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Heart Health, Explained

Risk Assessment: Omnibus Risk Estimator

New statin-therapy cholesterol and heart disease prevention and treatment guidelines from the American College of Cardiology and the American Heart Association appear to abandon LDL cholesterol levels as targets for statin therapy and, instead, recommend an "Omnibus Risk Estimator," as detailed in a November 29, 2013 article in The New York Times, for determining whether taking a statin is necessary.

Omnibus Risk Estimator Q&A

Q: I’m already taking a statin (Crestor, Lipitor, Zocor, etc.), and now I am confused if it is right for me. How should I understand this new "Omnibus Risk Estimator"?

A: The “Omnibus Risk Estimator” is just one part of the new guidelines for determining risk of heart disease and reducing risk with the use of statins and lifestyle changes. Many people are confused with these new guidelines and specifically with how to use the new risk estimator. In simple terms, the estimator is a spreadsheet in which the individual enters information on nine factors, including age, sex, race, cholesterol levels, systolic blood pressure (the pressure in the arteries when the heart beats), and whether the individual is being treated for high blood pressure, has diabetes, and smokes or not. Any risk calculator can be imprecise, especially if the information entered is not accurate. However, this new risk estimator can be helpful in charting the 10-year and lifetime risk of cardiovascular disease, though it should be viewed as a starting point for dealing with cardiovascular risk, and should not drive all decision-making. Ascertaining an accurate lifetime risk estimate of cardiovascular disease, heart attack and stroke is the overriding goal. The primary use of lifetime risk estimates like the one derived from the new estimator is to facilitate a very important discussion between the individual and the primary care physician on reducing risk through lifestyle changes that include diet, exercise, managing weight, smoking cessation if necessary, and the use of cholesterol-lowering medications or other medications (for high blood pressure) when called for by individual circumstances. Quitting smoking, eating a healthy diet, getting enough exercise, maintaining a healthy weight, and controlling blood pressure, cholesterol and blood sugar are all important ways to improve cardiovascular and overall health. However, you should talk to your health care provider about your risk factors and lifestyle changes - before taking any actions.

Reference: American College of Cardiology, American Heart Association – 2013 Prevention Guideline Tools and Risk Calculator

Q: How did the panel that developed the new guidelines come up with the new risk estimates?

A: The panel reviewed the latest scientific studies and concluded there was no strong evidence to support treating with statins to achieve specific LDL cholesterol targets as a means to prevent heart attack or stroke. Instead, the panel relied on the results of studies of geographically and racially diverse groups of people, such as the Framingham Heart Study and the Cardiovascular Health Study, and state-of-the-art statistical methods to develop new guidelines and risk estimates that consider “the whole patient,” not simply an individual’s cholesterol numbers. The new guidelines focus on estimating and reducing risk in adults between the ages of 40 and 79, because the panel concluded that the strongest evidence supports the use of interventions in this age bracket. Within this age bracket, the panel established four major groups with varying levels of risk in which cholesterol-lowering statin treatment is advised – at varying dose intensities based on the risk level. The risk estimator described in the answer above is a tool to accompany these guidelines and to prompt discussion between patient and health care provider. Lifestyle changes are also recommended as part of these guidelines.

Reference: Pooled Cohort Equations, Appendix 4. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

Q: As gender is one of the factors for calculating cardiovascular disease risk, does this mean women and men do not have to follow different risk-reduction and treatment guidelines? Are there different risk factors for women and men?

A: Gender is factored into the new guidelines, so women and men should find them generally helpful in determining risk and prompting discussions about prevention options with their health care providers. But keep in mind that these guidelines and risk estimates are based on group averages so they produce a “rule of thumb” that is then applied to individual patients in practice. And, although the treatment guidelines apply to both women and men, there are differences in how some specific risk factors affect the average woman versus the average man. For example, diabetes and smoking seem to increase the risk of cardiovascular disease more in women than men. The risk increases significantly in women with the onset of menopause, due to hormonal changes and the related increase in triglycerides (the major form of fats, or lipids, stored by the body – coming from the foods we eat and produced by the body) and decreases in HDL or “good” cholesterol that typically occur. Thus, it can be particularly important for women to pay attention to lifestyle changes and treatment options that focus on these risk factors in the context of reducing lifetime cardiovascular disease risk. Moreover, making cardiovascular health part of a lifestyle over a lifetime should be the goal.

Resource: National Heart, Lung and Blood Institute “Lower Heart Disease Risk,” The Heart Truth

HEALTH NEWS IN PERSPECTIVE

Answers to your questions on timely topics in cardiac care to help make sense of research reports in the media. The series includes questions on your heart and the effect of medications, exercise, diet, and hormones.

Team Specialist

Scott H. Merryman, MD, Diplomate of the American Board of Clinical Lipidology and American Board of Family Medicine Cardiovascular Prevention Services Lipid Clinic Director – McConnell Heart Health Center OhioHealth Healthcare System, Columbus, Ohio

Q&A Editor

Teresa Caulin-Glaser, MD, FACC, FAACVPR System Vice President, Heart & Vascular Services OhioHealth Healthcare System, Columbus, Ohio

Heart Health Explained is a collaboration of Women’s Health Research at Yale and the OhioHealth Healthcare System, a nationally recognized not-for-profit organization with providers across 46 counties, offering a holistic approach to prevention, treatment and rehabilitation of heart disease. OhioHealth is staffed by physicians, psychologists, nutritionists and nurses who answer the questions of the moment on heart and vascular health.

The information provided here may help you make more informed choices. However, it is not a substitute for an individualized medical opinion or diagnosis, and everyone should always consult with their personal physicians to make decisions about their condition or treatment.