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Cardiovascular Disease Risk Classification

Cardiovascular Disease Risk Classification 

  • A new cardiovascular disease (CVD) risk classification for women was adopted in 2007 and reaffirmed in the 2011 update with minimal modifications.1 Women are stratified into three categories: At high risk, at risk and at optimal risk as shown in Table 119A.
  • The Women’s Health Study involving 161,808 women has validated the usefulness of this classification. 1 Among high-risk, at-risk, optimal risk, and unclassified women, the rates of heart attack, cardiac death, or stroke per 10 years were 19.0%, 5.5%, and 2.2% respectively.
  • Although absolute event rates differed among women of different race/ethnic groups, the  risk classification algorithm appropriately observed event rates in all groups, with an almost 10-fold difference in event rates between optimal-risk and high-risk women.

Table 119 A. Classification of cardiovascular risk status in women.1

1 High-risk Based on the presence of documented CVD, diabetes mellitus, end stage or chronic kidney disease, or ten year predicted risk of CAD more than 20% or CVD more than 10%. 
2 At- risk Based on the presence of one or more major CVD risk factors, metabolic syndrome, evidence of subclinical vascular disease (e.g.: coronary classification, or poor exercise tolerance on treadmill testing). 
3 Optimal- risk Absence of major CVD risk factors, and engagement in a healthy lifestyle.
  • The 2007 update algorithm discriminated those who experienced coronary events with accuracy similar to current National Cholesterol Education Panel Adult Treatment Panel III risk categories (<10%, 10% to 20%, and >20%) based on Framingham 10-year predicted risks. Therefore, the current panel elected to continue this general approach to risk classification in women for the 2011 guidelines with some modifications.1
  • The current guidelines recommend for defining high-risk as more than 10% ten year risk for all CVD, not just coronary artery disease (CAD) alone.1 This is in accordance with the recent data that showed this threshold for statin therapy is associated with high cost effectiveness and possible cost savings in the era of generic statins.2
  • Furthermore, it is difficult for a women less than 75 years of age even with several markedly elevated risk factors, to exceed 10% (let alone a 20% risk) 10-year predicted risk of CAD by the ATP III estimator.3
  • Researchers have now begun to focus on long-term risk not solely the 10-year CAD risk, because 64% of women 60 to 79 years of age have a 10-year predicted risk less than 10%.4
  • Preeclampsia is considered an early indicator of CVD risk with the doubling of the risk 5-15 years after pregnancy.1 5-7
  • Other pregnancy related conditions that increase CVD risk include gestational diabetes, pre-term birth, or birth of an infant small for gestation age.8-10

Sources

1. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update a guideline from the american heart association. J Am Coll Cardiol. Mar 22 2011;57(12):1404-1423.

2. Statin cost-effectiveness in the United States for people at different vascular risk levels. Circ Cardiovasc Qual Outcomes. Mar 2009;2(2):65-72.

3. D’Agostino RBSr, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. Feb 12 2008;117(6):743-753.

4. Marma AK, Berry JD, Ning H, Persell SD, Lloyd-Jones DM. Distribution of 10-year and lifetime predicted risks for cardiovascular disease in US adults: findings from the National Health and Nutrition Examination Survey 2003 to 2006. Circ Cardiovasc Qual Outcomes. Jan 2010;3(1):8-14.

5. Wilson B J, Watson MS, Prescott GJ, et al. Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study. BMJ. Apr 19 2003;326(7394):845.

6. Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet. Nov 19 2005;366(9499):1797-1803.

7. Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. Nov 10 2007;335(7627):974.

8. Banerjee M, Cruickshank JK. Pregnancy as the prodrome to vascular dysfunction and cardiovascular risk. Nat Clin Pract Cardiovasc Med. Nov 2006;3(11):596-603.

9. Garovic VD, Hayman SR. Hypertension in pregnancy: an emerging risk factor for cardiovascular disease. Nat Clin Pract Nephrol. Nov 2007;3(11):613-622.

10. Sattar N. Do pregnancy complications and CVD share common antecedents? Atheroscler Suppl. May 2004;5(2):3-7.

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