'Should we reconsider the role of age in treatment allocation for primary prevention of cardiovascular disease?' No, but we can improve risk communication metrics.

Abstract

The opinion piece published in this edition of the European Heart Journal by Leening and colleagues1 represents one of the two main opposing views on the role of age in cardiovascular disease (CVD) risk prediction scores and for determining risk-reducing treatment thresholds. Leening et al . raise concerns about the dominance of age in CVD risk prediction scores and propose the use of two new risk metrics that do not rely on age. In contrast Wald and colleagues have advocated that for simplicity, age, rather than multivariable predicted risk, should be the sole criterion used to determine eligibility for treatment.2 In our opinion both positions are problematic. We agree with Wald et al . that age is the single best predictor of a patient's short-term (e.g. 5- or 10-year) CVD risk and is also the single best predictor of the short-term benefits of CVD risk reduction.2 However, we disagree that the simplicity of an age-only treatment threshold would outweigh the incremental improvement in predictive power and the greater acceptability (to patients and clinicians) of risk prediction scores that include the standard modifiable CVD risk factors alongside age. We also disagree with Leening and colleagues that the dominant role of age in CVD risk prediction calculators is a problem because, as stated above, age is best single predictor of future CVD risk and treatment benefit. We acknowledge the concerns that they and many others have regarding the apparent dominance of age in CVD risk prediction, but we disagree with their assumptions about the role of age in CVD risk prediction and about how predicted CVD risk should be used to inform management decisions. …