Lifetime Risk of Cardiovascular Disease: The Next Generation in Risk Prediction

The Development of Lifetime Risk Prediction Amid mounting concern that younger individuals are inadequately served by short-term risk prediction, the assessment of lifetime risk of a cardiovascular event is gaining credence. The majority of US adults (82%) are at low shortterm risk of a cardiovascular event, with almost all young individuals and women classified as low risk by current algorithms, in part because models such as Framingham weight excessively for age and sex (Table 1). This is misleading, as more than half of all cardiovascular events will occur in those labelled with a low or intermediate 10-year risk score (Fig. 1). To some degree, this apparent paradox may be attributed to the extent of the lowand intermediate-risk population, meaning that by sheer volume these individuals are expected to accrue the majority of events. However, within the low-risk category, there is a substantial variation in lifetime risk, with the emergence of a significant new group of those who are low short-term but high longterm risk. In those younger than 50 years, around half of those in the low short-term risk category fall into this group. The question is, why do some individuals continue to experience a low level of threat of an event for their life duration while others seemingly accumulate risk at a much greater rate? The answer may in part be found in the influence of various risk factors at different stages of life. For instance, absence of any risk factor at the age of 50 years is associated with persistently low lifetime risk compared with those with at least 2 risk factors, who seem to experience a dramatic escalation in risk over the course of their lifetime: 5.2% vs 68.9% in men and 8.2% vs 50.2% in women. What may be underappreciated is the interplay between separate risk factors and the potential for quiet accumulation of subclinical