Panjak Arora, M.D., and Garima Arora, M.D., published the study evaluating cardiovascular risk equations.Researchers from the University of Alabama at Birmingham Marnix E. Heersink School of Medicine have recently published three manuscripts evaluating the American Heart Association’s PREVENT CVD risk equation, which is designed to help predict a person’s risk of a cardiovascular event during their lifetime.

In three studies, published in Mayo Clinic Proceedings, Journal of the American College of Cardiology: Advances and the American Journal of Cardiology, researchers found that, while the PREVENT equations are promising, they may need further validation before being adopted as a replacement for the current gold standard, known as Pooled Cohort Equations, in a clinical setting. Their findings suggest that the PREVENT equations may underestimate cardiovascular risk in patients, which could affect statin and antihypertensive therapy initiation.

“We are on the precipice of a major shift in cardiovascular risk assessment, but the data we have now simply is not sufficient to justify replacing PCEs with the PREVENT equations just yet,” said Pankaj Arora, M.D., lead investigator and director of the UAB Cardiogenomics Clinic. “Our research shows concerning patterns — especially the misclassification of at-risk individuals into lower-risk categories — that could have serious implications for clinical decision-making, particularly when it comes to treatment and prevention.”

Researchers examined data from the National Health and Nutrition Examination Survey, the UK Biobank, and the Systolic Blood Pressure Intervention Trial — which includes populations that span different ethnic groups, risk profiles and age ranges. Researchers found that the PREVENT equations consistently reclassified individuals into lower-risk categories, raising the risk of undertreatment, especially in key demographic groups like Black individuals and older adults.

• NHANES Data: Analysis published in JACC Advances revealed that the PREVENT equations underestimated ASCVD risk, significantly lowering the number of individuals considered high-risk, particularly for men and Black individuals. This reclassification could lead to a major drop in statin eligibility — leaving individuals with higher risks for heart disease under-treated and at increased risk for adverse cardiovascular events.
• UK Biobank: With a massive cohort of 261,303 participants, published in American Journal of Cardiology, this study showed that the PREVENT equations classified just 14 percent as high-risk, compared to 36.9 percent using the PCEs. Meanwhile, 75.3 percent of participants who were considered intermediate-risk by the PCEs were shifted into a low-risk group by PREVENT, suggesting a substantial underestimation of risk. This results in a staggering reduction in statin eligibility, from 40.7 percent using PCEs to just 19.9 percent using PREVENT.
• SPRINT Trial: In a post-hoc analysis, published in Mayo Clinic Proceedings, in a population of hypertensive individuals over 50, the PREVENT equations classified only 0.9 percent as high-risk, compared to 35.4 percent with the PCEs. Arora says the sharp contrast in risk classification suggests that the PREVENT model is not ready to replace the PCEs in high-risk populations where targeted interventions like statins and blood pressure-lowering drugs are essential.

“The potential clinical consequences are enormous,” said Garima Arora, M.D., co-investigator and co-director of the UAB Cardiogenomics Clinic. “For some populations, the PREVENT equations could drastically reduce the number of people who are eligible for critical preventive treatments, which could lead to thousands of unnecessary heart attacks and strokes.”

The studies also found that Black individuals were disproportionately affected by the underestimation of ASCVD risk by the PREVENT equations, highlighting a serious concern for exacerbating existing health disparities. The misclassification of Black individuals into lower-risk categories could result in under-treatment for a population that already experiences higher rates of cardiovascular disease.

“We need to move cautiously,” Arora said. “While the PREVENT equations show promise in predicting cardiovascular risk, their ability to replace PCEs needs work. We cannot afford to rush this process.”

UAB researchers emphasize the critical need for further research to validate the PREVENT equations across diverse populations before they are widely implemented. These findings stress the importance of refining cardiovascular risk assessment tools to ensure equitable and effective care for all patients.