The Adult Treatment Panel III guidelines place the 72-year-old female in the category of multiple risk factors (age, hypertension, smoking, family history) and thus recommend calculating her 10-year risk. In using the Framingham Risk Score, the physician was correct in classifying the patient as having “low” cardiovascular risk (<10% over 10 years), and with an LDL cholesterol concentration of 2.67 mmol/L, she thus would not be considered for pharmacologic treatment.
Why Did This Strategy Fail for This Patient?
First, the Framingham model fails to include components of inflammatory and genetic risk. The patient’s risk as calculated with the Reynolds Risk Score, which includes high-sensitivity C-reactive protein (hs-CRP) and family history, is 23.2% over 10 years, which is in the high-risk category; she would therefore be eligible for statin therapy.
Second, the definition of intermediate risk, which is currently 10%–20%, should be lowered to 5%–20%. Most women have a <10% risk. Statins have been shown to be effective in this range, and tests such as hs-CRP measurement or imaging improve risk stratification in the 5%–20% category.
Alternatively, a simpler approach would be to count traditional risk factors, especially hypertension, as well as age, smoking, and family history. On the basis of these risk factors and ASCOT-LLA findings, a clinician could justify starting the patient on statin therapy along with therapeutic lifestyle changes, including smoking cessation. The current approach of calculating 10-year risk with an equation is not used frequently in clinical practice. Finally, a new approach would be to incorporate the findings of JUPITER into practice. Before telling men older than 50 years or women older than 60 years that they would not benefit from statin therapy, a physician could measure hs-CRP. If the hs-CRP concentration is ≥2 mg/L, then statin therapy could be offered on the basis of evidence from JUPITER, in which high-efficacy statin therapy that reduced LDL cholesterol by approximately 50% and hs-CRP by 37% reduced events by almost 50%.
Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article.
Authors’ Disclosures of Potential Conflicts of Interest: Upon manuscript submission, all authors completed the Disclosures of Potential Conflict of Interest form. Potential conflicts of interest:
Employment or Leadership: None declared.
Consultant or Advisory Role: C.M. Ballantyne, Abbott Laboratories, AstraZeneca, Atherogenics, GlaxoSmithKline, Merck, Merck/Schering-Plough, Novartis, Pfizer, Sanofi-Synthelabo, Schering-Plough, and Takeda.
Stock Ownership: None declared.
Honoraria: C.M. Ballantyne, Abbott Laboratories, AstraZeneca, Atherogenics, GlaxoSmithKline, Merck, Merck/Schering-Plough, Novartis, Pfizer, Sanofi-Synthelabo, Schering-Plough, and Takeda.
Research Funding: C.M. Ballantyne, Abbott Laboratories, AstraZeneca, GlaxoSmithKline, Merck, Pfizer, Sanofi-Synthelabo, Schering-Plough, and Takeda.
Expert Testimony: None declared.
Role of Sponsor: The funding organizations played a direct role in the final approval of the manuscript.
- © 2009 The American Association for Clinical Chemistry