Applied Evidence

CV risk prediction tools: Imperfect, Yes, but are they serviceable?

J Fam Pract. 2018 September;67(9):E3-E8

References

1. Taylor F, Huffman MD, Macedo AF, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD004816.

2. Holt T. Predicting cardiovascular disease. BMJ. 2016;353:i2621.

3. Kannel WB, McGee D, Gordon T. A general cardiovascular risk profile: the Framingham Study. Am J Cardiol. 1976;38:46-51.

4. Preiss D, Kristensen SL. The new pooled cohort equations risk calculator. Can J Cardiol. 2015;31:613-619.

5. Koller MT, Steyerberg EW, Wolbers M, et al. Validity of the Framingham point scores in the elderly: results from the Rotterdam study. Am Heart J. 2007;154:87-93.

6. Franklin SS, Larson MG, Khan SA, et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation. 2001;103:1245-1249.

7. Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ. 1994;308:367-372.

8. Koller MT, Leening MJ, Wolbers M, et al. Development and validation of a coronary risk prediction model for older U.S. and European persons in the Cardiovascular Health Study and the Rotterdam Study. Ann Intern Med. 2012;157:389-397.

9. Damen JA, Hooft L, Schuit E, et al. Prediction models for cardiovascular disease risk in the general population: systematic review. BMJ. 2016;353:i2416.

10. Hippisley-Cox J, Coupland C, Vinogradova Y, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ. 2008;336:1475–1482.

11. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Amer Coll Cardiol. 2014;63:2889-2934.

12. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935-2959.

13. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316:1997-2007.

14. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. New Engl J Med. 2014;370:1422-1431.

15. Loprinzi PD, Addoh O. Predictive validity of the American College of Cardiology/American Heart Association pooled cohort equations in predicting all-cause and cardiovascular disease–specific mortality in a national prospective cohort study of adults in the United States. Mayo Clin Proc. 2016;91:763-769.

16. Pursnani A, Massaro JM, D’Agostino RB Sr, et al. Guideline-based statin eligibility, coronary artery calcification, and cardiovascular events. JAMA. 2015;314:134-141.

17. Rana JS, Tabada GH, Solomon MD, et al. Accuracy of the atherosclerotic cardiovascular risk equation in a large contemporary, multiethnic population. J Am Coll Cardiol. 2016;67:2118-2130.

18. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013;382:1762-1765.

19. Cook NR, Ridker PM. Further insight into the cardiovascular risk calculator: the roles of statins, revascularizations, and underascertainment in the Women’s Health Study. JAMA Intern Med. 2014;174:1964-1971.

20. Yeboah J, McClelland RJ, Polonsky TS, et al. Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals. JAMA. 2012;308:788-795.

21. Yadlowsky S, Hayward RA, Sussman JB, et al. Clinical implications of revised pooled cohort equations for estimating atherosclerotic cardiovascular disease risk. Ann Intern Med. 2018;169:20-29.

22. Dyakova M, Shantikumar S, Colquitt J, et al. Systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2016 Jan 29;(1):CD010411.

The resulting CVD risk calculator incorporates 4 risk equations: 1 each for African-American and non-Hispanic white males and females.¹¹ Of note, PCR equations are typically used to estimate 10-year CVD risk, but they can be modified to estimate risk over any period. The associated Guideline on the Assessment of Cardiovascular Risk recommends statin therapy for primary prevention of CVD in patients with a predicted 10-year risk ≥7.5% and consideration of statin therapy for patients with a predicted 10-year risk between 5% and 7.5%.¹²

In late 2016, the US Preventive Services Task Force (USPSTF) recommended low- to moderate-dosage statin therapy in adults 40 to 75 years of age without a history of CVD but with at least 1 CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking), and a PCR-calculated 10-year CVD risk of ≥10%. For people with a PCR-calculated risk of 7.5% to 10%, the USPSTF recommended that clinicians “selectively offer” low- to moderate-dosage statin therapy, noting a smaller likelihood of benefit and uncertainty in an individual’s risk prediction.¹³

Pooled cohort risk equations have predictive validity

Estimates are that nearly 50% of US adults and as many as 65% of European adults would be candidates for statin therapy if, using PCR equations, the 2013 ACC/AHA guidelines were broadly applied.¹⁴ Since PCR equations were released, multiple groups have attempted to evaluate the predictive validity of the algorithm in various populations, with mixed findings.

The true impact of systematic CVD risk assessment alone for healthy people has yet to be demonstrated, in terms of hard clinical outcomes.

Data from the 1999-2010 NHANES—the National Health and Nutrition Examination Survey—were used to calculate estimated CVD risk for patients free of atherosclerotic CVD at baseline. Risk prediction using PCR equations was compared to true all-cause and CVD mortality using the National Center for Health Statistics National Death Index. In this large, US adult population without CVD at baseline, PCR-estimated CVD risk was significantly associated with all-cause and CVD-specific mortality risk.¹⁵

In a community-based primary prevention cohort, 39% of participants were found statin-eligible—ie, they had an estimated 10-year CVD risk ≥7.5%—by ACC/AHA guidelines, compared with 14% found statin-eligible by the guidelines of the National Cholesterol Education Program’s 2004 updated “Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III).” Despite the larger percentage, participants who were statin-eligible by ACC/AHA guidelines had an increased hazard ratio for incident CVD compared with those who were statin-eligible by ATP III; investigators concluded that ACC/AHA guidelines using PCR equations were associated with greater accuracy and efficiency in identifying increased risk of incident CVD.¹⁶

Continue to: Pooled cohort risk equations might overestimate CVD risk