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Cardiovascular Disease Risk Prediction in the HIV Outpatient Study
Angela M Thompson-Paul1,2, Kenneth A Lichtenstein3, Carl Armon4
1Division of HIV/AIDS Prevention.
Insights
Cardiovascular disease (CVD) risk scores developed for the general population may not accurately predict CVD events in adults with human immunodeficiency virus (HIV). The Framingham Risk Score (FRS) showed the best calibration for this population.
Area of Science:
- Cardiology
- Infectious Diseases
- Epidemiology
Background:
- Cardiovascular disease (CVD) risk prediction tools are frequently applied to populations for which they were not originally developed, especially when validated tools for specific subpopulations are scarce.
- This practice is common in human immunodeficiency virus (HIV)-infected populations, where CVD is a significant concern.
Purpose of the Study:
- To evaluate the performance of commonly used CVD risk prediction models in a cohort of HIV-infected adults.
- To compare the accuracy of general population CVD risk scores (Framingham Risk Score [FRS], Pooled Cohort Equations [PCEs], Systematic COronary Risk Evaluation [SCORE]) against a model developed in HIV-infected individuals (Data Collection on Adverse Effects of Anti-HIV Drugs [D:A:D] study equation).
Main Methods:
- The study utilized data from 2283 HIV-infected adults in the HIV Outpatient Study (HOPS).
- Performance was assessed using C-statistics for discrimination and the ratio of expected to observed events (E/O) with Hosmer-Lemeshow P values for calibration.
- Three general CVD risk models (FRS, PCEs, SCORE) and one HIV-specific model (D:A:D) were evaluated.
Main Results:
- Over 15,056 person-years, 195 (8.5%) participants experienced a CVD event.
- The FRS demonstrated moderate discrimination and good calibration (C-statistic: 0.66, E/O: 1.01).
- PCE and D:A:D showed good discrimination but underestimated risk (C-statistics: 0.71-0.72, E/O: 0.80-0.88), while SCORE performed poorly (C-statistic: 0.59).
Conclusions:
- Among the evaluated models, only the FRS accurately estimated CVD risk in this HIV-infected cohort.
- General population CVD risk scores like PCE and D:A:D tended to underestimate risk in HIV-infected individuals.
- While these models can help stratify risk, they may miss a significant number of HIV-infected persons who could benefit from intensified CVD management.
Background:
Cardiovascular disease (CVD) risk prediction tools are often applied to populations beyond those in which they were designed when validated tools for specific subpopulations are unavailable.
Methods:
Using data from 2283 human immunodeficiency virus (HIV)-infected adults aged ≥18 years, who were active in the HIV Outpatient Study (HOPS), we assessed performance of 3 commonly used CVD prediction models developed for general populations: Framingham general cardiovascular Risk Score (FRS), American College of Cardiology/American Heart Association Pooled Cohort equations (PCEs), and Systematic COronary Risk Evaluation (SCORE) high-risk equation, and 1 model developed in HIV-infected persons: the Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) study equation. C-statistics assessed model discrimination and the ratio of expected to observed events (E/O) and Hosmer-Lemeshow χ2 P value assessed calibration.
Results:
From January 2002 through September 2013, 195 (8.5%) HOPS participants experienced an incident CVD event in 15 056 person-years. The FRS demonstrated moderate discrimination and was well calibrated (C-statistic: 0.66, E/O: 1.01, P = .89). The PCE and D:A:D risk equations demonstrated good discrimination but were less well calibrated (C-statistics: 0.71 and 0.72 and E/O: 0.88 and 0.80, respectively; P < .001 for both), whereas SCORE performed poorly (C-statistic: 0.59, E/O: 1.72; P = .48).
Conclusions:
Only the FRS accurately estimated risk of CVD events, while PCE and D:A:D underestimated risk. Although these models could potentially be used to rank US HIV-infected individuals at higher or lower risk for CVD, the models may fail to identify substantial numbers of HIV-infected persons with elevated CVD risk who could potentially benefit from additional medical treatment.
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