Physicians' Academy for Cardiovascular Education

Lifetime risk for CVD considerable

Literature - Wilkins JT, Ning H, Berry J, et al. JAMA. 2012;308(17):1795-801

Lifetime risk and years lived free of total cardiovascular disease.

John T. Wilkins, Hongyan Ning, Jarett Berry, Lihui Zhao, Alan R. Dyer, Donald M. Lloyd-Jones
JAMA. 2012;308(17):1795-801. doi: 10.1001/jama.2012.14312



Background:

For coronary heart disease (CHD), ten-year absolute risk estimates have been developed and well validated in multiple cohorts. These risk estimates are used in current treatment guidelines for lipid-lowering treatment in primary prevention [1,2]. Lifetime risk estimates for atherosclerotic cardiovascular disease (CVD) (angina pectoris, coronary insufficiency, myocardial infarction, atherosclerotic stroke, or death from CVD) and congestive heart failure (CHF) have been reported separately [3-5]. To date, no data have been published on the lifetime risk for total CVD (including CHD, atherosclerotic and hemorrhagic stroke, CHF, and other CVD death). It is unclear how the addition of CHF and other nonatherosclerotic forms of CVD will affect remaining lifetime risk estimates overall and in the context of aggregate burden of atherosclerosis risk factors.

This study was conducted to estimate lifetime risk for total CVD in separate models for men and women overall and by aggregate risk factor burden at index ages of 45, 55, 65 and 75 years. A pooled survival analysis of data was performed from 1964 through 2008 from five National Heart, Lung and Blood Institute-funded community-based cohorts. All participants were free of CVD at study entry and had data on risk factors and total CVD outcomes.


Results:

  • Across all index ages, 1.7% to 7.9% of participants were in the all optimal risk factor group; however, more than 55% were in the one major or at least two major risk factor strata at all index ages.
  • Approximately 30% to 35% of participants experienced CVD events at some time during follow-up across all index age groups.
  • At an index age of 45 years, overall lifetime risk estimates for total CVD through age 95 years were 60.3% for men and 55.6% for women. Women had significantly lower lifetime risk estimates than men at all index ages.
  • At index ages of 55 and 65 years, lifetime risk estimates to age 95 years exceeded 50% for men and women with at least one elevated risk factor (BP 140-149/90-99 mm Hg; triglycerides 200-239 mg/dL), but no diabetes or smoking; those with one major risk factor; and those with at least two major risk factors (BP >160/100 mm Hg or related treatment; triglycerides >240 mg/dL or related treatment; diabetes; current smoking).
  • At an index age of 55 years, participants with optimal risk factor profiles had remaining lifetime risks for total CVD that exceeded 40% and women had risks that approached 30% through age 85 years. An optimal risk factor profile included BP <120/80 mm Hg, triglycerides <180 mg/dL and no diabetes or smoking.
  • Participants with optimal risk factor levels had longer survival time free of total CVD when compared with those with at least two major risk factors, across all index ages.

Conclusion:

Achieving older age free of total CVD does not guarantee an escape from remaining lifetime risk for total CVD. Maintenance of optimal risk factor levels in middle age is associated with substantially longer morbidity-free survival.
Estimates of lifetime risk for total CVD may provide projections of the future population burden of CVD and may assist in clinician-patient risk communication.


Lifetime Risk Estimates for Total CVD Stratified by Sex, Index Age, and Aggregate
Risk Factor Burden



References

1. D’Agostino RB Sr, Grundy S, Sullivan LM, Wilson P; CHD Risk Prediction Group. Validation of the Framingham coronary heart disease prediction scores: results of amultiple ethnic groups investigation. JAMA.2001;286(2):180-187.
2. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). JAMA. 2001;285(19):2486-2497.
3. Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary heart disease. Lancet. 1999;353(9147):89-92.
4. Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006; 113(6):791-798.
5. Lloyd-Jones DM, Larson MG, Leip EP, et al; Framingham Heart Study. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation. 2002;106(24):3068-3072.


Abstract

Context:
Estimates of lifetime risk for total cardiovascular disease (CVD) may provide projections of the future population burden of CVD and may assist in clinician-patient risk communication. To date, no lifetime risk estimates of total CVD have been reported.

Objectives:
To calculate lifetime risk estimates of total CVD by index age (45, 55, 65, 75 years) and risk factor strata and to estimate years lived free of CVD across risk factor strata.

Design, setting, and participants:
Pooled survival analysis of as many as 905,115 person-years of data from 1964 through 2008 from 5 National Heart, Lung, and Blood Institute-funded community-based cohorts: Framingham Heart Study, Framingham Offspring Study, Atherosclerosis Risk in Communities Study, Chicago Heart Association Detection Project in Industry Study, and Cardiovascular Health Study. All participants were free of CVD at baseline with risk factor data (blood pressure [BP], total cholesterol [TC], diabetes, and smoking status) and total CVD outcome data.

Main outcome measures:
Any total CVD event (including fatal and nonfatal coronary heart disease, all forms of stroke, congestive heart failure, and other CVD deaths).

Results:
At an index age of 45 years, overall lifetime risk for total CVD was 60.3% (95% CI, 59.3%-61.2%) for men and 55.6% (95% CI, 54.5%-56.7%) for women. Men had higher lifetime risk estimates than women across all index ages. At index ages 55 and 65 years, men and women with at least 1 elevated risk factor (BP, 140-149/90-99 mm Hg; or TC, 200-239 mg/dL; but no diabetes or smoking), 1 major risk factor, or at least 2 major risk factors (BP, ≥160/100 mm Hg or receiving treatment; TC, ≥240 mg/dL or receiving treatment; diabetes mellitus; or current smoking) had lifetime risk estimates to age 95 years that exceeded 50%. Despite an optimal risk factor profile (BP, <120/80 mm Hg; TC, <180 mg/dL; and no smoking or diabetes), men and women at the index age of 55 years had lifetime risks (through 85 years of age) for total CVD of greater than 40% and 30%, respectively. Compared with participants with at least 2 major risk factors, those with an optimal risk factor profile lived up to 14 years longer free of total CVD.

Conclusions:
Lifetime risk estimates for total CVD were high (>30%) for all individuals, even those with optimal risk factors in middle age. However, maintenance of optimal risk factor levels in middle age was associated with substantially longer morbidity-free survival.

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