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Published on: September 26, 2018
Impact of outcome definitions on cardiovascular risk prediction in a contemporary primary prevention population
Maneesh Sud1,2,3,4, Anna Chu3,4, Peter C Austin2,3
1Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada.
Insights
Estimating broader cardiovascular disease (CVD) events, including heart failure and revascularization, nearly doubles risk incidence compared to atherosclerotic CVD (ASCVD) alone. This comprehensive view improves patient risk discussions and decision-making.
Area of Science:
- Cardiology
- Public Health
- Epidemiology
Background:
- Cardiovascular disease (CVD) risk estimation is crucial for patient management.
- Current atherosclerotic CVD (ASCVD) risk models exclude key outcomes like heart failure (HF) and coronary revascularization.
- Incorporating broader CVD endpoints may provide a more accurate risk assessment.
Purpose of the Study:
- To determine the incidence of ASCVD in a primary prevention population over 10 years.
- To evaluate how ASCVD risk estimates change when including additional CVD endpoints.
- To inform clinical decision-making by providing a more complete picture of cardiovascular risk.
Main Methods:
- Utilized the Cardiovascular Health in Ambulatory Care Research Team database for Ontario residents (2008-2018).
- Defined ASCVD outcomes (myocardial infarction, stroke, circulatory death) and global CVD outcomes (including HF, revascularization, etc.).
- Followed a large cohort (7,496,165 individuals) free of prior CVD for incident and recurrent events.
Main Results:
- The incidence rate of ASCVD was 3.95 per 1000 person-years, nearly doubling to 6.67 per 1000 person-years for global CVD events.
- Heart failure (12.0%) and coronary revascularization (12.7%) were the most common additional first CVD events.
- Including recurrent events, ASCVD rate was 5.20, while global CVD rate more than doubled to 10.90 per 1000 person-years, driven by recurrent HF and revascularization.
Conclusions:
- ASCVD represents only about half of all preventable first cardiovascular events.
- Estimating broader CVD endpoints, beyond traditional ASCVD, is essential for accurate risk assessment.
- A comprehensive CVD risk estimation enhances patient-physician discussions and improves informed decision-making.
Background:
Estimation of an individual's cardiovascular disease (CVD) risk may enhance risk discussion and treatment decisions. Yet, common cardiovascular outcomes such as heart failure (HF) or coronary revascularization are not included in the estimation of atherosclerotic cardiovascular disease (ASCVD) risk. Our objective was to determine the incidence of ASCVD in a contemporary primary prevention population with >10 years of follow-up and how incidence estimates change when incorporating additional cardiovascular endpoints.
Methods:
We used the population-level Cardiovascular Health in Ambulatory Care Research Team database of all Ontario residents alive 1 January 2008, aged 30-99 years, and with no prior history of CVD. Individuals were followed to 31 December 2018 for incident first and recurrent cardiovascular events. ASCVD outcomes were defined by hospitalizations for myocardial infarction, stroke, and circulatory death, while global CVD outcomes also included hospitalizations for unstable angina, transient ischemic attacks, peripheral arterial disease, out-of-hospital cardiac arrests, HF, and coronary revascularization.
Results:
Among 7496 165 individuals free of CVD, their mean age was 50 years (SD: 13.9 years) and 52.3% were women. After 11 years of follow-up, the rate of an incident ASCVD event was 3.95 per 1000 person-years, while the rate of a global CVD event was almost doubled at 6.67 per 1000 person-years. The most common additional first manifestations of CVD were HF, which accounted for 12.0% of additional events and coronary revascularization, which accounted for 12.7%. When considering first and recurrent events, the rate of ASCVD was 5.20 per 1000 person-years, while the rate of all global CVD events was more than double at 10.90 per 1000 person-years. This was mainly due to a higher proportion of recurrent HF (13.8%) and coronary revascularization (23.2%) events.
Conclusions:
ASCVD accounts for just over half of all preventable first cardiovascular events and even fewer first and recurrent cardiovascular events in contemporary practice. Estimating broader CVD endpoints may enhance risk-discussions with patients and improve informed decision-making.
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