacks, and strokes. More than half of participants at elevated risk of heart failure had high blood pressure; half were overweight or obese.
“That’s a newly high risk population,” Anderson said. “Early detection of risk is so important because once it’s there, it’s not quite like having a heart attack where we can stent it and fix it. We’re often pretty limited in being able to reverse damage. This is really about slowing or preventing” heart failure.
The jury is still out on how the PREVENT model will shape new guidelines to be jointly reached by AHA and the American College of Cardiology on statin use. (Those guidelines, which influence the standard of care in primary and specialty care, aren’t expected until 2026.) But it is already allowing new insight into cardiovascular disease, the No. 1 killer in the United States.
The newly updated calculator estimates that 15 million American adults are at high risk for heart failure. Most of them are also at high risk for the heart attacks and strokes than can be caused by plaque-clogged arteries. But 4.3 million of those at high risk of heart failure appear unlikely to develop these other forms of heart and vascular disease, known as atherosclerotic cardiovascular disease, or ASCVD.
To reach these estimates, the researchers applied the PREVENT calculator to data from 4,872 adults age 30 to 79 who had no known cardiovascular disease and answered national surveys from 2017 through 2020. The goal was to use the PREVENT equations to model risk of heart failure and cardiovascular disease over 10 years for the 143.2 million Americans in this age range.
Their conclusion: The average estimated 10-year risk for heart failure was 3.7%, while 15 million adults were at a higher than 10% risk. Most of these people also had a high risk of atherosclerotic cardiovascular disease. An estimated 4.3 million adults had a low risk of atherosclerotic cardiovascular disease, but a risk above 10% for heart failure. Among that group, most (62%) were 70 to 79 years old and 14% were Black adults.
Sadiya Khan, a cardiologist at Northwestern Medicine and lead chair of the AHA writing group that produced the PREVENT risk model, cited two factors that influenced the addition of heart failure: a recognition of the rising burden of heart failure hospitalizations and deaths as well as a growing body of evidence about therapies to reduce heart failure.
“Overall these are really helpful data to quantify the distribution of the risk for each type of cardiovascular disease,” she told STAT. She was not involved in the study. “I think it really emphasizes and highlights the importance of the PREVENT model actually allowing you to not just calculate total CVD, or just ASCVD, or just heart failure, but being able to do this simultaneously.”
While not surprising, she said, it’s important to pinpoint factors like obesity or high BMI in heart failure risk and cholesterol in atherosclerotic cardiovascular disease.
Until PREVENT, there hasn’t been a paradigm to estimate risk of heart failure. Anderson envisions the risk calculator being used to determine who might benefit from more testing. Future avenues to explore would be learning which blood pressure medications might be best, not just for people who have heart failure but perhaps to keep them from developing it.
“There’s a lot to consider in terms of thinking about how therapies reduce risk of cardiovascular disease, whether that’s ASCVD or heart failure, and which therapies may more differentially benefit someone who has a higher heart failure risk than ASCVD risk or vice versa,” Khan said. “I think that’s really important work that needs to be done as well.”
But don’t forget about statins.
“We don’t think of statins as being something that’s particularly helpful for heart failure, but we do know that heart attacks can lead to heart failure, and statins are certainly helpful for preventing heart attacks,” Anderson said. “There’s probably quite a bit more to do to better customize risk estimation for people.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.