Accuracy of the Atherosclerotic Cardiovascular Risk Equation in a Large Contemporary, Multiethnic Population

Abstract

Background The accuracy of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) risk equation for atherosclerotic cardiovascular disease (ASCVD) events in contemporary and ethnically diverse populations is not well understood. Objectives We sought to evaluate the accuracy of the 2013 ACC/AHA risk equation within a large, multiethnic population in clinical care. Methods The target population for consideration of cholesterol-lowering therapy in a large, integrated health care delivery system population was identified in 2008 and followed through 2013. The main analyses excluded those with known ASCVD, diabetes mellitus, low-density lipoprotein cholesterol levels <70 or ≥190 mg/dl, prior statin use, or incomplete 5-year follow-up. Patient characteristics were obtained from electronic medical records and ASCVD events were ascertained using validated algorithms for hospitalization databases and death certificates. We compared predicted versus observed 5-year ASCVD risk, overall and by sex and race/ethnicity. We additionally examined predicted versus observed risk in patients with diabetes mellitus. Results Among 307,591 eligible adults without diabetes between 40 and 75 years of age, 22,283 were black, 52,917 Asian/Pacific Islander, and 18,745 Hispanic. We observed 2,061 ASCVD events during 1,515,142 person-years. In each 5-year predicted ASCVD risk category, observed 5-year ASCVD risk was substantially lower: 0.20% for predicted risk <2.50%; 0.65% for predicted risk 2.50 to 3.74%; 0.90% for predicted risk 3.75 to 4.99%; and 1.85% for predicted risk ≥5.00%, with C: 0.74. Similar ASCVD risk overestimation and poor calibration with moderate discrimination (C: 0.68 to 0.74) was observed in sex, racial/ethnic, and socioeconomic status subgroups, and in sensitivity analyses among patients receiving statins for primary prevention. Calibration among 4,242 eligible adults with diabetes was improved, but discrimination was worse (C: 0.64). Conclusions In a large, contemporary “real-world” population, the ACC/AHA Pooled Cohort risk equation substantially overestimated actual 5-year risk in adults without diabetes, overall and across sociodemographic subgroups.

Temporal shifts in clinical presentation and underlying mechanisms of atherosclerotic disease

“…overestimates the 5 year risk of atherosclerotic cardiovascular events 95 . Indeed, Blaha has argued that risk score calibration is among the most important issues in preventive cardiology 96 .…”

Strategies to Prioritize Clinical Options in Primary Care

“…17 For these and other reasons, the ACC/ AHA and most other cardiovascular risk equations are somewhat obsolete and tend to overestimate event and death rates. 18 Despite such limitations, explicit estimation of benefits and risks of treatment options is usually far more accurate than intuitive risk estimation by either clinician or patient. 19 The availability of large databases that include detailed clinical data on millions of patients and novel analytic approaches, such as marginal structural models and machine learning, will likely lead to improved risk prediction and prioritization methods in the near future.…”

Human Oral Buccal Microbiomes Are Associated with Farmworker Status and Azinphos-Methyl Agricultural Pesticide Exposure

“…have not been investigated in this cohort to date. Hispanics have a disproportionate disease burden for many common diseases related to vasculature (i.e., diabetes and cardiovascular disease) (82)(83)(84)(85)(86)(87)(88)(89)(90) that have also been shown to have microbiome-related disease variables in many other experimental contexts (91)(92)(93)(94)(95)(96)(97)(98)(99)(100)(101)(102)(103)(104). Dental health, bacterial infection, and peripheral vascular disease have many independent associations (105), and some of the etiology could be affected by systemic loosening of tight junctions as induced by organophosphates (78).…”