Table 4.
Factors not included in risk calculators.
| Patient A | Patient B | |
|---|---|---|
| Required by calculator | ||
| Age | 40 | 40 |
| Gender | Male | Male |
| Race | Non-African American | Non-African American |
| Smoker | No | No |
| Treated for diabetes | No | No |
| Treated for Hypertension | No | No |
| Total Cholesterol (mg/dl) | 175 | 220 |
| HDL cholesterol (mg/dl) | 55 | 55 |
| Systolic blood pressure (mmHg) | 110 | 110 |
| Diastolic blood pressure (mmHg) | 70 | 70 |
| Not included in calculator | Patient A | Patient B |
| Fasting Triglycerides (mg/dl) | 80 | 210 |
| LDL-C (mg/dl) | 75 | 150 |
| LDL-P (Nmol/L) | 800 | 2300 |
| Strong family history of ASCVD | No | Yes |
| Hemoglobin A1C (%) | 5.4 | 6.3 |
| Waist circumference (inches) | 35 | 42 |
| Lipoprotein (a) (mg/dl) | 70 | 250 |
| AHA/ACC Risk Score by calculator | ||
| (% ten-year risk) | 0.6% | 0.9% |
Consider two hypothetical male non-African-American patients, each 40 years old and their AHA Risk Calculator scores as follows (Patient B has a common profile) (Table 4). The latest guidelines recommend taking ancillary factors into account, as for Patient B, but with a risk score below 1%, most calculator users would be unlikely to recommend treatment for Patient B, yet he appears at very high risk of an acute event in the relatively near future, as well as slow-developing manifestations of atherosclerosis. Changing only the age for Patient B to 60 years in the AHA Risk Calculator means a Risk Score of only 6.8%, still below the treatment threshold of 7.5%.
Every decade of delay in treatment could mean risk of an acute event, damage to other organs, poor aging and ever greater physiological resistance to treatment once finally begun.
Treating Patient B at age 40 or younger would likely prevent premature morbidity and mortality and would be significantly easier, safer and more effective.