assessment of cardiovascular risk: thai and …...thai and international algorithms categories of...
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Krittin Bunditanukul Pharm.D, F.A.C.P, BCPS.Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University
Assessment of Cardiovascular Risk:
Thai and International Algorithms
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Categories of Risk for Coronary HeartDisease (CHD)
Established CVD
CVD equivalent: DM, PVD, AAA, TIA, stroke
Risk factor ≥ 2
• 10-year risk 10 – 20%
• 10-year risk < 10%
Risk factor 0 - 1
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Framingham risk score
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Framingham Risk Score
• Very age dependent
• Short-term (10-year) risk projections
• Ignores many factors that likely contribute to
cardiovascular risk
• Developed in USA with people of (western)
European descent
– Does it have to be modified for developing nations
or different racial or ethnic groups?
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0%
5%
10%
15%
20%
25%
30%
35%
30 40 50 60 70
Age (years)
10-Y
ear R
isk
Male
Female
Framingham 10-year risk by age for a male
or female
● smokes 1 ppd
● TC = 212, HDL-C = 42
● No DM, normal BP
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Algorithm for Guideline
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013.
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ASCVD Risk Calculator: Considerations
• Risk Assessment Work Group endorsed the
paradigm of 10-year risk estimation
• Existing risk scores vary with regard to:
• Derivation populations: age, sex, race, birth
cohort, and country/region of origin
• Inputs: traditional RFs ± family history, BMI,
socioeconomic status, region, and C-reactive
protein
• Outcomes: CVD death, Total CHD (incl. revasc.),
Total CHD, Hard CHD, Total CVD ( incl. revasc.),
Hard CVD (incl. heart failure)
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• Risk Assessment Work Group judged new risk tool
was needed
• Inclusive of African Americans and with expanded
endpoint including stroke
• Sought cohorts representative of the U.S. population
as a whole
• Community- or population-based
• Whites and African Americans (at a minimum)
• Recent follow-up data of at least 10 years
• Reflect more contemporary risk factor trends
and event rates, ideally without significant
downstream uptake of statins/revascularization
ASCVD Risk Calculator: Development
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• Pooled Cohort Equations
• Atherosclerosis Risk in Communities (ARIC)
• Cardiovascular Heath Study (CHS)
• Coronary Artery Risk Development in Young
Adults (CARDIA)
• Framingham Original and Offspring
• Hard ASCVD
• CHD death, nonfatal MI, fatal/nonfatal stroke
• Models tested using traditional RFs + newer markers
when possible
• Internal and external validation
ASCVD Risk Calculator: Development (cont.)
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Controversy in risk
assessment tool A potential pitfall of using pooled cohort
equations is that calculation of 10- year risk
is not recommended until the age of 40
years.
As the algorithm is heavily driven by age,
another quandary is what to do in healthy
patients without risk factors who exceed the
7.5% threshold based on age alone.
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Controversy in risk
assessment tool Limitation assessment tools:
Age dependent
Patient population included.
Duration of follow-up.
Change in statin use over time.
Do not reflect the improvement in lifestyle factor
and disease state management of more modern
population.
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