Elsevier

Atherosclerosis

Volume 237, Issue 1, November 2014, Pages 1-4
Atherosclerosis

The new “intermediate risk” group: A comparative analysis of the new 2013 ACC/AHA risk assessment guidelines versus prior guidelines in men

https://doi.org/10.1016/j.atherosclerosis.2014.08.024Get rights and content

Abstract

Background

The 2013 ACC/AHA Report on the Assessment of Cardiovascular (CVD) Risk redefined “intermediate risk”. We sought to critically compare the intermediate risk groups identified by prior guidelines and the new ACC/AHA guidelines.

Methods

We analyzed data from 30,005 adult men free of known CVD from a large, multi-ethnic study of middle-aged adults. The Framingham Risk Score was calculated using published equations, and CVD risk was calculated using the new ACC/AHA Pooled Cohort Equations Risk Estimator. We first compared the size and characteristics of the intermediate risk group identified by the old (ATP III, 10–20% 10-year CHD risk) and new guidelines (5–7.4% 10-year CVD risk). We then defined time-to-high-risk as the length of time an individual patient resides in the intermediate risk group before progressing to high risk status based on advancing age alone.

Results

The mean age of the study population was 53 ± 13 years, and 24% were African-American. Patients identified as intermediate risk by the new ACC/AHA Guidelines were younger and more likely to be African-American and have lower risk factor burden (all p < 0.05). The new intermediate risk group was just 37% the size of the traditional ATP III intermediate risk group, while the new high risk group was 103% larger. Under the new guidelines, men remain intermediate risk for an average of just 3 years, compared to 8 years under the prior guidelines (63% shorter time-to-high-risk, p < 0.05), before progressing to high risk based on advancing age alone.

Conclusion

The new 2013 ACC/AHA risk assessment guidelines produce a markedly smaller, lower absolute risk, and more temporary “intermediate risk” group. These findings reshape the modern understanding of “intermediate risk”, and have distinct implications for risk assessment, clinical decision making, and pharmacotherapy in primary prevention.

Section snippets

Background

Prior guidelines on risk assessment and therapy in the primary prevention of coronary heart disease (CHD) identified a large intermediate risk group (10–20% 10-year CHD risk) in whom treatment decisions were considered uncertain [1]. In this group, further testing was recommended to further personalize risk estimates [2]. The new 2013 ACC/AHA Report on the Assessment of Cardiovascular (CVD) Risk, which contains new Pooled Cohort Risk Equations, reinterpreted conventional risk categories [3].

Methods

We analyzed data from 30,005 adult men free of known CVD from a large, multi-ethnic electronic medical record (EMR)-based registry study of middle-aged adults underdoing cardiovascular testing at a single metropolitan hospital system in the United States (1991–2009). Baseline demographic and risk factor data were derived from an in-person questionnaire and were supplemented and verified using data from the EMR and pharmacy claims files. Resting blood pressure was measured in the seated position

Results

The mean age of our sample was 52.8 ± 13 years. Approximately 24% were African-American. Table 1 shows the baseline characteristics for the two intermediate risk groups. Patients identified as intermediate risk under the new ACC/AHA guidelines were younger, more likely to be African-American, with lower risk factor burden compared to the traditional intermediate risk group (all p < 0.05).

Table 2 and Fig. 1 compare the risk categories between the two guidelines. Approximately 16% of patients

Discussion

In summary, the new 2013 ACC/AHA risk assessment guidelines produce a smaller “intermediate risk” group with less severe risk factor abnormalities compared to the traditional intermediate risk group. Based on our time-to-high-risk analysis, patients appear to rapidly progress out of the intermediate risk group and into the high risk group based on advancing age alone. These findings have distinct implications for risk assessment and clinical decision making in primary prevention.

The

Conflict of interest

None declared.

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