Combined clinical, metabolomic, and polygenic scores for cardiovascular risk prediction

Clinical biomarkers, nuclear magnetic resonance (NMR) metabolomics biomarker scores, and polygenic risk scores (PRS) have shown promise for improving cardiovascular disease (CVD) prediction but have not yet been evaluated in the context of current prediction models (SCORE2) and ESC recommendations for 10-year prediction of fatal and non-fatal CVD.

NMR metabolomic biomarker scores were constructed and compared to clinical biomarkers, PRS and SCORE2 in 297 463 UK Biobank participants (8919 incident CVD cases) aged 40-69 without previous CVD, diabetes, or lipid-lowering treatment. Improvement in risk discrimination when added to SCORE2 was assessed using Harrel's C-index. Improvement in risk stratification following ESC guideline risk thresholds was assessed using categorical net reclassification. Population modelling was subsequently applied to estimate the impact on CVD prevention if applied at scale.

Risk discrimination provided by SCORE2 (C-index: 0.719) improved when 11 clinical biomarkers (ΔC-index: 0.014 [0.012-0.015]), NMR metabolomic biomarker scores (ΔC-index: 0.010 [0.009-0.012]) and PRSs (ΔC-index 0.009; [0.008-0.011]) were added individually. The combination of 11 clinical biomarkers, NMR metabolomic biomarker scores, and PRSs yielded the largest improvement risk discrimination, with ΔC-index 0.024 (0.022-0.027). Concomitant improvements in risk stratification were observed in categorical net reclassification index, with net case reclassification of 16.66% (15.50%-17.81%). Modelling suggested that addition of these biomarkers to SCORE2 for targeted risk reclassification would increase the number of CVD events prevented per 100 000 screened from 229 to 413 (ΔCVDprevented: 184 [174-194]) while essentially maintaining the number of statins prescribed per CVD event prevented.

Combining NMR metabolomic, polygenic, and clinical biomarkers with SCORE2 enhanced prediction of first-onset CVD and could have substantial population health benefit if applied at scale.