PracticeUpdate Cardiology June 2019

ACC 2019 21

in some ways to have it a little bit more uni- form in terms of the cut points. What I mean there is that for the cholesterol guideline and the statin allocation guideline, the usual recommendation is a threshold of 7.5% 10-year CVD risk in primary prevention as a trigger to consider statin therapy. And then that contrasts with the blood pressure guideline, which uses a risk cut point of 10% to allocate more intense therapy down to 130/80 in patients who have high blood pressure. So, there’s a little bit of discrep- ancy there. And the newer guideline that just was released has even more cut points. So, they say less than 5% is low risk, 5% to 7.5% is intermediate risk, greater than 5% is elevated risk, and greater than 20% is very high risk, and so it does get complicated. I think, having tools, informatics tools, and the electronic tools, like the EHR, should help primary care physicians to automate the calculation of these risk scores to give the provider recommendations based on the guidelines around blood pressure goals and cholesterol goals. And I think all that can be automated, and certainly, many health care systems already do that, includ- ing systems that use Epic, for example, as an EHR. So, thankfully, the technology is helping the physician in this case. " …the most newsworthy and noteworthy recommendations were around aspirin. … but been recent trials, three large trials last year, that really make this quite a timely topic. " aspirin has been an area of controversy and there have

risk equation website. And in fact, instead of taking that time to put in every variable, the EHR can automate the estimation of risk based on what’s already in the electronic health record. So, I think that’s helpful. In terms of the tool to use, obviously, the ACC/AHA recommends the Pooled Cohort Equations, which is unchanged from 2013. And the nice thing about the Pooled Cohort Equations is that it does usemore contempo- rary cohorts of patient to calibrate the various risk factors, and it’s probably more accurate than older equations like Framingham in the context of more contemporary patients. That being said, I will say another nice attribute of the Pooled Cohort Equations is that it can be race specific, so you can kind of modulate your risk based on important drivers of risk. On the other hand, there have been some concerns about overestimation of risk, with the newPooled Cohort Equations or the one that was released in 2013. Overall, I think that it does a good job, better than the other risk equations. Some research would suggest that when you incorporate events that aren’t captured by adjudication in studies, and you take all events that are billed for by Medi- care, for example, that the Pooled Cohort Equations actually does a pretty good job. So, that’s what the guidelines recommend. In terms of cut points, those have varied over the years. At the moment, it’s some- what complicated, I think. It would be nice

talk about 10 years, but some physicians feel like it should be lifetime risk in younger patients, and then some people don’t really sit down and calculate the risk. How do you approach it and what would you recommend a community cardiologist do when estimating the risk of her patient? Dr. McEvoy: Yes, it’s complicated, and I agree there’s a lot of variability in what guidelines recommend and a lot of different tools out there, which can add to the confusion and complexity of this. And it’s really important, particularly in primary prevention, to use risk as a triage to allocate preventive ther- apy. The cholesterol recommendations in this 2019 guideline, which also were simi- lar to the ones from last year, as well as the blood pressure recommendations, both rely on an estimation of CVD risk before you make a decision about how intense to treat that blood pressure or cholesterol target to, and so it is critical. I acknowledge that it’s sometimes difficult and challenging, in a very busy primary health care setting, in particular, to take the time to estimate a CVD risk. I think the good news is that most primary physicians are now using electronic health records (EHR), and there is a very well established mechanism by which the EHR can auto- mate the estimation of risk, such that the physician themselves doesn’t need to take the time to plug in the information into the

Go to www.practiceupdate.com/c/81076 to watch this interview with Dr. McEvoy.

VOL. 4 • NO. 2 • 2019