Outside researchers have criticized a new cardiovascular disease risk calculator promoted by a major health association, warning that it could unfairly block up to 16 million people from taking their medications, primarily because it doesn’t take race into account.
Experts outlined this criticism in a new study published in 2011. JAMA A study released Monday found that changes to the American Heart Association’s PREVENT screening tool, including removing race as a variable, could cause millions of patients to miss recommended high blood pressure and cholesterol medications and lead to as many as 107,000 more heart attacks and strokes over the next decade.
To compare patient outcomes from the new PREVENT calculator with the 2013 version, researchers used data from 7,700 patients aged 30 to 79 years to approximate the U.S. population.
Using the new risk calculator, only 67.5 million people would be recommended to take anti-cholesterol medication, compared with 81.8 million using the 2013 model. Similarly, only 72.7 million people would be eligible to take blood pressure medication, compared with 75.3 million using the 2013 formula.
This is in part because race has been removed from the 2023 calculator, a step taken by the AHA based on the belief that race is a social construct and an imprecise proxy for genetic, behavioral or other factors that may lead to heart disease, including racism.
According to the Department of Health and Human Services’ Office of Minority Health, black Americans are 30% more likely to die from a heart attack than white Americans. Black people are also 30% more likely than white people to have high blood pressure, but are less likely to have it under control.
Black women are 50% more likely to have high blood pressure than white women.
Dr. James Diao, the study’s lead author and a research associate in Harvard’s School of Biomedical Informatics and at Brigham and Women’s Hospital, said what’s surprising is that the increase in heart attacks after the PREVENT calculator change doesn’t disproportionately include black patients.
Diao said that’s probably because black patients are less likely to take blood pressure or cholesterol medications when they are eligible for them. In other words, under the old accounting system, many black people were eligible for them but didn’t take them. Under the new accounting system, those same people will no longer be eligible for them.
“One would expect that heart attacks and strokes would occur disproportionately among black people as statins are no longer indicated for use, but our data did not reflect this expectation,” Diao said in a press release. “We suspect this is because fewer black Americans have access to these medications and recommended treatments in the first place. This is clearly an example of two wrongs not making a right.”
The removal of race isn’t the only difference from the 2013 model: the equation now also takes into account several other variables, including kidney function, blood glucose levels and urinary protein.
The 2023 equation also takes into account a patient’s ZIP code and reflects socioeconomic factors such as access to fresh grocery stores and income, but it does not take into account biological predispositions to the disease.
The study authors recommended that the scientific community reevaluate dosing eligibility for cholesterol and blood pressure medications to reflect the changes in the PREVENT calculator.
“I would be concerned if we were to change only one side of this equation without reexamining the other side, which is the treatment threshold,” said Dr. Arjun Raj Manraj, senior study author and assistant professor at Harvard Medical School.
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However, the authors stressed that ultimately, careful decisions should be made on an individual basis for each patient rather than relying solely on prescriptions.
“The nuanced decision-making that needs to take place in the doctor’s office means that after careful discussion, two patients with the same estimated risk level may choose different treatment plans,” Manray said.
