216. Guidelines: 2021 ESC Cardiovascular Prevention – Question #13 with Dr. Eugene Yang

The following question refers to Section 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr.Hirsh Elhence, answered first by Mayo Clinic FellowDr. Teodora Donisan, and then by expert facultyDr. Eugene Yang.

Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelinesrepresents a collaboration with theACC Prevention of CVD Section, theNational Lipid Association, andPreventive Cardiovascular Nurses Association.

Question #13

You are seeing a 45-year-old woman with a past medical history of hypertension, overweight status, hyperlipidemia, and active tobacco use disorder. Her BMI is 27 kg/m2, BP is 150/75, HbA1C is 5.8%, total cholesterol is 234 mg/dL, HDL is 59 mg/dL, and LDL is 155 mg/dL. She is from Romania, a country with very high CVD risk. Which of the following statements is CORRECT?

A. LDL-C needs to be decreased by at least 50%, as small absolute LDL-C reductions would not provide clinical benefit

B. Hypertension is not an important CVD risk factor in our patient, as she is young.

C. Prediabetes is not a significant CV risk factor for our patient, as she is not yet diabetic.

D. Smoking confers a higher CVD risk for women than for men.

E. Her weight does not increase her CVD risk, as she is overweight rather than obese

Answer #13

The correct answer is D – Smoking confers a higher CVD risk for women than for men.

Prolonged smoking increases the CVD risk more in women than in men. Our patient is 45 years old. CVD risk in smokers < 50 years-old is 5x higher than in non-smokers. Of note, smoking is responsible for 50% of all avoidable deaths in smokers and a lifetime smoker will lose 10 years of life, on average. Secondhand smoke and smokeless tobacco can also increase the CVD risk.

Option A is incorrect. The SCORE2 risk chart for populations at very high CVD risk places her at a 14% (very high) 10-year risk for myocardial infarction, stroke, or cardiovascular death. She would derive benefit even from incremental reductions in LDL-C values. The absolute benefit of lowering LDL-C depends on both the absolute risk of ASCVD and the absolute reduction in LDL-C,