Circulation: Cardiovascular Quality and Outcomes

ORIGINAL ARTICLE

Patient-Perceived Versus Actual Risk of

Cardiovascular Disease and Associated
Willingness to Consider and Use Prevention
Therapy
BACKGROUND: Cardiovascular prevention guidelines use estimated 10- Ann Marie Navar, MD,
year atherosclerotic cardiovascular disease (CVD) risk based on the pooled PhD
cohort equations to guide treatment decisions and engage patients in Tracy Y. Wang, MD, MHS,
shared decision-making. We sought to determine patient perceived versus MSc
actual risk of atherosclerotic CVD and associations with willingness for Shuang Li, MS
preventive therapy. Xiaojuan Mi, PhD
Zhuokai Li, PhD
METHODS: We evaluated calculated and perceived CVD risk among Jennifer G. Robinson, MD
4187 patients across 124 sites in the Patient and Provider Assessment of Salim S. Virani , MBBS,
Lipid Management Registry. Ten-year risk was assessed using the pooled PhD
cohort equations; risk relative-to-peers was determined based on age-, Eric D. Peterson, MD, MPH
sex-, and race-based percentiles; and patient estimates of risk were
assessed using patient surveys. Poisson regression models evaluated
Downloaded from http://ahajournals.org by on June 10, 2023

associations between risk estimates, statin use, and willingness to take

prevention therapy.
RESULTS: Overall, there was no correlation between patients’ estimates
of their 10-year CVD risk and calculated 10-year risk (ρ=−0.01,
Pcorrelation=0.46), regardless of age, sex, race, or socioeconomic status. The
majority (72.2%) overestimated their 10-year CVD risk relative to the
pooled cohorts equation (mean perceived 33.3% versus mean calculated
17.1%, Pdifference<0.01). Patients’ perceptions of their risk relative-to-
peers were slightly correlated with standardized risk percentiles (ρ=0.19,
P<0.01), although most had overly optimistic views of how risk compared
with their peers. Increasing perceived risk was not associated with current
statin use (P=0.18) but was associated with willingness to consider
future prevention therapy (P<0.01). Perceived risk relative-to-peers was
associated with increased prevalent statin use (risk ratio 1.04 per category
increase [95% CI, 1.02–1.06]) and reported willingness for prevention
therapy (risk ratio 1.11 [95% CI, 1.07–1.16]).
CONCLUSIONS: When asked, most patients overestimate their 10-year
risk but hold an optimistic bias of their risk relative to age-, race-, and sex-
matched peers. Providing accurate absolute risk assessments to patients
without proper context may paradoxically decrease many patients’ Key Words:  ◼ cardiovascular diseases
perceived risk of CVD, thereby disincentivizing initiation of CVD risk ◼ lipids ◼ risk ◼ risk assessment

reduction therapy. © 2021 American Heart Association, Inc.

https://www.ahajournals.org/journal/
circoutcomes

Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548 January 2021 49

 Navar et al; Patient Perceived vs Actual Risk
WHAT IS KNOWN
• Cardiovascular prevention guidelines emphasize
using estimated 10-year atherosclerotic cardio-
vascular disease risk based on the pooled cohort
equations to guide treatment decisions and
engage patients in shared decision-making.
WHAT THE STUDY ADDS
• Patients’ estimates of their own atherosclerotic
cardiovascular disease risk do not correlate with
calculated risk estimates, regardless of age, sex,
education, or numeracy.
• Using relative-to-peers risk in addition to absolute
10-year risk may improve risk understanding and
help prevent a paradoxical lowering of perceived
risk by using absolute 10-year risk estimates alone.
C
urrent guidelines for cardiovascular disease (CVD)
prevention use estimates of patient risk of de-
veloping atherosclerotic CVD (ASCVD) to guide
treatment decisions. The cholesterol and blood pressure
guidelines currently used in the United States recom-
mend estimating a patient’s 10-year risk of ASCVD (fa-
tal and nonfatal heart attack and stroke) using pooled
cohort equations (PCE) as the primary tool for these
estimates.1–3 The use of ASCVD risk is also emphasized
in the 2018 American College of Cardiology/American
Downloaded from http://ahajournals.org by on June 10, 2023
Heart Association cholesterol guidelines as part of a
clinician-patient discussion regarding whether or not
to initiate cholesterol-lowering therapy.1 While much
research has focused on refining and understanding
the accuracy of these risk calculators, relatively little has
been done to understand how patients at baseline per-
ceive their own ASCVD risk.
In this study, we sought to evaluate the degree to
which patients’ own estimates of their 10-year risk of
heart disease or stroke correlated with actual PCE risk
estimates. In particular, we wanted to better understand
the degree to which patients underestimated or overes-
timated their CVD risk. Second, we determined whether
patients were better or worse at estimating their CVD
risk relative to their peers using age-, sex-, and race-
specific population risk percentiles. Finally, we assessed
whether perceived or actual CVD risk was associated
with current statin use or patient willingness to take
preventive therapies.
METHODS
The data, analytic methods, and study materials will not be
made available to other researchers for purposes of reproduc-
ing the results or replicating the procedure. The Patient and
Provider Assessment of Lipid Management (PALM) Registry
was designed to evaluate lipid management practices for
adults with and at risk for ASCVD in the United States. The
Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548
PALM Registry has been described previously in detail.4 Briefly,
7938 patients from 140 outpatient primary care, cardiology,
and endocrinology sites were enrolled between May 2015
and November 2015. Chart reviews performed by study coor-
dinators at each site were used to obtain clinical data, core lab
lipid panels were drawn on all patients, and patients were sur-
veyed about their experience with lipid-lowering therapy, as
well as their beliefs about cholesterol, statins, and CVD. The
survey was conducted on an iPad at the time of enrollment,
which generally took place before the clinic visit. Demographic
data were self-reported. Numeracy was assessed using the
subjective numeracy scale.5
A unique feature of PALM was that patients were asked
a series of questions regarding their perceptions and worries
regarding CVD risk. For this analysis, we identified adults with
completed surveys, laboratory data, and chart review data
(n=7375 across 139 sites). Since this particular study sought
to evaluate perceived risk of developing CVD, we excluded
adults who already had prevalent ASCVD (defined as history
of coronary heart disease, including obstructive coronary
disease, prior myocardial infarction, or prior coronary revas-
cularization; cerebrovascular disease including carotid steno-
sis; and prior stroke or transient ischemic attack); n=3188.
After these exclusions, our study population was comprised
n=4187 patients; of these, n=3470 (82.9%) patients across
124 sites responded to the survey questions.
In the survey, patients were asked to estimate their
10-year risk of heart attack or stroke. For this question,
patients were provided a vertical slider from 0% to 100%
and asked: “Using your finger, drag the slider to the area
on this scale that represents what you think is your chance
of having a heart attack or stroke over the next 10 years.”
Next, patients were asked to estimate how their risk of
heart attack or stroke compared with other men/women
their same age: “How do you think your risk of heart
attack or stroke compares with other men/women your
age?” For this question, 5 choices were provided: much
lower, slightly lower, about the same, slightly higher, or
much worse. Finally, patients were asked about their gen-
eral willingness to take therapy to reduce their risk of CVD:
“If you had no side effects, how willing would you be to
take a pill every day to reduce your risk of heart attack or
stroke?” Answer choices were as follows: not at all willing,
probably not willing, maybe willing, probably willing, or
almost certainly willing.
Characteristics of patients at different levels of their esti-
mated 10-year risk perceived risk are presented by quartile
of patient perceived risk. P values testing the association
between quartile of perceived risk (treated as an ordinal
variable) and patient characteristics that were collected as
continuous variables (ie, age, household income, and blood
pressure) are estimated using the Spearman correlation
coefficient. P values testing the association between quartile
of perceived risk (treated as an ordinal variable) and patient
characteristics that were collected as binary variables (ie, sex,
presence or absence of a comorbidity) are estimated using
the Cochran-Armitage test for trend with 2-sided P values.
In addition, the associations between patient characteristics
and perceived risk as a continuous variable (rather than by
quartile) were evaluated using linear regression; these P val-
ues are also presented.
January 2021 50
 Navar et al; Patient Perceived vs Actual Risk
Calculated 10-year risk was determined using the PCE,3
which obtained clinical information from chart abstractions
by study coordinators at each site. A paired t test was used
to test the null hypothesis that the mean difference between
patient perceived 10-year risk and calculated risks was zero.
Next, the Spearman correlation coefficient was calculated to
evaluate the degree of correlation between the 2 in overall
population and by subgroups: age (<65 versus ≥65 years),
sex, diabetes, smoking, race (non-Black versus Black), LDL-C
(low-density lipoprotein cholesterol <130 versus ≥130 mg/
dL), systolic blood pressure (<140 mm  Hg versus ≥140
mm Hg), education (high school or less versus at least some
college), numeracy score (<median or ≥median), income cat-
egories (<$35 000 per year, $35 000 to <$75 000 per year,
and ≥$75 000 per year), and statin use. For descriptive pur-
poses, patient perceived risk and calculated risk estimates are
described overall and stratified by subgroup. Because partici-
pant responses to perceived risk and calculated risk estimates
were not normally distributed, data in the descriptive tables of
risk are presented as median (25th–75th percentile).
To determine how a patient’s perceived risk compared
with other men/women their age, we calculated each per-
son’s standardized risk percentile based on their 10-year risk
estimate from the PCE. Standardized risk percentiles relative-
to- peers risk were calculated based on previously published
work using data from the National Health and Nutritional
Examination Survey. This analysis evaluated calculated age-,
sex-, and race-specific distributions of 10-year PCE risk.6 Using
this data, we translated each PALM participant’s 10-year PCE
estimate into an age-, sex-, and race-based percentile, allow-
ing for a numerical estimate of how an individual’s actual risk
Downloaded from http://ahajournals.org by on June 10, 2023
compares to age-, sex-, and race-matched peers in the United
States. The correlation between participant’s calculated per-
centile based on PCE and their estimated risk relative-to-peers
was evaluated using the Spearman correlation coefficient (ρ)
overall and by subgroup.
Finally, we estimated the association between perceived
absolute and relative-to-peers 10-year risk and whether
patients were on a statin (based on chart abstraction) using
modified Poisson regression models with robust sandwich
variance estimators to account for clustering of patients
within sites. Univariable analyses were performed to evalu-
ate the association between prevalent statin use and each
of the following: perceived 10-year risk, calculated 10-year
risk, actual population risk percentile, and perceived risk rel-
ative-to-peers. This analysis was then repeated for patients
who met 2013 American College of Cardiology/American
Heart Association cholesterol guideline recommendations
for statins, but who were not on a statin, using the univari-
able analysis to evaluate the association between patient-
reported willingness to take therapy to lower CVD risk
versus perceived absolute and relative-to-peers CVD risk, as
well as calculated CVD risk. The results were presented as
relative risk with 95% CI.
All subjects provided written informed consent for partici-
pation, and Institutional Review Board approval was obtained
at each site. Statistical analyses were performed using SAS
version 9.4 (SAS Institute Inc, Cary, NC). To account for mul-
tiple testing, P<0.01 was prespecified as required for statisti-
cal significance for the correlation analysis; otherwise, P<0.05
was considered statistically significant.
Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548
RESULTS
Of the 3470 survey participants included in this analy-
sis, the median age was 65 years, 54.8% were female,
and 14.1% were Black (Table I in the Data Supplement).
The median 10-year calculated risk using the PCE was
13.4% (25th–75th percentile: 6.7%–24.4%). General-
ly, the 3470 (82.9%) participants who responded to the
questions about CVD risk were similar to those who did
not respond (n=717, 17.1%, Table I in the Data Supple-
ment), although nonrespondents were slightly older
(median age 67.0 versus 65.0 years, P=0.02), less likely
to be White (76.7% versus 84.1%, P<0.01), and less
likely to report at least some college education (58.6%
versus 63.5%, P=0.02).
The median of patient perceived risk was 30.0%
(25th–75th percentile: 13.8%–49.8%). In general,
patients’ estimates of their risk of CVD (mean 33.3%)
were higher than their calculated risk (mean 17.1%);
P value from paired t test <0.001. Figure  1A and 1B
shows patient perceived 10-year risk compared with
their calculated risk based on the PCE. Overall, there
was no correlation (spearman correlation coefficient
=−0.01, P=0.46) between patient perceived and calcu-
lated 10-year risk. Neither perceived nor calculate risk
were normally distributed (P<0.01 for both, Figure I in
the Data Supplement). The vast majority of patients
(72.2%) overestimated their absolute 10-year risk of
CVD compared with their calculated risk using the PCE,
with a large proportion (n=1393, 41.8%) estimating
their risk of CVD to be 20% or greater on an absolute
scale than what was calculated using the PCE.
Table  1 shows characteristics of the population by
quartile of perceived risk. Those with higher perceived
10-year risk included more women, more patients with
diabetes, more smokers, lower household incomes, and
slightly lower subjective numeracy scores. Despite these
differences, in no subgroup of patients evaluated was
perceived 10-year risk correlated with calculated risk
including age, sex, diabetes status, smoking, race, LDL-
C, high systolic blood pressure, education, numeracy,
or income subgroups (Table  2). Across all subgroups,
the pattern was consistent: Patients generally overesti-
mated their absolute 10-year risk of CVD, with no cor-
relation between perceived and calculated 10-year risk.
Participant estimates of how their overall CVD risk
compares with their peers was correlated with actual
population risk percentiles (Spearman correlation coef-
ficient=0.19, P<0.01, Figure  2); however, in general,
adults tended to underestimate their risk relative-to-
peers. For example, among adults who felt their risk
was much lower than men/women their age, the medi-
an 10-year risk percentile was 51.0%. This correlation
once again held across the various age, sex, race, and
socioeconomic subgroups examined (Table II in the
Data Supplement).
January 2021 51
 Navar et al; Patient Perceived vs Actual Risk
Figure 1. Patient perceived vs calculated 10-year risk.
Patient: (A) perceived vs (B) calculated 10-year risk of cardiovascular disease (CVD).
Table  3 shows the associations between patient
perceived absolute 10-year risk, as well as patient esti-
mated risk relative-to-peers, based on population risk
percentiles with prevalent statin use (first column) and
willingness to take therapy to lower CVD risk among
Downloaded from http://ahajournals.org by on June 10, 2023
patients not on a statin (second column). Patient esti-
mated risk relative-to-peers was the only factor asso-
ciated with increased likelihood of being on a statin
at baseline (P<0.01). Both patient perceived absolute
10-year risk and patient estimated relative-to-peers
risk were associated with increased reported willing-
ness to take a preventative therapy to lower CVD risk
(all P<0.01).
DISCUSSION
Despite longstanding recommendations for clinicians
to use 10-year risk estimates to identify candidates for
statin therapy, and an increasing focus on shared deci-
sion-making around CVD prevention, our study found
that most patients were unable to accurately estimate
their risk of CVD. In this study, there was no correla-
tion between what a patient estimated his or her risk
of heart attack or stroke to be in the next 10 years and
their calculated risk using the PCE. In fact, the over-
whelming majority of patients (nearly 3 in 4) overes-
timated their risk of CVD events. In contrast, patients
were somewhat better at estimating their general CVD
risk relative to their peers, albeit with an optimistic bias.
Importantly, both patients’ perceived absolute risk of
CVD and relative-to-peers risk were associated with
patient willingness to take prevention therapy.
Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548
Regardless of clinical, demographic, or socioeconomic
factors, patients’ estimates of their CVD risk on an abso-
lute scale were inaccurate, with no correlation between
patients’ perceived CVD risk and their PCE-calculated
risk. This finding is somewhat surprising since the major
risk factors for CVD (ie, hypertension, diabetes, smoking,
and high cholesterol) have been known for decades,7
and the majority of providers in the PALM Registry who
saw these patients in clinical practice reported using the
PCE to estimate patient risk.3,7 Furthermore, longstand-
ing public health campaigns from organizations such as
the American Heart Association and the National Heart
Institute (later renamed the National Heart, Lung, and
Blood Institute) have attempted to increase awareness of
the importance of these risk factors for decades. How-
ever, estimating an absolute risk of CVD requires both an
understanding of CVD risk factors and also a general ref-
erence range for what is considered high versus low risk
on an absolute scale. One concerning finding was that
when asked to estimate their chance of a heart attack
or stroke over the next 10 years, the majority of patients
overestimated their risk—many markedly so. This raises
the concern that providing patients with accurate numer-
ical descriptions of their risk of CVD without proper con-
text may have unintended consequences. For example, if
a patient who believes they have a 50% chance of hav-
ing a heart attack or stroke over the next 10 years is told
that they actually have a 20% chance, then this patient
may be falsely reassured and less motivated to engage
in preventive therapy. However, providing patients who
overestimate their risk with accurate risk estimates may
provide reassurance to those with unrealistic levels of
January 2021 52
 Navar et al; Patient Perceived vs Actual Risk

Table 1.  Characteristics of Patients by Quartile of Patient Perceived 10-Year Risk of Cardiovascular Events

First quartile Second quartile Third quartile Fourth quartile P value (by P value
(N=833) (N=840) (N=840) (N=823) quartile) (continuous)
Patient perceived risk 8.3 (4.4–10.6) 21.6 (18.4–25.2) 40.3 (33.9–47.8) 59.8 (51.2–72.9)
10-year risk by PCE 14.9 (7.1–26.2) 12.2 (6.2–21.5) 13.8 (6.5–25.6) 13.3 (6.9–24.0)
Age, y 67.0 (58.0–74.0) 64.0 (57.0–71.0) 66.0 (56.0–72.0) 65.0 (57.0–72.0) 0.04 0.34
Female 427 (51.3%) 426 (50.7%) 475 (56.6%) 506 (61.5%) <0.01 <0.01
Race (% Black) 133 (16.0%) 106 (12.6%) 122 (14.5%) 106 (12.9%) 0.17 0.40
Diabetes 277 (33.3%) 310 (36.9%) 340 (40.5%) 341 (41.4%) <0.01 <0.01
Current smoker 74 (8.9%) 84 (10.0%) 104 (12.4%) 123 (15.0%) <0.01 <0.01
Statin use 509 (61.1%) 551 (65.6%) 546 (65.0%) 506 (61.5%) 0.94 0.78
Education (% at least some 536 (65.9%) 527 (64.3%) 510 (62.0%) 499 (61.5%) 0.04 0.04
college)
Annual household income 206 (38.4%) 202 (34.3%) 169 (29.3%) 160 (28.1%) <0.01 <0.01
≥$75 000*
Annual household income 296 (35.5%) 251 (29.9%) 264 (31.4%) 254 (30.9%) 0.08 0.25
not reported
Subjective numeracy score 17.0 (12.0, 21.0) 17.0 (12.0, 21.0) 15.5 (10.0, 20.0) 16.0 (10.0, 20.0) <0.01 <0.01
LDL-C, mg/dL 105.0 (82.0–127.0) 106.0 (83.0–132.0) 103 (80.0–128.5) 103 (82.0–130.0) 0.46 0.29
SBP, mm Hg 129 (120–139) 128 (120–138) 129 (120–140) 129 (120–140) 0.27 0.30
Aspirin use 262 (31.5%) 267 (31.8%) 290 (34.6%) 295 (35.9%) 0.03 0.01

Continuous variables are presented as median (25th–75th percentile); categorical variables presented as number (percentage). P values presented represent
the P values for trend in association between patient characteristics and quartile of risk (first column), and patient characteristic and risk when analyzed as a
continuous variable in univariable analysis (second column). LDL-C indicates low-density lipoprotein cholesterol; PCE, pooled cohort equations; and SBP, systolic
blood pressure.
*Income variable of ≥75 000 represents % among those reporting income, P value represents association among those with income reported.

worry, as has been shown in cancer risk related work.8 Optimism bias has frequently been demonstrated in
Downloaded from http://ahajournals.org by on June 10, 2023

These results should not be interpreted to suggest that
patients should not be provided with their numerical
risk estimates; rather, sufficient conversation should
take place to ensure qualitative understanding of that
risk, with treatment decisions based on a comprehen-
sive risk-benefit discussion that incorporates patient
preferences.
In contrast to 10-year estimates, on the whole,
patients were better at estimating their risk relative-
to-peers. This may reflect that risk relative-to-peers
is impacted by CVD risk factors and does not require
an understanding of what is a high or low absolute
10-year risk. Nevertheless, unlike absolute 10-year risk,
patients tended to underestimate their risk relative-to-
peers. Even in the group of adults who estimated their
risk to be much lower than their peers, the median
risk percentile was 51.0%; more than half of adults
who reported their risk to be much lower than men/
women their age had a 10-year PCE-predicted risk that
placed them above the median for age-, sex-, and race-
matched US adults. This finding is likely due to opti-
mism bias, a cognitive bias leading people to perceive
their risk to be lower than their peers. Optimism bias
can arise from either underestimating one’s own risk or
overestimating the risk of the average person; the rela-
tive contribution of either factor towards optimism bias
in PALM subjects was not studied.9
other health-related studies. The finding that some cor-
relation exists at baseline between patient perceived and
calculated relative-to-peers risk suggests that relative-to-
peers risk may be a more intuitive measure to present to
patients. Prior work in risk communication has suggested
that providing information about a specific similar other,
not the average person may be useful.9 Furthermore,
unlike absolute 10-year risk, which patients often overes-
timated, true relative-to-peers risk estimates may be less
likely to demotivate patients through false reassurance. In
either case, providing patients with a relative anchor (ie,
people with a risk >7.5% are considered high risk and
those >20% are very high risk) or a more intuitive anchor
(ie, your risk of 7.5% places you in the top 10% of risk
compared with other women your age) may improve risk
understanding and decrease optimism bias in perceived
risk. Importantly, because a person’s interpretation of a
qualitative risk expression (ie, high versus low) can vary,
any qualitative statements should be accompanied by the
numerical description of such a statement.10
Although education, socioeconomic status, and health
literacy play a key role in understanding health issues, we
found that patients were equally unable to actually esti-
mate their 10-year risk of CVD regardless of education,
income, and patient numeracy. This is consistent with
prior work showing that optimism bias is common across
age, sex, occupation, and educational groups.11 Similarly,

Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548 January 2021 53

 Navar et al; Patient Perceived vs Actual Risk

Table 2.  Association Between Calculated and Patient Perceived 10-Year Absolute Risk of Cardiovascular
Events by Subgroup

Calculated Perceived Spearman correlation

Median (Q1–Q3) Median (Q1–Q3) ρ P value
Age, y
 <65 6.7 (3.3–11.6) 30.0 (15.3–49.9) 0.04 0.15

 ≥65 21.4 (13.7–31.9) 30.0 (12.4–49.7) <0.01 0.87

Sex
 Female 10.6 (5.0–20.7) 31.9 (14.8–50.2) 0.00 0.97
 Male 17.2 (9.0–28.0) 26.2 (12.5–48.9) 0.02 0.39
Race
 Non-Black 13.0 (6.2–24.3) 30.1 (14.2–49.8) −0.02 0.42
 Black 15.3 (8.6–25.0) 29.5 (12.3–49.6) 0.01 0.76
Education
 High school or less 14.8 (7.4–27.5) 31.1 (14.6–50.1) −0.07 0.02
 At less some college 12.5 (6.0–23.1) 29.6 (13.1–49.7) 0.01 0.55
Numeracy
 <Median 13.8 (6.9–25.7) 32.5 (15.5–50.1) −0.01 0.65
 >Median 12.8 (6.4–23.2) 27.1 (12.4–49.6) −0.02 0.45
Annual income
 <$35  000 14.0 (7.0–25.8) 31.5 (14.7–50.1) −0.08 0.02
 $35  000–75  000 12.3 (6.1–22.5) 31.7 (16.3–50.1) 0.02 0.62

 ≥$75 000 9.7 (4.9–18.9) 25.5 (12.3–49.0) 0.02 0.512

Smoker
 No 13.1 (6.4–24.2) 29.6 (13.2–49.7) −0.02 0.31
Downloaded from http://ahajournals.org by on June 10, 2023

 Yes 15.1 (8.3–25.8) 35.6 (19.6–52.3) −0.01 0.89

Diabetes
 No 11.3 (5.6–20.6) 27.6 (12.9–49.7) 0.00 0.86
 Yes 17.9 (8.8–31.6) 32.1 (15.6–50.1) −0.06 0.03
High LDL, mg/dL

 ≥130 11.9 (5.5–21.9) 29.9 (14.9–49.9) −0.04 0.26

 <130 13.9 (7.0–25.0) 30.1 (13.3–49.8) 0.00 0.88

High SBP, mm Hg

 ≥140 20.1 (11.6–34.5) 31.7 (14.3–50.4) −0.07 0.041

 <140 11.5 (5.6–21.4) 29.6 (13.6–49.7) −0.01 0.80

Statin use
 On statin 13.2 (6.5–24.8) 30.0 (14.3–49.8) −0.02 0.45
 Not on statin 13.7 (6.9–24.0) 30.0 (13.0–50.0) −0.01 0.80

LDL indicates low-density lipoprotein cholesterol; Q1, quarter 1; Q3, quarter 3; and SBP, systolic blood pressure.

the correlations between estimated and actual relative-to-
peers risk were similar regardless of education, numeracy,
and income. This does not indicate that risk communi-
cation interventions should ignore factors of socioeco-
nomic status or health literacy; rather, efforts to improve
risk communication should target all patients. Nor does
this finding rule out differences in risk understanding;
for example, patients in our study with lower education
levels, as well as those of non-White races, were more
likely to skip the risk-based questions altogether. Previ-
ously, we found that the format of risk presentation, as
well as using other risk horizons (eg, lifetime risk) impacts
perceived risk and willingness for therapy.12
Accurate risk perception is a key component of effec-
tive patient and clinician shared decision-making. In our
study, we found that patients who perceived themselves
to be at higher risk than their peers were more likely to
be on a statin. Attitudes about CVD risk were not col-
lected before statin initiation, so this study cannot deter-
mine if associations between perceived risk and statin

Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548 January 2021 54

 Navar et al; Patient Perceived vs Actual Risk
Downloaded from http://ahajournals.org by on June 10, 2023
Figure 2. Patient perceived risk compared with others vs population percentile.
Patient perceived risk compared with others vs population percentile of 10-year calculated cardiovascular disease (CVD) risk.
utilization are causal in either direction: statins use could
have decreased perceived risk because of the known
benefit of statins, or those with lower perceived risk
may have been more likely to be on a statin because of
lower fear about statin therapy in general. Nonetheless,
we did ask adults who met a guideline recommenda-
tion for statin therapy, but were not on a statin, about
their willingness to take a medication to lower CVD
risk; this group most closely parallels the group targeted
by guidelines for the clinician-patient risk discussion.
Among these individuals, increasing perceived risk on
both the absolute and relative scale was associated with
patient-reported willingness to take preventive therapy.
Notably, patients at higher calculated absolute risk of
heart disease or stroke were neither more likely to be
on a statin nor more willing to consider preventive ther-
apy; such a finding underscores the lack of association
between patient perceived and calculated 10-year risk.
While clinician-patient discussions around CVD pre-
vention may begin with risk estimation and communi-
cation, effective prevention and shared decision-mak-
ing goes beyond risk communication. Patient-reported
barriers to statin therapy, including fears about medi-
cation side effects, understanding of therapy benefits,
Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548
and financial concerns should all be evaluated and
addressed.13,14 Furthermore, considerable work has
shown that risk information processing also triggers
emotional responses, leading to affective responses,
which may not align with actual cognitive responses;
understanding how CVD risk communication impacts
patient emotional responses will also be critical to a
complete assessment of its impact.15 Given heteroge-
neity in how often and the ways in which providers
engage in discussions with their patients, more work
should be conducted to help standardize the content
of risk communication around CVD.16 As more research
is conducted on the most effective way to engage in
this comprehensive discussion, our research suggests
that contextualizing 10-year risk estimates in the form
of risk relative-to-peers may improve patients’ qualita-
tive understanding of risk and potentially improve their
willingness to take prevention therapy. Relative-to-peer
risk must be applied with caution, as it may impact a
person’s ability to integrate other information related
to therapy, such as potential risks.17 Moving forward,
these concepts should be empirically tested across a
broad range of patients with varying levels of CVD risk,
education, income, health literacy, and numeracy.
January 2021 55
 Navar et al; Patient Perceived vs Actual Risk
Table 3.  Results From Poisson Regression Evaluating the Association Between Perceived 10-Year Risk of Event and Risk
Relative-to-Peers With CVD Preventive Therapy
Association with prevalent statin use
Factors RR (95% CI)
Patient perceived absolute 10-year risk 0.99 (0.98–1.00)
(per 10% increase)
Patient perceived risk relative-to-peers 1.04(1.02–1.06)
(per category increase)
CVD indicates cardiovascular disease; and RR, risk ratio.
*Among adults recommended for statin but not on treatment.
We chose to calculate patients’ 10-year risk using their
last lipid values. More than half of the population was on
a statin, so these values would have represented on-treat-
ment lipid values. Pretreatment lipid levels were unavail-
able, which would have led to lower 10-year risk estimates
for those on statins. How to calculate 10-year risk for those
on statins remains unclear. While the impact of therapy on
lipid levels would lead to an underestimation of risk, statin
therapy itself lowers CVD risk and is not accounted for in
the PCE. Nevertheless, we found a similar lack of correla-
tion between patient perceived and calculated 10-year risk
among those who were and were not on statins. Since
patients who were on statins were generally higher risk
than those not on statins, the absolute difference between
perceived and calculated 10-year risk was lower among
those on statins compared with those not on statins. If risk
scores been recalculated using higher pretreatment lipid
values, then this difference would have been even larger.
Downloaded from http://ahajournals.org by on June 10, 2023
This study has several other important limitations. First,
although the survey response rate was high overall, nearly
20% did not answer the question that asked them to esti-
mate their risk of myocardial infarction or stroke in the
next 10 years; these 20% had higher overall risk, were
more likely to be non-White, and had lower education
levels than those who answered this question. Conse-
quently, the generalizability of study results may be lim-
ited, particularly to adults with lower education levels and
minority populations. As cardiovascular risk communica-
tion interventions are developed, special focus should be
placed on adults with lower numeracy and educational
levels, including those with low numeracy assessed using
the subjective numeracy scale, as these adults may be less
likely to accurately interpret quantitative risk data.18,19 Due
to the study design emphasizing primary and second-
ary prevention, as well as clinic-based enrollment, PALM
participants recommended for statins are not representa-
tive of the national population of statin-eligible patients.
Compared with estimates of those who are statin-eligible
under the 2013 American College of Cardiology/Ameri-
can Heart Association guideline, PALM patients were older
(age 68 versus 59 years), had higher rates of CVD (56%
versus 21%), diabetes (43% versus 29%), and hyperten-
sion (81% versus 59%), and were less often smokers
(13% versus 25%). Similar rates of male sex were seen
in both (57% versus 56%).20,21 Overall, PALM participants
Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548
Association with therapy willingness*
P value RR (95% CI) P value
0.18 1.05 (1.03, 1.08) <0.01
0.03 1.11 (1.073, 1.16) <0.01
had high rates of education (63% with at least some col-
lege) and were predominately white (84.2%).21 Neverthe-
less, we found no differences in the correlation between
risk perception and calculated risk, suggesting that this
finding is likely to hold true for the majority of statin-eli-
gible US adults. Second, due to the cross-sectional nature
of the study, we were unable to determine the degree to
which attitudes about CVD risk affected future therapy
initiation or medication adherence and persistence.
Third, while risk relative-to-peers is calculated using
age-, sex-, and race-matched individuals, we asked
patients how they compared with adults their same age
and sex, but not race. If patients interpreted this ques-
tion to compare their risk relative to all men/women
their age regardless of race and factored in the relative
impact of their own race on their risk of cardiovascular
events, then this would have diminished the apparent
association between perceived and calculated relative-
to-peers risk. Had we asked individuals to estimate how
they compared with others in their racial group, the find-
ings may have been even stronger. Finally, the survey was
designed to be completed while patients were in waiting
rooms before their clinician visit. Therefore, the survey
results reflect patient beliefs before the conversations
that took place that day with their health care team.
CONCLUSIONS
Although 10-year risk estimation has been part of
cholesterol treatment guidelines for many years, the
patients we studied were unable to accurately estimate
their 10-year absolute risk of CVD, regardless of demo-
graphics, education, income, or numeracy level. Most
patients overestimated their 10-year risk of CVD. Patient
estimates of their risk relative-to-peers were better cor-
related with actual population risk percentiles, but most
demonstrated an optimistic bias, perceiving their risk
to be lower than their peers. Both perceived 10-year
risk and relative-to-peers risk were correlated with will-
ingness to take preventive therapy, but only perceived
relative-to-peers risk was associated with actual preva-
lent statin use. Using relative-to-peers risk in addition
to absolute 10-year risk may improve risk understand-
ing and provide a helpful context for a fully informed
patient/provider conversation about preventive care.
January 2021 56
 Navar et al; Patient Perceived vs Actual Risk
ARTICLE INFORMATION
Received January 30, 2020; accepted October 23, 2020.
The Data Supplement is available at https://www.ahajournals.org/doi/
suppl/10.1161/CIRCOUTCOMES.120.006548.
Correspondence
Ann Marie Navar, MD, PhD, Duke Clinical Research Institute, 2400 Pratt St,
Durham, NC 27705. Email Ann.navar@utsouthwestern.edu
Affiliations
Duke Clinical Research Institute, Duke University School of Medicine, Durham,
NC (A.M.N., T.Y.W., S.L., X.M., Z.L., E.D.P.). University of Iowa (J.G.R.). Baylor
College of Medicine, Houston, TX (S.S.V.).
Acknowledgments
We thank Erin Campbell, MS, for her editorial contributions to this article.
Sources of Funding
This study was funded by Sanofi and Regeneron. Dr Navar is funded by the
National Institutes of Health K01HL133416.
Disclosures
Dr Navar has received funding for research to her institution from Amgen, Jans-
sen, Amarin, Sanofi, Regeneron, and honoraria and consulting fees from Amarin,
Amgen, AstraZeneca, BI, Esperion, Janssen, Lilly, Sanofi, Regeneron, Novo Nor-
disk, Novartis, The Medicines Company, New Amsterdam, Cerner, 89Bio, and
Pfizer. Dr Wang reports research grant from Modest; Pfizer, Bristol Myers Squibb;
research grant: Significant; AstraZeneca, Boston Scientific, Daiichi Sankyo, Eli Lilly,
Gilead Sciences, Regeneron Pharmaceuticals; received honoraria from Modest;
Merck, Gilead; and received honoraria: Significant; Sanofi. Dr Robinson reports
research grant: Significant; Acasti, Amarin, Amgen, AstraZeneca, Esai, Merck,
Downloaded from http://ahajournals.org by on June 10, 2023
Novartis, Pfizer, Regeneron/Sanofi, Takeda; consultant/advisory board for Mod-
est; Amgen, Merck, Novo Nordisk, Pfizer; and consultant/advisory board: Signifi-
cant; Sanofi, Regeneron. Dr Virani reports research grant: Significant; American
Heart Association (AHA), ADA, VA; honoraria: Significant; American College of
Cardiology (Associate Editor for Innovations, acc.org). Dr Peterson reports re-
search grant: Significant; Amgen, Sanofi, AstraZeneca, Merck; consultant/advi-
sory board; Modest; Amgen; consultant/advisory board: Significant; AstraZeneca,
Merck, and Sanofi Aventis. The other authors report no conflicts.
Supplemental Material
Figure I
Tables I and II
REFERENCES
1. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB,
Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, et al; Ameri-
can College of Cardiology/American Heart Association Task Force on
Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood
cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report
of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S1–45.
doi: 10.1161/01.cir.0000437738.63853.7a
2. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ,
Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW,
et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/
PCNA Guideline for the prevention, detection, evaluation, and man-
agement of high blood pressure in adults: a report of the American
College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines. Hypertension. 2018;71:e13–e115. doi:
10.1161/HYP.0000000000000065
Circ Cardiovasc Qual Outcomes. 2021;14:e006548. DOI: 10.1161/CIRCOUTCOMES.120.006548
3. Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB,
Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, et al; Ameri-
can College of Cardiology/American Heart Association Task Force on Prac-
tice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovas-
cular risk: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. 2014;129(25
suppl 2):S49–S73. doi: 10.1161/01.cir.0000437741.48606.98
4. Navar AM, Wang TY, Goldberg AC, Robinson JG, Roger VL, Wilson PF,
Virani SS, Elassal J, Lee LV, Webb LE, et al. Design and rationale for the
patient and provider assessment of lipid management (PALM) registry. Am
Heart J. 2015;170:865–871. doi: 10.1016/j.ahj.2015.08.002
5. Fagerlin A, Zikmund-Fisher BJ, Ubel PA, Jankovic A, Derry HA, Smith DM.
Measuring numeracy without a math test: development of the Sub-
jective Numeracy Scale. Med Decis Making. 2007;27:672–680. doi:
10.1177/0272989X07304449
6. Navar AM, Pencina MJ, Mulder H, Elias P, Peterson ED. Improving patient
risk communication: translating cardiovascular risk into standardized risk
percentiles. Am Heart J. 2018;198:18–24. doi: 10.1016/j.ahj.2017.12.005
7. Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes J III. Factors of
risk in the development of coronary heart disease–six year follow-up ex-
perience. The Framingham Study. Ann Intern Med. 1961;55:33–50. doi:
10.7326/0003-4819-55-1-33
8. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. How making a risk estimate can
change the feel of that risk: shifting attitudes toward breast cancer risk
in a general public survey. Patient Educ Couns. 2005;57:294–299. doi:
10.1016/j.pec.2004.08.007
9. Rothman AJ, Klein WM, Weinstein ND. Absolute and relative biases in
estimations of personal risk. J App Social Psych. 1996;26:1213–1236.
10. Kong A, Barnett GO, Mosteller F, Youtz C. How medical professionals
evaluate expressions of probability. N Engl J Med. 1986;315:740–744.
doi: 10.1056/NEJM198609183151206
11. Weinstein ND. Unrealistic optimism about susceptibility to health prob-
lems: conclusions from a community-wide sample. J Behav Med. 1987;10:
481–500. doi: 10.1007/BF00846146
12. Navar AM, Wang TY, Mi X, Robinson JG, Virani SS, Roger VL, Wilson PWF,
Goldberg AC, Peterson ED. Influence of cardiovascular risk communication
tools and presentation formats on patient perceptions and preferences.
JAMA Cardiol. 2018;3:1192–1199. doi: 10.1001/jamacardio.2018.3680
13. Bradley CK, Wang TY, Li S, Robinson JG, Roger VL, Goldberg AC, Virani SS,
Louie MJ, Lee LV, Peterson ED, et al. Patient-reported reasons for declin-
ing or discontinuing statin therapy: insights from the PALM registry. J Am
Heart Assoc. 2019;8:e011765. doi: 10.1161/JAHA.118.011765
14. Navar AM, Stone NJ, Martin SS. What to say and how to say it: effective
communication for cardiovascular disease prevention. Curr Opin Cardiol.
2016;31:537–544. doi: 10.1097/HCO.0000000000000322
15. Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Risky feelings: why a 6%
risk of cancer does not always feel like 6%. Patient Educ Couns.
2010;81(suppl):S87–S93. doi: 10.1016/j.pec.2010.07.041
16. Kalet A, Roberts JC, Fletcher R. How do physicians talk with their pa-
tients about risks? J Gen Intern Med. 1994;9:402–404. doi: 10.1007/
BF02629523
17. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. “If I’m better than average, then
I’m ok?”: comparative information influences beliefs about risk and
benefits. Patient Educ Couns. 2007;69:140–144. doi: 10.1016/j.pec.
2007.08.008
18. Schwartz LM, Woloshin S, Black WC, Welch HG. The role of numeracy in
understanding the benefit of screening mammography. Ann Intern Med.
1997;127:966–972. doi: 10.7326/0003-4819-127-11-199712010-00003
19. Zikmund-Fisher BJ, Smith DM, Ubel PA, Fagerlin A. Validation of the sub-
jective numeracy scale: effects of low numeracy on comprehension of risk
communications and utility elicitations. Med Decis Making. 2007;27:663–
671. doi: 10.1177/0272989X07303824
20. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, Williams K, Neely B,
Sniderman AD, Peterson ED. Application of new cholesterol guidelines
to a population-based sample. N Engl J Med. 2014;370:1422–1431. doi:
10.1056/NEJMoa1315665
21. Navar AM, Wang TY, Li S, Robinson JG, Goldberg AC, Virani S,
Roger VL, Wilson PWF, Elassal J, Lee LV, et al. Lipid management in con-
temporary community practice: results from the provider assessment of
lipid management (PALM) registry. Am Heart J. 2017;193:84–92. doi:
10.1016/j.ahj.2017.08.005
January 2021 57