Dyslipidemia Estimating CV Risk

Question 1

How do we asses cardiovascular risk? What is the phrase we use?

Answer 1

What is the %PROBABILITY this patient will experience the OUTCOME in the next X YEARS

Question 2

Differentiate between framingham and ASCVD risk calculators. What do they calculate the risk of? Over/under estimate?

Answer 2

Framingham
- risk of heart attack or stroke, heart failure, angina, or intermittent claudication, and mortality
- includes “soft” outcomes which overestimates risk in most population

ASCVD
- calculates: heart attack or stroke (fatal or non-fatal), and mortality
- “HARD” outcomes only (less outcomes) -> leads to a lower risk calculation score overall

Question 3

What kind of regression analysis do the risk score assessment use?
What kind of estimate is used?
What outcomes it is used for?

Answer 3

Multiple linear regression model
- Parameter estimate

Continuous outcome variables (normal distribution), ex.
- Days of hospitalization
- % risk of CVD outcomes

Question 4

What regression model is used for death?
What kind of estimate is used?
What outcomes it is used for?

Answer 4

Logistic regression
- uses Odds ratio
- used for dichotomous outcomes, anything yes or no

Question 5

What regression model is used for time-to-event (survival data)
What kind of estimate is used?
What outcomes it is used for?

Answer 5

Cox regression
- Hazard ratio (proportional hazards regression)
- Used for time to event such as time to first heart attack or how many months before death

Question 6

What are the 3 phases in multivariable prognostic research?

Answer 6

1. Development studies
   - identifying important predictors and assigning relative weights to them to INTERNALLY validate model
2. Validation studies
   - EXTERNAL validating the study by assessing predictive performance (discrimination) and improving performance (calibration)
3. Impact studies
   - Quantifying if the new model truly improves clinical decision and clinical outcomes

Question 7

What are common variables of risk calculators for CV risk factors?

Answer 7

• Age
• Gender
• total cholesterol
• HDL cholesterol
• systolic BP
• diabetes
• current smoking

Question 8

What key variables are excluded in the following risk scores:
Framingham
QRISK2
ACC/AHA pooled cohort ASCVD risk

Answer 8

Framingham
- family history of CVD

QRISK2
- Diabetes

ACC/AHA pooled cohort ASCVD risk
- Family history

Question 9

Is framingham risk used for primary or secondary prevention

Answer 9

Primary prevention

Question 10

What are the guidelines for low, intermediate, & high risk.

Answer 10

Low: Under 10%
Intermediate: 10-20%
High: 20%

Question 11

Which study did most of our knowledge on CVD risk factors come from?

Answer 11

Framingham study

Question 12

What was the FRS cohort mainly included?

Answer 12

White, middle-class American individuals

Question 13

Which population does the FRSH overestimate? Underestimate?

Answer 13

Overestimate:
- Japanese, Hispanic, mediterranean

Underestimate:
- south asians, Indians, Pakistan, Bangladesh

Question 14

What was NOT included in the FRS

Answer 14

• No socioecomonic status
• not designed for diabetes
• No family history (due to recall bias, important)
• Novel biomarkers: (coronary artery calcification CAC, CRP, BNP, however did not really impact)

Question 15

Define B-type Natriuretic peptide biomarker

Answer 15

A cardiac hormone synthesized in the LV in response to inc ventricular VOLULE or inc pressure in ventricular WALL STRESS

Question 16

When do we consider biomarkers in risk scores?

Answer 16

When they are intermediate-risk
- can make them be pushed to high risk

Question 17

ACC/AHA inclusion criteria

Answer 17

• Caucasian and African American patients
• Diabetes as a yes/no (not severity)

Question 18

What was not included in the ACC/AHA criteria

Answer 18

• Family history of premature CVD
  (Dad <55 and Mom <65)

Question 19

Does ACC/AHA study over/under estimate? By how much

Answer 19

50% overestimation

Question 20

End points of ACC/AHA study? What are they looking for?

Answer 20

Fatal + non-fatal MI
Stroke
CHD death

Question 21

What does the SCORE study look at?

Answer 21

The vascular age compared to your actual age

Question 22

How often should you use the risk score on patients? What age group?

Answer 22

Every 5 years for patients aged 40-75

Question 23

What is the approach to risk score (5 steps)

Answer 23

1. Determine if patient has 1 or more CVD risk factors (HTN, smoking, DM, premature family history, CKD, obesity)
2. Obtain lipid panel for 20+ age
3. For primary prevention 40-79yo, use FRS FIRST
   - for patients 20-39 input age as 40
4. Do 30 years or lifetime if risk is low
5. Do ASCVD or SCORE
6. Repeat every 5 years or when a major change happens
7. Convey results to clinicians and patients (include overestimation)