What is the purpose and application of the PREVENT (Patient Risk Evaluation and Visualization for Enhanced Treatment) risk calculator in assessing cardiovascular risk?

PREVENT Risk Calculator Overview

The PREVENT (Predicting Risk of CVD EVENTs) equations are the American Heart Association's newest cardiovascular risk assessment tool, developed in 2023-2024 to replace the Pooled Cohort Equations, providing more accurate 10-year and 30-year risk predictions for total CVD (atherosclerotic CVD plus heart failure) in adults aged 30-79 years. 1, 2

Key Features and Advantages

PREVENT addresses critical limitations of older calculators:

• Eliminates race from the calculation, making it a race-free prediction model 1, 2
• Includes kidney function (estimated glomerular filtration rate) as a standard predictor, recognizing the cardiovascular-kidney-metabolic syndrome connection 1, 2
• Predicts total CVD (both atherosclerotic CVD and heart failure), not just atherosclerotic events 1, 2
• Corrects for overprediction: The Pooled Cohort Equations overestimated ASCVD risk by nearly twofold in contemporary populations, while PREVENT demonstrates accurate calibration 2, 3
• Provides separate risk estimates for atherosclerotic CVD and heart failure individually, allowing targeted prevention strategies 2

Required Input Variables

The base PREVENT model uses these routinely available clinical variables: 2

• Age (30-79 years)
• Sex
• Systolic blood pressure
• Total cholesterol and HDL cholesterol
• Current smoking status
• Diabetes status
• Use of antihypertensive medications or statins
• Estimated glomerular filtration rate (eGFR)

Enhanced Models with Optional Predictors

PREVENT offers enhanced equations when additional data are available: 1, 2

• Urine albumin-to-creatinine ratio: Significantly improves calibration in patients with marked albuminuria (>300 mg/g) 2
• Hemoglobin A1c: Provides enhanced predictive utility for cardiovascular-kidney-metabolic risk assessment 1, 2
• Social Deprivation Index: Incorporates social determinants of health when geographic data are available, addressing upstream drivers of CVD 1, 3

Development and Validation

PREVENT was derived from exceptionally large and diverse datasets: 2

• Developed using 3,281,919 participants from 25 datasets (1992-2017)
• Externally validated in 3,330,085 participants from 21 additional datasets
• Total of over 6.6 million adults included in development and validation
• Demonstrated excellent discrimination with C-statistics of 0.794 in women and 0.757 in men 2
• Calibration slopes near 1.0 indicate accurate risk prediction across risk deciles 2

Clinical Applications

PREVENT enables multiple time horizons for risk assessment: 1

• 10-year risk estimates: For standard primary prevention decision-making
• 30-year risk estimates: Particularly valuable for younger adults (30-50 years) where 10-year risk may be artificially low despite unfavorable risk factor profiles 1
• Competing risk adjustment: Accounts for non-CVD death, improving accuracy in older adults 1

Comparison with European Tools

PREVENT differs substantially from European risk calculators: 4

• European guidelines use SCORE2 and SCORE2-OP, which were developed from 45 European cohorts and calibrated to four geographic risk regions 4
• SCORE2 uses age-specific thresholds that differ from American guidelines, with lower percentage thresholds for defining high risk 4
• The U-Prevent tool (www.U-Prevent.com) is recommended by the European Association of Preventive Cardiology and provides algorithms for all patient subgroups with lifetime risk perspectives 5

Treatment Thresholds Using PREVENT

Risk-based treatment decisions can be guided by PREVENT scores: 6

• ≥10% 10-year ASCVD risk: Consider initiating statin therapy for cholesterol management 6
• ≥10% 10-year ASCVD risk with stage 1 hypertension (130-139/80-89 mmHg): Consider antihypertensive therapy 6
• Borderline (5-7.5%) or intermediate (7.5-20%) risk: Use risk-enhancing factors (family history, chronic inflammatory conditions, metabolic syndrome) to guide decisions 6

Implementation Strategies

Practical approaches to integrate PREVENT into clinical practice: 6

• Embedding the calculator into electronic health records increases CVD risk documentation four-fold in primary care 6
• Use visual outputs showing CVD-free life years gained with interventions to facilitate shared decision-making 6
• Generate printed reports demonstrating the impact of specific interventions on lifetime CVD risk to improve patient motivation and adherence 6
• Present risk as both percentages and absolute numbers alongside CVD-free life years gained 6

Important Limitations and Caveats

PREVENT has specific populations where validation is limited or accuracy is reduced:

• People with HIV: PREVENT significantly underpredicts risk in this population, with observed risks more than double predicted risks (observed-to-expected ratio of 2.69) 7
• Extreme risk factor levels: Predictions may be less accurate in familial hypercholesterolemia or other extreme presentations 5
• Life-limiting comorbidities: Not suitable for patients with metastatic malignancy, severe pulmonary disease, or end-stage renal disease 5
• Age restrictions: Validated only for ages 30-79 years; do not extrapolate beyond these boundaries 1, 2

Risk Assessment Timing

When to perform cardiovascular risk assessment: 6

• Measure traditional risk factors at least every 4-6 years starting at age 20 6
• Formal risk calculation with PREVENT is most useful after age 40 6
• For adults 20-39 years, use 30-year or lifetime risk rather than 10-year risk to guide lifestyle interventions 6