Aims Hypertriglyceridaemia in patients with atherosclerotic cardiovascular disease (ASCVD) has been in focus following the REDUCE-IT trial showing benefit with icosapent ethyl. Among individuals with prevalent ASCVD, we sought to quantify the contemporary, real-world risk of ASCVD events associated with hypertriglyceridaemia, as well as estimate icosapent ethyl eligibility and compare trial participants with REDUCE-IT-like individuals in the population. Methods and results We examined data from 2 424 865 adults with lipid panels in the Ontario population. Among those with prevalent ASCVD, we examined adjusted associations between triglyceride (TG) and ASCVD events (first occurrence of myocardial infarction, unstable angina, stroke or transient ischaemic attack, coronary revascularization, or cardiovascular death). The proportion of patients with ASCVD potentially eligible for icosapent ethyl was estimated as those with TG 135–499 mg/dL (1.52–5.63 mmol/L) and low-density lipoprotein cholesterol (LDLc) 41–100 mg/dL (1.06–2.59 mmol/L), similar to the lipid cut-offs in REDUCE-IT, and their demographics and event rates examined. Among 196 717 individuals with ASCVD, median age was 69 years and 30% were female. A total of 24 097 composite ASCVD events occurred over a mean (standard deviation) 2.9 (0.5) years of follow-up. Increasing TG was associated with a graded, progressively higher hazard of ASCVD events. Twenty-five percent (49 886) of individuals with ASCVD had hypertriglyceridaemia and controlled LDLc; these patients were demographically similar to those in REDUCE-IT with comparable event rates. Conclusions Among patients with ASCVD, hypertriglyceridaemia is common, and is associated with higher ASCVD risk across a range of TG. It is possible that as many as one in four patients with ASCVD may be candidates for emerging therapies.

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Accurate individual risk estimation is essential in guiding informed treatment decisions in primary prevention, because treatment has greater benefit in those at increased risk of developing the disease. 1,2 Primary prevention guidelines in cardiology around the world have endorsed the use of risk prediction scores to estimate the risk of atherosclerotic cardiovascular disease as an initial step in assessing the need for preventive treatment. [2][3][4][5][6] The Canadian Cardiovascular Society (CCS) guideline recommends using the Framingham Risk Score to assess risk of atherosclerotic cardiovascular disease. 2 The American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines currently endorse the use of the Pooled Cohort Equations over the Framingham Risk Score for risk estimations. 1,4 Since the Framingham cohort was assembled more than 3 decades ago, there have been substantial declines in the risk of cardiovascular events. 7 Furthermore, these risk scores predict cardiovascular events but do not consider the potential competing impact of noncardiovascular deaths during follow-up. The accuracy of commonly used risk scores has also not been evaluated in a large contemporary Canadian cohort and has not been measured using newer statistical techniques. Our main objective was to assess the calibration and discrimination of the Framingham Risk Score and Pooled Cohort Equations in Ontario, Canada. Second, we aimed to assess the validity of these risk scores in prespecified subgroups to gain additional perspectives. Methods Study design and data sourcesWe performed an observational study of Ontario adults to evalu ate the calibration and discrimination of the Framingham Risk Score and Pooled Cohort Equations using the Electronic RESEARCH