Cost-effectiveness of medical primary prevention strategies to reduce absolute risk of cardiovascular disease in Tanzania: a Markov modelling study

The value of primary preventative therapies for cardiovascular disease (CVD) in older adults (age ≥75 years) is less certain than in younger patients. There is a lack of quality evidence in older adults due to underenrolment in pivotal trials. While aspirin is no longer recommended for routine use in primary prevention of CVD in older adults, statins may be efficacious. However, it is unclear which patient subgroups may benefit most, and guidelines differ between expert panels. Three relevant geriatric conditions (cognitive impairment, functional impairment and polypharmacy) may influence therapeutic decision making; for example, baseline frailty may affect statin efficacy, and some have advocated for deprescription in this scenario. Evidence regarding statins and incident functional decline are mixed, and vigilance for adverse effects is important, especially in the setting of polypharmacy. However, aspirin has not been shown to affect incident cognitive or functional decline, and its lack of efficacy extends to patients with baseline cognitive impairment or frailty. Ultimately, the utility of primary preventative therapies for CVD in older adults depends on potential lifetime benefit. Rather than basing treatment decisions on absolute risk alone, consideration of comorbidities, polypharmacy and life expectancy should play a significant role in decision making. Coronary calcium score and new tools for risk stratification validated in older adults that account for the competing risk of death may aid in evaluating potential benefits. Given the complexity of therapeutic decisions in this context, shared decision making provides an important framework.

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Abstract MP41: Implications of the Use of the New ACC/AHA Guidelines for Cardiovascular Disease Prevention in a Brazilian Cohort - The Elsa Brasil Study

Circulation ◽

10.1161/circ.131.suppl_1.mp41 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Marcio S Bittencourt ◽

Isabela Bensenor ◽

Dora Chor ◽

Paulo Vasconcelos ◽

Paulo Lotufo

Keyword(s):

Cardiovascular Disease ◽

Primary Prevention ◽

Prediction Model ◽

Urban Areas ◽

Absolute Risk ◽

Adult Health ◽

Older Individuals ◽

Cvd Risk ◽

The Impact ◽

Brazilian Cohort

Introduction: The 2013 American College of Cardiology / American Heart Association (ACC/AHA) guidelines developed a new prediction model for cardiovascular disease (CVD) and suggested the use of a lower threshold of 7.5% 10 year hard CVD risk for primary prevention. The implications of the use of this model in other cohort and admixed races has not yet been tested. The current study sought to evaluate the potential impact of its use in a large Brazilian cohort. Methods: We have included 15105 participants of the (Brazilian Longitudinal Study of Adult Health) ELSA-Brasil study, a multicenter prospective study that enrolled civil servants aged 35 to 74 years in 6 different urban areas in brazil. We have calculated the both the Framingham risk score (FRS) and the new risk prediction model to the entire cohort, and estimated the impact of changing current recommendations based on the FRS and lipid targets to the new recommendations based on the absolute risk estimated by the new model. Results: The mean age was 52±9.1 years, with 8218 (54%) women. The race distribution included 52% white, 16% black, 28% mixed (brown), and 4% of other. While 19.2% (95% CI: 18.4 to 19.6) of the cohort would require statins for primary prevention accordion to prior recommendations, the new guidelines would recommend treatment for approximately 40.2% (95%CI: 39.4 to 41.0) of the cohort. A substantial increase in the population in whom statins are recommended occurred for males, from 23.3% (95%CI: 22.6 to 24.0%) to 55.7% (95%CI: 54.9 to 56.5), as well as females, from 16.6 (95%CI: 16.0 to 17.2) to 27.1 (95%CI: 26.4 to 27.8), and across all races and age levels (figure). Conclusion: The new ACC/AHA guidelines for primary prevention would approximately double the proportion of Brazilian adults in whom statins are indicated, mostly among older individuals. The epidemiological and economical impact of this changes are not yet known.

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