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Utility of Nontraditional Risk Markers in Atherosclerotic Cardiovascular Disease Risk Assessment
Joseph Yeboah1, Rebekah Young2, Robyn L McClelland2
1Department of Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, North Carolina.
Insights
Adding coronary artery calcium (CAC) score to the atherosclerotic cardiovascular disease (ASCVD) risk estimator modestly improved risk prediction. Other markers like ankle-brachial index (ABI) and family history (FH) did not significantly enhance prediction accuracy.
Area of Science:
- Cardiology
- Preventive Medicine
- Biostatistics
Background:
- The 2013 ACC/AHA cholesterol guidelines suggest incorporating nontraditional cardiovascular risk markers into the ASCVD risk estimator (PCE).
- The added predictive value of these markers to the PCE remains largely untested.
- This study investigates the utility of novel risk factors in refining ASCVD risk prediction.
Purpose of the Study:
- To evaluate the predictive accuracy of adding coronary artery calcium (CAC) score, ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP), and family history (FH) to the PCE.
- To assess the improvement in risk reclassification provided by these nontraditional markers.
- To validate these additions within the Multi-Ethnic Study of Atherosclerosis (MESA) cohort.
Main Methods:
- Calibrated PCE (cPCE) was utilized for analysis.
- Cox proportional hazards models and Harrell's C statistics were employed to assess model discrimination.
- Net reclassification improvement (NRI) analyses quantified changes in risk prediction accuracy.
Main Results:
- In a 10-year follow-up of 5,185 participants, 320 ASCVD events occurred.
- Coronary artery calcium (CAC) score, ABI, and FH were identified as independent predictors of ASCVD events.
- CAC score significantly improved the Harrell's C statistic (0.74 to 0.76, p=0.04), while ABI, hsCRP, and FH did not.
Conclusions:
- CAC score, ABI, and FH independently predict ASCVD events.
- CAC score offers a modest improvement in the discriminative ability of the calibrated PCE.
- Nontraditional risk markers, particularly CAC score, enhance ASCVD risk prediction beyond traditional factors.
Background:
The improvement in discrimination gained by adding nontraditional cardiovascular risk markers cited in the 2013 American College of Cardiology/American Heart Association cholesterol guidelines to the atherosclerotic cardiovascular disease (ASCVD) risk estimator (pooled cohort equation [PCE]) is untested.
Objectives:
This study assessed the predictive accuracy and improvement in reclassification gained by the addition of the coronary artery calcium (CAC) score, the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) levels, and family history (FH) of ASCVD to the PCE in participants of MESA (Multi-Ethnic Study of Atherosclerosis).
Methods:
The PCE was calibrated (cPCE) and used for this analysis. The Cox proportional hazards survival model, Harrell's C statistics, and net reclassification improvement analyses were used. ASCVD was defined as myocardial infarction, coronary heart disease-related death, or fatal or nonfatal stroke.
Results:
Of 6,814 MESA participants not prescribed statins at baseline, 5,185 had complete data and were included in this analysis. Their mean age was 61 years; 53.1% were women, 9.8% had diabetes, and 13.6% were current smokers. After 10 years of follow-up, 320 (6.2%) ASCVD events occurred. CAC score, ABI, and FH were independent predictors of ASCVD events in the multivariable Cox models. CAC score modestly improved the Harrell's C statistic (0.74 vs. 0.76; p = 0.04); ABI, hsCRP levels, and FH produced no improvement in Harrell's C statistic when added to the cPCE.
Conclusions:
CAC score, ABI, and FH were independent predictors of ASCVD events. CAC score modestly improved the discriminative ability of the cPCE compared with other nontraditional risk markers.
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