Modifiable lifetime risk for recurrent major cardiovascular events: observations in a contemporary pooled cohort
Authors: Van Trier T J , Snaterse M , Ter Hoeve N , Sunamura M , Moll Van Charante E P , Galenkamp H , Deckers J W , Hageman S H J , Visseren F L J , Scholte Op Reimer W J M , Peters R J G , Jorstad H T 
Published: October 2021

Abstract

Introduction
The major modifiable risk factors for atherosclerosis – lifestyle, hypertension, diabetes and cholesterol – collectively account for 80 to 90% of disease burden. Currently, the majority of coronary patients does not meet the guideline-directed treatment targets for these risk factors, resulting in high levels of residual risk. An increasing number of novel preventive drugs aims to reduce this residual risk, but are not considered cost-effective when added routinely to all patients. Quantifying the potential lifetime risk reduction one year after an acute coronary syndrome (ACS) may aid in optimum use of available treatment and value-based use of novel drugs.

Purpose
The purpose of this analysis was to quantify the loss of lifetime risk reduction due to suboptimal modifiable risk factor control in patients with prior ACS or revascularisation.

Methods
We pooled six recent prospective studies (Response 1 [1] and 2 [2], Opticare [3], EuroAspire IV [4] and V [5] and HELIUS [6]) with Dutch patients (n=3,230, 24% women) at mean age 61±8 years and follow-up at median 1.1 [IQR 1.0–1.8] years after an ACS or revascularisation. We investigated individual lifestyle- and drug-modifiable risk factors at guideline-directed targets. Using the SMART-REACH model [7], we calculated % reduction of individual residual lifetime risk for myocardial infarction, stroke, or cardiovascular death and event free years gained by the change from current treatment to a (simulated) guideline-directed optimal situation.

Results
Risk factor control was far from optimal: only 7% met all lifestyle-related risk targets, whereas 10% met none: 30% persist smoking, 79% was overweight (BMI ≥25 kg/m2), of which 40% obese (BMI ≥30 kg/m2), and 45% reported insufficient physical activity (&lt;150 minutes per week). Systolic blood pressure ≥140 mmHg was found in 40%, and LDL-cholesterol ≥1.8 mmol/L or ≥2.5 mmol/L (depending on the target at that time) in 65%. Basic preventive medication use was, however, common: 87% used antithrombotic agents, 85% lipid lowering drugs and 86% any blood pressure lowering drugs. By the change from current to optimal guideline-directed treatment, residual lifetime risk for cardiovascular events and cardiovascular death would decrease from a mean of 54±11% to 25±10% (Figure 1), and a median of 7.4 [IQR 5.2–10.6] event free years would be gained (Figure 2).

Conclusion
Suboptimal risk factor control resulted in avoidable high residual lifetime risk of myocardial infarction, stroke, or cardiovascular death and loss of event free years in patients with prior ACS or revascularisation. This finding highlights the unexploited potential of optimised use of available lifestyle- and drug treatment to significantly reduce residual lifetime risk.

Funding Acknowledgement
Type of funding sources: None. Figure 1. Modifiable residual lifetime riskFigure 2. Lifetime benefit in CVD event free years