{"id":40456,"date":"2013-12-10T10:56:03","date_gmt":"2013-12-10T15:56:03","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=40456"},"modified":"2015-06-15T18:33:04","modified_gmt":"2015-06-15T18:33:04","slug":"guideline-co-chairs-discuss-a-difficult-patient","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/12\/10\/guideline-co-chairs-discuss-a-difficult-patient\/","title":{"rendered":"Co-Chairs of CVD Risk Guidelines Discuss a Difficult Case"},"content":{"rendered":"

University of Utah cardiology fellow Eric Lindley<\/b> presents a challenging case to the co-chairs of the new 2013 ACC\/AHA Guideline on the Assessment of Cardiovascular Risk:\u00a0David Goff<\/b>, Dean of the Colorado School of Public Health, and Donald Lloyd-Jones<\/b>, Chairman of the Department of Preventive Medicine at Northwestern University.<\/i><\/p>\n

Lindley:<\/i><\/b> My patient is an asymptomatic 38-year-old white male who comes to the office concerned about his future CV risk. He is a lifetime nonsmoker and takes no medications. Asymptomatic and very active, he frequently rides his bike to and from work, and spends his weekends hiking and camping. By trade, he is a horticulturist, eats out of his garden in Oregon, and eats red meat approximately once a week.<\/p>\n

The patient has a significant family history of early atherosclerotic disease. His father, uncles, and grandfathers had either an MI or a CABG when they were in their mid-to-late 40’s. His physical exam is unremarkable, with a normal BMI and\u00a0blood pressure (systolic blood pressure <125 mm Hg). His total cholesterol has ranged over the last five years from 200-240, with his LDL <190, and his HDL hovering around 35-40.<\/p>\n

He is reluctant to start a statin at this age, as he doesn’t want to start a medicine he’ll need for life unless the benefits truly outweigh the risk. Using the new lipid guidelines and risk calculator, his lifetime CVD risk is estimated at 50%. However, until he is age 40, no 10-year risk is calculated. Estimating for him in the future, and only changing his age in the calculator, leaving all other numbers the same, his 10-year CVD risk isn’t above 7.5% until he’s 53. Yet a significant number of his relatives have already had their events by the time they were 53.<\/p>\n

Would you start a statin based on his lifetime risk alone?<\/b><\/b><\/p>\n

Goff:<\/i><\/b>\u00a0<\/b>I would be reluctant to recommend a statin based on his lifetime risk estimate alone, primarily because he expresses reluctance to take a life-long medicine at this point, he appears committed to a healthy lifestyle, and his short-term risk and short-term benefit are both estimated to be low. I would reinforce a healthy lifestyle and try to help him reduce his cholesterol further. You stated that his blood pressure is normal. If it were higher than optimal, that is, higher than 120 systolic or 80 diastolic, I would include an emphasis on the blood-pressure lowering benefits of more intensive lifestyle change to motivate adherence.<\/p>\n

Lloyd-Jones:<\/i><\/b> This is a very interesting scenario, and this is the kind of patient I encounter very frequently in my preventive cardiology clinic.\u00a0First and foremost, we must respect his family history. This kind of premature CVD family history is not particularly well represented in any risk assessment approach from the broad population. He must be congratulated on trumping as much of his inherited risk as possible by following the healthy lifestyle he follows. He sounds like he is quite active and currently asymptomatic at a good workload. That he has stayed lean (\u201cnormal BMI\u201d) is a good sign. If he wants to avoid medication, he <\/b>should certainly be offered a referral to a nutritionist or dietician to explore options, explicitly including a vegan diet. <\/b>But, at this point, I would not start a statin based solely on the lifetime risk estimate.<\/p>\n

Would you wait until his 10-year risk exceeded 7.5% to start a statin?<\/b><\/p>\n

Goff:<\/i><\/b>\u00a0<\/b>Given his strong family history, I am concerned that the risk calculator might under-estimate his risk. All risk estimates are averages for people with the same values of the risk factors that are included in the model, but no one really has 7.5% of a heart attack or stroke. The patient will either have an event or not during the 10-year period. From that point of view, it is all or nothing!<\/p>\n

The challenge is that it is difficult to predict who will have the event and who will not in a group with any specified level of risk, and when we examined the contribution to risk prediction of information regarding family history, that added value was quite small for the general population. Of course, most people don\u2019t have the very strong family history of this patient. For him, I would be interested in discussing disease screening, especially if we were not able to achieve substantial reductions in his cholesterol through lifestyle change.<\/p>\n

Lloyd-Jones:<\/i><\/b>\u00a0<\/b>Let\u2019s think about his risk. I would start by plugging in his risk factor levels with an age of 40. Recognizing that we have not quantitatively considered his family history, I get 10-year risk estimates in the range of 1.4% to 2.4% (if he were black it would be as high as ~3.1%). Lifetime risks are in the range of 46-50%. This is not where we prescribe a statin per the guidelines (despite what the media seems to think), this is where we start the risk discussion. And this is very much how I practice.<\/p>\n

As you know, the guidelines provide\u00a0<\/b>6\u00a0 different things that should potentially be considered to color in our risk assessment. In this framework, the first 3 questions to ask, before we consider any additional testing, are:<\/p>\n