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An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic
Insights
The new American Heart Association (AHA) and American College of Cardiology (ACC) atherosclerotic cardiovascular disease (ASCVD) risk score, along with others, overestimated risk in a multiethnic cohort. This overestimation has significant implications for primary prevention strategies.
Area of Science:
- Cardiovascular Disease Epidemiology
- Risk Stratification
- Preventive Cardiology
Background:
- Accurate atherosclerotic cardiovascular disease (ASCVD) risk assessment is crucial for primary prevention therapy.
- Balancing the risks and benefits of preventive treatments relies on precise risk evaluation.
Purpose of the Study:
- To compare the calibration and discrimination of the new AHA-ACC-ASCVD risk score against alternative scores.
- To investigate if preventive therapies contribute to the observed risk overestimation by the AHA-ACC-ASCVD score.
Main Methods:
- Prospective epidemiologic study utilizing the Multi-Ethnic Study of Atherosclerosis (MESA) cohort.
- Analysis of 4227 participants aged 50-74 without diabetes, comparing observed ASCVD events with predicted risks over 10.2 years.
- Evaluation of 5 different risk scores, including the AHA-ACC-ASCVD score.
Main Results:
- Four of the five risk scores, including the new AHA-ACC-ASCVD score, overestimated ASCVD events in a modern, multiethnic cohort.
- Overestimation ranged from 25% to 115% across the evaluated risk scores.
- Preventive therapies like aspirin or lipid-lowering drugs did not account for the observed risk overestimation.
Conclusions:
- The new AHA-ACC-ASCVD risk score and older Framingham-based scores demonstrated significant overestimation of cardiovascular risk.
- The Reynolds Risk Score showed less overestimation in men and underestimation in women.
- Widespread overestimation of ASCVD risk has substantial implications for patient care and healthcare systems if not addressed.
Background:
Accurate risk assessment of atherosclerotic cardiovascular disease (ASCVD) is essential to effectively balance the risks and benefits of therapy for primary prevention.
Objective:
To compare the calibration and discrimination of the new American Heart Association (AHA) and American College of Cardiology (ACC) ASCVD risk score with alternative risk scores and to explore preventive therapy as a cause of the reported risk overestimation using the AHA-ACC-ASCVD score.
Design:
Prospective epidemiologic study of ASCVD.
Setting:
MESA (Multi-Ethnic Study of Atherosclerosis), a community-based, sex-balanced, multiethnic cohort.
Patients:
4227 MESA participants aged 50 to 74 years and without diabetes at baseline.
Measurements:
Observed and expected events for the AHA-ACC-ASCVD score were compared with 4 commonly used risk scores-and their respective end points-in MESA after a 10.2-year follow-up.
Results:
The new AHA-ACC-ASCVD and 3 older Framingham-based risk scores overestimated cardiovascular events by 37% to 154% in men and 8% to 67% in women. Overestimation was noted throughout the continuum of risk. In contrast, the Reynolds Risk Score overestimated risk by 9% in men but underestimated risk by 21% in women. Aspirin, lipid-lowering or antihypertensive therapy, and interim revascularization did not explain the overestimation.
Limitation:
Comparability of MESA with target populations for primary prevention and possibility of missed events in MESA.
Conclusion:
Of the 5 risk scores, 4, including the new AHA-ACC-ASCVD score, showed overestimation of risk (25% to 115%) in a modern, multiethnic cohort without baseline clinical ASCVD. If validated, overestimation of ASCVD risk may have substantial implications for individual patients and the health care system.
Primary Funding Source:
National Heart, Lung, and Blood Institute.
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