Performance of the Predicting Risk of Cardiovascular Disease Events Calculator in Rheumatoid Arthritis

Evaluate performance of the Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator in rheumatoid arthritis (RA).

Patients with RA were matched up to 10 controls on age, sex, and enrollment year using National Veterans Health Administration, Medicare, and National Death Index data (2006-2020). Ten-year estimated cardiovascular disease (CVD) risk was calculated using PREVENT. Calibration (standardized incidence ratio [SIR] and observed/predicted events) and discrimination (sensitivity and Harrel's C-statistics) were compared between RA cases and controls. PREVENT performance was compared with the Pooled Cohort Equations (PCE) for atherosclerotic CVD (ASCVD) prediction in RA, including net reclassification index (NRI) calculation.

Among 30,687 patients with RA and 231,752 patients without RA, 28,061 ASCVD and 13,851 heart failure (HF) outcomes were identified over >2 million person-years. PREVENT underestimated overall CVD (SIR 1.83, 95% confidence interval [CI] 1.79-1.88), ASCVD (SIR 2.25, 95% CI 2.19-2.32) and HF risk (SIR 1.41, 95% CI 1.36-1.46) to a greater degree in RA compared with controls and exhibited poor sensitivity for ASCVD (61.9%) and HF (63.2%) development. PREVENT performance was poorer for ASCVD prediction compared with the PCE (SIR 1.38, 95% CI 1.34-1.41, sensitivity 76.0%). NRI for PREVENT was modest (5.3%). Among 657 reclassified patients who experienced ASCVD, 626 were inappropriately reclassified as low or borderline risk. PREVENT performance significantly improved when including hemoglobin A1c (overall CVD: SIR 1.21, 95% CI 1.18-1.24; ASCVD: SIR 1.45, 95% CI 1.41-1.50; HF: SIR 0.79, 95% CI 0.76-0.82; sensitivity ASCVD 80.3%).

PREVENT underestimates CVD risk in RA, consistent with suboptimal performance of existing risk calculators. Preferential use of PREVENT including hemoglobin A1c should be considered. Improving CVD risk stratification in RA remains a high priority.