Coronary risk assessment by point-based vs. equation-based Framingham models: significant implications for clinical care

A cross-sectional validation study comparing the accuracy of different risk scores in assessing the risk of acute coronary syndrome among patients in a tertiary care hospital in Kerala

Background

There are many cardiovascular disease (CVD) risk score calculators in practice, which are not based on Indian population data.

Objectives

To identify the best CVD risk score calculator applicable in the Indian population.

Materials and methods

A total of 1000 patients presenting with acute coronary syndrome (ACS) were included in the study and their CVD risk score, had they presented before the event, was calculated. The Framingham risk score (FRS–body mass index [BMI], FRS–fasting lipid profile [FLP]), the American College of Cardiology/American Heart Association pooled cohort equation risk calculator (ACC/AHA PCE), Joint British Society risk calculator 3 (JBS3) and the World Health Organization (WHO) risk prediction charts (WHO TC and WHO without TC [WHO NO TC]) were used.

Results

It was seen that among the 1000 people included in the study, the FRS-BMI (59.2%), FRS-FLP (61.5%), ACC/AHA (70.1%) and the JBS3 (62.5%) identified a majority as having a risk of ≥20%, whereas both the WHO TC (65.3%) and the WHO NO TC (64.5%) identified a majority of the ACS patients as having a risk of <20%. The sensitivity was highest for the ACC/AHA (87.8%), FRS-FLP (85.1%) and then JBS3 (80.1%), whereas the specificity was highest for the WHO TC (83.6%) and the WHO NO TC (82.1%). When looking at the accuracy, the FRS-FLP was the most accurate with 80.1%, whereas the ACC/AHA and the JBS3 followed at 74.7% and 73.1%, respectively.

Conclusion

The ACC/AHA seems to be an acceptable risk prediction system to be used in the Indian population and is also relatively easy and cheap to use.

Cardiovascular Disease Risk Among Older Immigrants in the United States: A Comparison of Risk Measures

BACKGROUND

In the United States, 16 million immigrants are 50 years and older, but little is known about their cardiometabolic health and how to best assess their cardiovascular disease (CVD) risk. Aging immigrants may therefore not be benefitting from advances in CVD prevention.

OBJECTIVE

In this study, we estimate and compare CVD risk in a nationally representative sample of aging immigrants using 3 different measures.

METHODS

This was a cross-sectional analysis using National Health and Nutrition Examination Survey data. Immigrants 50 years and older with no history of CVD were eligible. The Framingham Risk Score (FRS), the American College of Cardiology/American Heart Association Pooled Cohort Risk Equation, and presence of metabolic syndrome (MetS) were used to estimate risk. Bivariate statistics were analyzed using SPSS version 23.0 Complex Survey module to account for National Health and Nutrition Examination Survey unique weighting scheme.

RESULTS

The mean age of the sample was 61.3 years; 40% had hypertension, 17% had diabetes, 10% were smokers, and 95% did not meet the recommended physical activity guidelines. Proportions at an elevated CVD risk were as follows: American College of Cardiology/American Heart Association, 42% female and 76% male; FRS, 17.4% female and 76% male; and MetS, 22% female and 24% male.

CONCLUSIONS

Immigrants had a lower overall risk using MetS and the American College of Cardiology/American Heart Association equation than has been found using these tools in similarly aged samples. The opposite was true for the FRS. The discrepancy between the proportion at risk and those being treated may reflect healthcare access gaps that warrant further investigation. A more holistic approach to risk measurement is needed that accounts for determinants of health that disproportionately affect immigrants, including language and socioeconomic status.

Manipal diabetes coronary artery severity score

AIMS

To develop a risk score, for identifying severe and complex CAD in patients with type 2 diabetes mellitus.

METHODS

In this cross sectional study, 179 patients with type 2 diabetes mellitus undergoing coronary angiogram for the evaluation of suspected coronary artery disease (CAD) were recruited at a tertiary-care hospital. Patients were divided into developmental (n=124) and validation (n=55) cohorts. Biochemical and anthropometric parameters were analysed. Predictors of severe and complex CAD (SYNTAX Score>22) were identified by multiple logistic regression analysis.

RESULTS

Insulin resistance>3.4 (OR: 21.26, 95% CI: 5.71-79.09), duration of diabetes>5years (OR: 13.50, 95% CI: 3.13-58.25), total cholesterol/HDL-C ratio>5 (OR: 2.75, 95% CI: 0.66-11.55) and waist circumference>96cm (OR: 5.08, 95% CI: 1.27-20.42) were independent predictors of severe and complex CAD, and Manipal Diabetes Coronary Artery Severity Score was developed.

CONCLUSIONS

The prediction of severe and complex CAD was achieved with this simple score, and thus enabling effective identification of patients beforehand, who are not likely to be suitable for angioplasty.

An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort

BACKGROUND

Accurate risk assessment of atherosclerotic cardiovascular disease (ASCVD) is essential to effectively balance the risks and benefits of therapy for primary prevention.

OBJECTIVE

To compare the calibration and discrimination of the new American Heart Association (AHA) and American College of Cardiology (ACC) ASCVD risk score with alternative risk scores and to explore preventive therapy as a cause of the reported risk overestimation using the AHA-ACC-ASCVD score.

DESIGN

Prospective epidemiologic study of ASCVD.

SETTING

MESA (Multi-Ethnic Study of Atherosclerosis), a community-based, sex-balanced, multiethnic cohort.

PATIENTS

4227 MESA participants aged 50 to 74 years and without diabetes at baseline.

MEASUREMENTS

Observed and expected events for the AHA-ACC-ASCVD score were compared with 4 commonly used risk scores-and their respective end points-in MESA after a 10.2-year follow-up.

RESULTS

The new AHA-ACC-ASCVD and 3 older Framingham-based risk scores overestimated cardiovascular events by 37% to 154% in men and 8% to 67% in women. Overestimation was noted throughout the continuum of risk. In contrast, the Reynolds Risk Score overestimated risk by 9% in men but underestimated risk by 21% in women. Aspirin, lipid-lowering or antihypertensive therapy, and interim revascularization did not explain the overestimation.

LIMITATION

Comparability of MESA with target populations for primary prevention and possibility of missed events in MESA.

CONCLUSION

Of the 5 risk scores, 4, including the new AHA-ACC-ASCVD score, showed overestimation of risk (25% to 115%) in a modern, multiethnic cohort without baseline clinical ASCVD. If validated, overestimation of ASCVD risk may have substantial implications for individual patients and the health care system.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Neighborhood socioeconomic status and coronary heart disease risk prediction in a nationally representative sample

OBJECTIVES

Test the association between coronary heart disease (CHD) risk scores and neighborhood socioeconomic status (NSES) in a US nationally-representative sample and describe whether the association varies by gender and race/ethnicity.

STUDY DESIGN

Cross-sectional study.

METHODS

We use Health and Nutrition Examination Survey (NHANES) data from 1999 to 2004 linked with Census tract data. Multivariable regression models and propensity score adjusted models are employed to test the association between NSES and 10-year risk of CHD based on the Framingham Risk Score (FRS), adjusting for individual-level characteristics.

RESULTS

An individual living in a neighborhood at the 75th percentile of NSES (high NSES) has, on average, a 10-year CHD risk that is 0.16 percentage points lower (95% Confidence Interval 0.16, 0.17) than a similar person residing in a neighborhood at the 25th percentile of NSES (low NSES). Race/ethnicity and gender were found to significantly modify the association between NSES and CHD risk: the association is larger in men than women and in whites than minorities. Propensity score models showed that findings on the main effects of NSES were robust to self-selection into neighborhoods. Similar results were observed between NSES and risk of cardiovascular disease events.

CONCLUSIONS

NSES is significantly associated with CHD risk, and the relationship varies by gender and race/ethnicity.

Overtreatment and undertreatment of hyperlipidemia in the outpatient setting

BACKGROUND

National guidelines recommend lipid-lowering therapy for patients with coronary heart disease (CHD), its equivalent (eg, diabetes mellitus, peripheral arterial disease, cerebrovascular disease), and those at high risk of CHD. Quality-of-care studies demonstrate that patients at high risk of CHD are undertreated. Overtreatment of patients at low risk of CHD remains relatively unexplored. Our study aimed to determine patient characteristics associated with under- and overtreatment of hyperlipidemia.

METHODS

We conducted a retrospective chart review of patients aged 35 to 80 years attending an inner-city ambulatory teaching clinic. We noted patients' 10-year cardiovascular risk based on the Framingham Heart Study equation, other patient demographics, pretreatment lipid levels, and whether they received a prescription for lipid-lowering therapy.

RESULTS

Of 676 patients included, 46% were at high (>15% for 10 years) and 37% were at low (<5%) risk. Of the patients at high risk for CHD, 34% received no drug therapy, including 5% of patients with known CHD; 37% of patients with diabetes mellitus; and 59% of patients without CHD equivalents. Undertreatment was associated with lower low-density lipoprotein (LDL; odds ratio [OR] per 30 mg/dL 2.7, confidence interval [CI] 2.0-3.6), fewer risk factors (OR per risk factor 1.5 CI 1.1-2.1), and not receiving other preventive care interventions (OR 2.1, CI 1.0-4.5). Of 247 patients at low risk for CHD, 8% received drug therapy. Overtreatment was associated with higher LDL (OR per 30 mg/dL 3.0, CI 1.7-5.3) and more cardiac risk factors (OR per risk factor 3.1, CI 1.4-6.7). Age, race, sex, and specific risk factors were not associated with overtreatment or undertreatment.

CONCLUSIONS

Both overtreatment and under-treatment are common. Physicians' decisions appear to reflect LDL values and number of risk factors rather than calculated cardiovascular risk.

Heart attack risk perception biases among hypertension patients: the role of educational level and worry

Risk biases such as comparative optimism (thinking one is better off than similar others) and risk inaccuracy (misestimating one's risk compared to one's calculated risk) for health outcomes are common. Little research has investigated racial or socioeconomic differences in these risk biases. Results from a survey of individuals with poorly controlled hypertension (N=813) indicated that participants showed (1) comparative optimism for heart attack risk by underestimating their heart attack risk compared to similar others, and (2) risk inaccuracy by overestimating their heart attack risk compared to their calculated heart attack risk. More highly educated participants were more comparatively optimistic because they rated their personal risk as lower; education was not related to risk inaccuracy. Neither race nor the federal poverty level was related to risk biases. Worry partially mediated the relationship between education and personal risk. Results are discussed as they relate to the existing literature on risk perception.