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Published on: January 28, 2020
Evaluation of newer risk markers for coronary heart disease risk classification: a cohort study
Maryam Kavousi1, Suzette Elias-Smale, Joost H W Rutten
1Erasmus University Medical Center, Rotterdam, the Netherlands.
Insights
Coronary heart disease (CHD) risk prediction improved significantly with coronary artery calcium (CAC) scores, outperforming other newer markers. Further research is needed to confirm clinical outcome benefits and cost-effectiveness.
Area of Science:
- Cardiovascular disease research
- Medical diagnostics
- Epidemiology
Background:
- Assessing the effectiveness of novel risk markers for coronary heart disease (CHD) prediction is crucial.
- The Framingham Risk Score (FRS) is a standard tool, but its predictive accuracy may be enhanced.
- The Rotterdam Study investigated newer markers against traditional FRS factors.
Purpose of the Study:
- To evaluate if newer CHD risk markers improve the accuracy of the Framingham Risk Score (FRS).
- To compare the predictive capabilities of various novel risk markers against established FRS factors.
Main Methods:
- A prospective, population-based study involving 5933 community-dwelling participants (mean age 69.1 years).
- Collected data on traditional FRS risk factors and newer markers including N-terminal fragment of prohormone B-type natriuretic peptide, von Willebrand factor antigen, fibrinogen, chronic kidney disease, leukocyte count, C-reactive protein, homocysteine, uric acid, coronary artery calcium (CAC) scores, carotid intima-media thickness, peripheral arterial disease, and pulse wave velocity.
- Assessed improvements in CHD risk prediction using c-statistic and net reclassification index.
Main Results:
- Adding coronary artery calcium (CAC) scores to the FRS significantly improved risk prediction accuracy (c-statistic increase: 0.05; net reclassification index: 19.3%).
- N-terminal fragment of prohormone B-type natriuretic peptide also improved predictions, but to a lesser extent (c-statistic increase: 0.02; net reclassification index: 7.6%).
- Other newer markers showed marginal improvements in risk prediction.
Conclusions:
- Coronary artery calcium (CAC) scores offer the most statistically and clinically significant improvement for FRS predictions among the evaluated CHD risk markers.
- Further research is required to determine if CAC score-based risk refinement translates to meaningful clinical outcome changes.
- The generalizability of findings to younger or nonwhite populations is uncertain, and the cost-effectiveness of routine CAC screening warrants careful consideration.
Background:
Whether newer risk markers for coronary heart disease (CHD) improve CHD risk prediction remains unclear.
Objective:
To assess whether newer risk markers for CHD risk prediction and stratification improve Framingham risk score (FRS) predictions.
Design:
Prospective population-based study.
Setting:
The Rotterdam Study, Rotterdam, the Netherlands.
Participants:
5933 asymptomatic, community-dwelling participants (mean age, 69.1 years [SD, 8.5]).
Measurements:
Traditional CHD risk factors used in the FRS (age, sex, systolic blood pressure, treatment of hypertension, total and high-density lipoprotein cholesterol levels, smoking, and diabetes) and newer CHD risk factors (N-terminal fragment of prohormone B-type natriuretic peptide levels, von Willebrand factor antigen levels, fibrinogen levels, chronic kidney disease, leukocyte count, C-reactive protein levels, homocysteine levels, uric acid levels, coronary artery calcium [CAC] scores, carotid intima-media thickness, peripheral arterial disease, and pulse wave velocity).
Results:
Adding CAC scores to the FRS improved the accuracy of risk predictions (c-statistic increase, 0.05 [95% CI, 0.02 to 0.06]; net reclassification index, 19.3% overall [39.3% in those at intermediate risk, by FRS]). Levels of N-terminal fragment of prohormone B-type natriuretic peptide also improved risk predictions but to a lesser extent (c-statistic increase, 0.02 [CI, 0.01 to 0.04]; net reclassification index, 7.6% overall [33.0% in those at intermediate risk, by FRS]). Improvements in predictions with other newer markers were marginal.
Limitation:
The findings may not be generalizable to younger or nonwhite populations.
Conclusion:
Among 12 CHD risk markers, improvements in FRS predictions were most statistically and clinically significant with the addition of CAC scores. Further investigation is needed to assess whether risk refinements using CAC scores lead to a meaningful change in clinical outcome. Whether to use CAC score screening as a more routine test for risk prediction requires full consideration of the financial and clinical costs of performing versus not performing the test for both persons and health systems.
Primary Funding Source:
Netherlands Organization for Health Research and Development (ZonMw).
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