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......................................................................................................................................... interventions.78 Lifetime benefit of preventive interventions can be expressed as gain in CVD-free life (years), which is easier to communicate to a patient and may support the shared decision-making process.

3.3 Potential risk modifiers

Apart from the conventional CVD risk factors included in the risk charts, additional risk factors or types of individual information can also modify calculated risk. Assessment of a potential modifier may be considered if:

• It improves measures of risk prediction, such as discrimination or reclassification (e.g. by calculation of net reclassification index) • Public health impact is clear (e.g. number needed to screen or net benefit) • It is feasible in daily practice • Information is not just available on how risk increases with an unfavourable result, but also on how risk decreases if the modifier shows a favourable result • The literature on this potential modifier is not distorted by publication bias. Very few potential modifiers meet all of these criteria. Metaanalyses in this field are, for example, susceptible to substantial publication bias.106 Also, the exact way of integrating additional information on top of regular risk calculator input parameters is mostly unknown. Finally, RCTs to determine whether the added risk information eventually leads to improved health outcomes are generally lacking. Assessment of potential risk modifiers seems particularly relevant if the individual’s risk is close to a decision threshold. In low-risk or very-high-risk situations, additional information is less likely to alter management decisions. The number of individuals in this ‘grey zone’ is large. Therefore, feasibility becomes a limitation as modifiers become more complex or expensive, such as some imaging techniques. Care should be taken not to use risk modifiers solely to increase risk estimates when the modifier profile is unfavourable, but also vice versa. Although an unfavourable risk modifier may increase an individual’s estimated risk, a more favourable profile than would be expected based on other patient characteristics must have the opposite effect. Finally, it is important to acknowledge that the degree to which calculated absolute risk is affected by modifiers is generally much smaller than the (independent) RRs reported for these modifiers in the literature.107 Taking the above into account, we summarize the literature on several popular risk modifiers in this section. 3.3.1. Psychosocial factors Psychosocial stress is associated, in a dose-response pattern, with the development and progression of ASCVD, independently of conventional risk factors and sex. Psychosocial stress includes stress symptoms (i.e. symptoms of mental disorders), as well as stressors such as loneliness and critical life events. The RRs of psychosocial stress are commonly between 1.2 and 2.0108,109 (Supplementary Table 4). Conversely, indicators of mental health, such as optimism and a strong sense of purpose, are associated with lower risk.109 Psychosocial stress has direct biological effects, but is also highly correlated with socioeconomic and behavioural risk factors (e.g. smoking, poor adherence).100,109113

Although the associations of psychosocial stress with CV health are robust, only ‘vital exhaustion’ has been proven to improve risk reclassification.101 Owing to the importance of stress symptoms among ASCVD patients, several guidelines and scientific statements recommend screening of ASCVD patients for psychological stress113115 (Box 2 and Supplementary Table 5). A recent prospective cohort study with a median follow-up of 8.4 years reported favourable effects of screening for depression on major ASCVD events.102

3.3.2. Ethnicity Europe includes many citizens whose ethnic background originates in countries such as India, China, North Africa, and Pakistan. Given the considerable variability in ASCVD risk factors between immigrant groups, no single CVD risk score performs adequately in all groups. Rather, the use of a multiplying factor would be helpful to take account of CVD risk imposed by ethnicity independent of other risk factors in the risk score. The most contemporary relevant data come from the QRISK3 findings in the UK,105 although this focuses on a wider range of CVD outcomes and not simply on CVD mortality. Immigrants from South Asia (notably India and Pakistan) present higher CVD rates independent of other risk factors, whereas adjusted CVD risks appear lower in most other ethnic groups. The reasons for such differences remain inadequately studied, as do the risks associated with other ethnic backgrounds. Based on such data, the following correction factors, based on data from the UK, could be applied when assessing CVD risk using risk calculators.105 Ideally, country and risk-calculator-specific RRs should be used, as the impact of ethnicity may vary between regions and risk calculators.

• Southern Asian: multiply the risk by 1.3 for Indians and Bangladeshis, and 1.7 for Pakistanis. • Other Asian: multiply the risk by 1.1. • Black Caribbean: multiply the risk by 0.85. • Black African and Chinese: multiply the risk by 0.7.

Box 2. Core topics for psychosocial assessment

Simultaneous diagnostic assessment At least one in five patients carries a diagnosis of a mental disorder, usually presenting with bodily symptoms (e.g. chest tightness, shortness of breath). Therefore, physicians should be equally attentive to somatic as to emotional causes of symptoms. Screening Screening instruments assessing depression, anxiety, and insomnia are recommended (e.g. Patient Health Questionnaire,116 see Supplementary Table 5).117,118 Stressors There are simple questions to get into a conversation about significant stressors112: Are you bothered by stress at work, financial problems, difficulties in the family, loneliness, or any stressful events? Need for mental health support Are you interested in a referral to a psychotherapist or mental health service? Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026