European CVD Prevention Guide Leans on Age Stratification

Comprehensive cardiovascular disease (CVD) prevention guidelines from the European Society of Cardiology introduced new risk score tools, with use and interpretation determined by age.

The update, released Monday at the European Society of Cardiology virtual meeting and in the European Heart Journal, switched to recommending two new risk assessment algorithms.

The SCORE2 tool now considers risk of nonfatal and fatal heart attacks and strokes, rather than just risk of fatal events as in the previous SCORE tool. And, there’s the separate SCORE2-OP for “older persons” (ages 70 and over) to take into account the competing risk of death from other causes.

The shift to considering nonfatal events, which are important to patients, “has been a long time coming and I’m pleased to see it,” commented American Heart Association (AHA) president Donald Lloyd-Jones, MD, who has been a key figure in CVD guidelines from the American College of Cardiology and the AHA.

And “in many ways it aligns risk thresholds where one would consider treatments, especially for statins,” he noted.

Another big change is that interpretation of the risk scores is stratified by age:

• Before age 70, apparently healthy people without established disease or known disorders are considered to have low to moderate CVD risk if their score is under 7.5% but very high risk if its 15% or higher.
• For a similar person, ages 50 to 69, those thresholds are under 5% and 10% or greater, respectively. For those under age 50, the cutoffs were 2.5% and 7.5%, respectively.

The rationale was “to avoid undertreatment in the young and to avoid overtreatment in older persons,” noted guideline chair Frank L.J. Visseren, MD, PhD, of the University Medical Center Utrecht, the Netherlands, and colleagues. “As age is a major driver of CVD risk, but lifelong risk factor treatment benefit is higher in younger people, the risk thresholds for considering treatment are lower for younger people.”

However, that’s a somewhat counterintuitive way to do it, argued Lloyd-Jones. “They say that the benefit of prevention is clearly tied to the absolute risk of the patient, which is why they have that SCORE2 algorithm.” But then with the different age-based thresholds, “they are applying a relative scale to that absolute risk equation,” he noted.

U.S. guidelines have attempted to achieve something similar through recommendation for use of additional factors like lifetime risk and coronary artery calcium (CAC) for decisions about treatment, he said. “These are better tie breakers than just changing the threshold for different ages.”

The European guidelines also differ from their U.S. counterpart in the class IIb recommendation for CAC or carotid plaque assessment (compared with a IIa recommendation) and the relative dearth of specific guidance on how to use it to reclassify risk, Lloyd-Jones noted. “It could lead to some decisions that are not ideal for those patients,” he said. “You could get the decision wrong a little more often.”

The European guidelines were also less aggressive on blood pressure, with an algorithm that specifies systolic blood pressure under 160 mmHg as the goal for all if there are no other risks.

U.S. guidelines say that hypertension is anything over 130 mmHg systolic, with pharmacologic treatment at that point if there are other risk factors or over 140 mmHg otherwise.

So for an otherwise healthy young person with a systolic pressure of 150 mmHg, for example, “they are accruing irreversible vascular damage and irreversible heart damage that, even if you then treat the person, you can’t reverse,” Lloyd-Jones said. “I worry this is much too high a threshold to let people go until.”

That’s particularly a concern at the population level, where even a 5 mmHg difference can play out into a dramatic uptick in event rates, and in the context of the global slide in risk factor management with the COVID-19 pandemic, he added. “We will see ripple effects for years to come.”

Cholesterol, blood pressure, and glycemic control strategies weren’t changed from preexisting guidelines, but a stepwise approach to treatment intensification was introduced for them. A new section on shared decision-making was also added.

“Personalized treatment decisions using CVD risk estimations and a stepwise approach to treatment is more complex than a more general one-size-fits-all prevention strategy, but reflects the diversity in patients and patient characteristics in clinical practice,” Visseren’s group wrote.

Other changes in the European guidelines included addressing mental health, a recommendation to consider bariatric surgery for people with obesity at high CVD risk, adoption of a Mediterranean style diet, and restricting alcohol intake.