Potential lifetime benefit of applying two-step ESC prevention strategy

Abstract

Abstract Background The 2021 ESC Prevention guideline recommends a two-step strategy for risk management in patients with atherosclerotic cardiovascular disease (ASCVD). We estimated the potential lifetime benefit of complete implementation of this approach, compared to current practice. Methods In a pooled cohort (N=1,937) of coronary patients >45 years, lifetime risk for recurrent events and gained event-free years with STEP 1 and STEP 2 were estimated using the SMART-REACH model. For all patients, STEP 1 included non-smoking, the use of antiplatelet therapy and specific targets for low-density lipoprotein cholesterol (LDL-C<1.8 mmol/L) and systolic blood pressure (SBP<140 mmHg), with use of diabetic medication if indicated. In patients with residual lifetime risk >30%, STEP 2 included stricter targets (LDL-C<1.4 mmol/L and SBP<130 mmHg) and intensified treatments (colchicine and dual antiplatelet therapy). Results With current treatment following a coronary event, 196 (10%) of patients (20% women, mean age 64) met targets of STEP 1 and 46 (2%) of STEP 2, indicating a lifetime risk of 52% [interquartile range (IQR) 45-59]. Implementing STEP 1 would lower lifetime risk to 37% [IQR 28-45] (Fig 1) and result in a gain of 3.2 [IQR 1.4-5.9] years without events (Fig 2). Intensified STEP 2 treatment was indicated in 70% (median residual risk 41% [36-48]), resulting in lifetime risk in all patients of 26% [21-31] and 5.5 [3.8-8.1] event-free years. Conclusion A two-step (residual) risk reduction strategy in ASCVD patients has the potential to lower lifetime risk of recurrent events and to approximately add three event-free years per step to their lifetime.Decrease in lifetime risk per stepGain of event-free years per step