Risk of Cardiac Death Pretty Much Set by 55

By Crystal Phend, Senior Staff Writer, MedPage TodayPublished: January 25, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

4 comment(s)

Action Points

• Two or more major risk factors for cardiovascular disease such as hypertension, elevated cholesterol, diabetes, and smoking at age 55 predicted 29.6% chance of death from cardiovascular disease by age 80 for men and 20.5% for women.
• For 55-year-olds without cardiovascular risk factors, lifetime risk was only 4.7% for men and 6.4% for women.

Even a couple of traditional cardiovascular risk factors in middle age spell high lifetime risk for the heart, researchers affirmed.
Two or more major risk factors at age 55 predicted a 29.6% chance of death from cardiovascular disease by age 80 for men and 20.5% for women, Donald M. Lloyd-Jones, MD, of Northwestern University in Chicago, and colleagues found.
But for 55-year-olds with a clean bill of cardiovascular health, lifetime risk was only 4.7% for men and 6.4% for women in the analysis of patient-level data from more than 250,000 individuals across 18 longitudinal studies.
The effect was similar for heart attacks and strokes and regardless of race or era in which one was born, the group reported in the Jan. 26 issue of the New England Journal of Medicine.
Risk assessment typically considers only short-term risk, such as 10-year risk with the Framingham prediction tool, the group noted.
"However, the majority of adults in the U.S. who are considered to be at low risk for cardiovascular disease in the short term are actually at high risk across their remaining lifespan," Lloyd-Jones and colleagues wrote.
Telling individuals they are safe until short-term risk becomes high may not be the best strategy, they suggested.
Instead, "efforts to lower the burden of cardiovascular disease will require prevention of the development of risk factors (primordial prevention) rather than the sole reliance on the treatment of existing risk factors (primary prevention)," the group concluded.
Their Cardiovascular Lifetime Risk Pooling Project pulled together cohort studies done over the past 50 years in order to dig deeper into risk factors than possible with any single data set.
Altogether, only 5% of the 257,384 studies' participants had an optimal cardiovascular risk factor profile, with total cholesterol under 180 mg/dL, blood pressure under 120/80 mm Hg, and no smoking or diabetes.
Having one major traditional risk factor -- smoking, diabetes, treated high cholesterol or an untreated level of at least 240 mg/dL, treated hypertension or untreated 160 mm Hg systolic or 100 mm Hg diastolic or higher -- was most common, accounting for about 40% of individuals across middle and older age ranges and gender groups.
Roughly another quarter had two or more major risk factors from that list.
Lifetime cardiovascular risks were "very low" with no risk factors in middle age but rose dramatically with even one or two risk factors.
Two or more major risk factors at 55 predicted drastically higher lifetime risk of fatal coronary heart disease or nonfatal myocardial infarction (MI) compared with having an optimal risk-factor profile (37.5% versus 3.6% among men and 18.3% versus less than 1% among women).
Likewise, fatal or nonfatal stroke risk was lower with no versus two or more major risk factors (2.3% versus 8.3% among men and 5.3% versus 10.7% among women).
For the overall risk of death from cardiovascular causes and for nonfatal MI, men carried about twice the lifetime risk of women. Stroke risk didn't differ much by gender.
For the same gender and level of risk factors, black individuals weren't more likely to die from cardiovascular causes than were white individuals, although the burden of risk factors was higher among blacks.
At the same age, individuals born more recently had fewer risk factors but roughly the same risk when risk factors were present.
"The presence or absence of traditional risk factors appears to represent a much more consistent determinant of the long-term risk of cardiovascular disease than race or birth cohort," the researchers concluded.
They cautioned that including treated patients in the analysis may have underestimated future risk, although such patients represented just a small proportion of the overall cohort.
Another limitation was that lifetime risk couldn't be estimated for individuals assessed in the most recent decade due to the short follow-up.
But because of the consistency of the results across the various birth cohorts included in the analysis, the findings likely generalize to people today, Lloyd-Jones' group noted.

The study was supported by grants from the National Heart, Lung, and Blood Institute, by funding from the Dedman Family Scholar in Clinical Care endowment at UT Southwestern Medical Center, and by an American Heart Association grant.
Lloyd-Jones reported funds paid to his institution from the NHLBI and AHA without any conflicts of interest to disclose. Several co-authors' institutions also received funds from NIH/NHLBI and AHA. Berry reported receiving funds from Merck. Tracy reported receiving funds from Merck, Tibotec-Johnson & Johnson, Abbott, and from two law firms for consulting, and is the owner of Haematologic Technologies.

From the American Heart Association:

• Cardiovascular Risk in Asymptomatic Adults

Primary source: New England Journal of Medicine
Source reference:
Berry JD, et al "Lifetime risks of cardiovascular disease" N Engl J Med 2012; 366: 321-329.