PREVENT Tool Accurately Predicts HF Risk, With ‘Strong’ ASCVD Overlap

The PREVENT equations developed by the American Heart Association (AHA) can accurately predict the risk of heart failure (HF) developing within 10 years, according to new data from the National Health and Nutrition Examination Survey (NHANES). This confirmation is helpful because while there is often substantial overlap between the risks of atherosclerotic cardiovascular disease (ASCVD) and HF, the two are not always identical.

In this analysis, PREVENT identified 15 million Americans, extrapolated from the NHANES sample, as having an intermediate or high (≥ 10%) risk of HF over 10 years. Notably, 4.3 million of them had a low risk (< 10%) of ASCVD.

For lead author Jeremy B. Sussman, MD (University of Michigan, Ann Arbor), what’s striking is the superimposable risk.

“The thing that surprised us most was quite how overlapping risk for heart failure and risk for ASCVD are,” he told TCTMD. “We expected them to be similar. They have fundamentally the same risk factors, such as high blood pressure, age, and diabetes status, with some differences. But in fact, the overlap was quite strong.”

The PREVENT tool—which includes calculators for ASCVD, HF, and CVD—was introduced by the AHA in 2023 to aid earlier prevention by encompassing the entire spectrum of cardiovascular, kidney, and metabolic risk factors that can predict disease over 10 and 30 years. The calculator for HF risk includes body mass index (BMI), while the one for ASCVD does not. A range of validation studies have confirmed the accuracy of the PREVENT equations in predicting CVD mortality.

Prior risk scores like the pooled cohort equations have been primarily focused on atherosclerotic disease, such that the inclusion of heart failure in PREVENT is noteworthy, said Sussman. “Risk scores for heart failure have been made before, but they have not had nearly this level of attention nor the support of American Heart Association,” he said. “So this score is going to have an influence that previous heart failure prediction scores have not had.”

Sadiya S. Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who originally presented the PREVENT equations at the 2023 American Heart Association Scientific Sessions, told TCTMD the study showed “a lot of what we would expect to see in terms of high heart failure risk is correlated with high ASCVD risk. We would expect the same risk factors that put somebody at risk for a heart attack to put them at risk for heart failure.”

Further, the study is valuable in that it “highlighted how the heart failure component could be used to intensify and improve prevention of heart failure, and I think this is a really important area to really expand upon the same way we approach ASCVD primary prevention,” she added. “We now have a framework for heart failure primary prevention, and these data help us start to move forward in that new paradigm.”

HF Risk Prediction

For the study, published as a brief research report this week in the Annals of Internal Medicine, Sussman and colleagues included data from 4,872 adults from NHANES representing 143.2 million Americans (mean age 51 years; 51.6% female) collected between 2017 and 2020. They calculated each person’s 10-year risks of HF and ASCVD using the PREVENT equations.

Overall, the mean estimated risk of HF over 10 years was 3.7%. This risk varied with age, with the oldest cohort of patients (70 to 79 years) making up the majority of the total population at highest risk (62.4%). Race was largely consistent across risk categories, but Black adults made up a smaller proportion of the low-risk group (9.7%) compared with the elevated-risk group (14.2%).

Sussman highlighted that the PREVENT equations, unlike other popular risk tools, do not consider racial information. The findings here for Black Americans are likely driven by “higher rates of high blood pressure, which we all have long known about and struggled with,” he said.

More than half of patients with elevated HF risk had a systolic BP above 130 mm Hg (54.3%) or a BMI above 30 kg/m² (55.6%). As patients got older, so did the prevalence of uncontrolled risk factors, except for elevated BP.

The correlation between HF and ASCVD risks was high (R² = 0.83) with 4.6% of participants having a higher risk of HF than ASCVD and 0.9% having a lower risk of HF than ASCVD.

Hypertension and obesity are likely the major factors in increasing HF risk regardless of ASCVD risk, said Jacob Joseph, MD (VA Providence Healthcare System, RI), who commented on the study for TCTMD. “[This] is something we know, but this study shows that in a more cross-sectional fashion across the population,” he said. “For individual patients, . . . the risk of heart failure could be influenced by other things like heart attacks. But in the population, it seems like we should consider targeting hypertension and obesity.”

Khan, agreed. “The main [HF risk factor] really is going to be around obesity because that's included in the heart failure risk assessment, but not in ASCVD,” she said.

What to Do With This Information?

While knowledge of an elevated ASCVD risk unlocks a wide variety of preventive measures, including statin initiation, the same is not currently as clear-cut for HF.

“What we do with high heart failure risk is not fully determined yet,” Sussman said. “I think there's a lot of promise for screening and early treatment, and that we could find that prediction of heart failure is very valuable for clinical decision making. But right now, it's not really standard of care to use that information and exactly what you'd use it for is still a little bit controversial.”

Joseph agreed that “that question doesn't have a real solid answer,” which further justifies the need for large primary prevention trials in people identified to be at high risk.

Still, Khan said there has been enough published evidence to support intensive blood-pressure lowering in patients at risk for heart failure. “The caveat is that there is some information about how we can optimize risk factors that would be helpful,” she said. “Where we really need to go is: how do we best develop the evidence base for what are the best strategies for preventing heart failure and how are these similar to and how are they different to preventing ASCVD?”

Going forward, Sussman said, future efforts should focus on ways to screen and treat patients with high risk of heart failure “that is not too burdensome for patients or providers, but can reduce the onset of heart failure effectively, and I think this is possible.”

Additionally, the threshold for what constitutes high risk for HF might also need to be reexamined. “The authors used very standard cutoff of 20%, but I would argue we probably want to think about increased risk at much lower cut points,” Khan said. “Another thing that I think we still need to better understand is what is the cut point at which risk factor intensification should occur, whether for blood pressure or considering for, I think, therapies like SGLT2 inhibitors or GLP-1s that can prevent heart failure.”