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The Accuracy of Cardiovascular Pooled Cohort Risk Estimates in U.S. Older Adults
Michael G Nanna1, Eric D Peterson2, Daniel Wojdyla2
1Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, 27710, USA. michael.nanna@duke.edu.
Insights
The Pooled Cohort Risk Equations (PCE) for atherosclerotic cardiovascular disease (ASCVD) risk are inaccurate in older adults. New models are needed for better risk assessment in this population.
Area of Science:
- Cardiology
- Geriatric Medicine
- Epidemiology
Background:
- Current ACC/AHA guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) utilize the Pooled Cohort Risk Equations (PCE).
- The PCE were developed using data from younger populations, raising concerns about their accuracy in older adults.
- Accurate risk stratification is crucial for guiding ASCVD prevention strategies in diverse age groups.
Purpose of the Study:
- To assess the predictive accuracy and calibration of the PCE in individuals aged 75 years and older.
- To compare the performance of the PCE in older adults versus younger adults (aged 40-74 years).
- To evaluate the association of PCE components with cardiovascular events across different age strata.
Main Methods:
- Utilized data from four large prospective cohort studies: Cardiovascular Health Study, Multiethnic Study of Atherosclerosis, Framingham Original, and Framingham Offspring.
- Estimated 5-year risk of stroke, myocardial infarction (MI), and coronary heart disease (CHD) death using PCE.
- Analyzed PCE performance (discrimination and calibration) stratified by age (≥75 vs. 40-74 years) and sex.
Main Results:
- The PCE demonstrated low discrimination for 5-year ASCVD risk in older adults (c-statistic=0.62) compared to younger adults (c-statistic=0.75).
- Calibration was suboptimal in both age groups, with the PCE overestimating risk in the highest-risk categories.
- Performance remained poor in older adults when stratified by sex or age (≥80 years).
Conclusions:
- The PCE exhibit suboptimal performance for estimating ASCVD risk in older adults.
- Existing risk prediction models may not adequately capture cardiovascular risk in the elderly population.
- Development of novel risk-assessment models tailored for older adults is warranted to improve primary prevention strategies.
Background:
The ACC/AHA guidelines for primary prevention rely on the Pooled Cohort Risk Equations (PCE) risk estimates of atherosclerotic cardiovascular disease (ASCVD) to guide treatment decisions. In light of the PCE being derived in younger populations, their accuracy in older adults is uncertain.
Objective:
To evaluate the predictive accuracy and calibration of the PCE in older individuals.
Design And Setting:
We estimated CVD predicted and observed risk among individuals from four large prospective cohort studies: Cardiovascular Health Study, Multiethnic Study of Atherosclerosis, Framingham Original, and Framingham Offspring.
Participants:
12,527 overall individuals without ASCVD, including 9864 individuals aged 40-74 years and 2663 aged ≥75 years.
Measurements:
We examined the operating characteristics of the PCE to estimate 5-year risk of stroke, MI, and CHD death overall and by age and sex strata. The associations between individual components of the PCE and cardiovascular events by age group (≥75 vs 40-74 years) were also evaluated.
Results:
The PCE had low discrimination for 5-year ASCVD risk in older (≥75 years) (c-statistic = 0.62, 95% CI 0.60-0.65) vs. younger (40-74 years) adults (c-statistic = 0.75, 95% CI 0.73-0.76). Calibration of the PCE was suboptimal in both older and younger adults, overestimating risk in the highest risk groups. Performance of the PCE in older adults was similarly poor when stratified by sex and age ≥ 80 years.
Limitations:
Since the PCE were derived from similar cohorts, though using different age groups and exams, this analysis likely overestimates the performance of the PCE.
Conclusion:
The performance of the PCE for ASCVD risk estimation in older adults is suboptimal; new models to effectively risk-stratify older adults are needed.
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