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Gulati G, Upshaw J, Wessler BS, Brazil RJ, Nelson J, van Klaveren D, Lundquist CM, Park JG, McGinnes H, Steyerberg EW, Van Calster B, Kent DM. Generalizability of Cardiovascular Disease Clinical Prediction Models: 158 Independent External Validations of 104 Unique Models. Circ Cardiovasc Qual Outcomes 2022; 15:e008487. [PMID: 35354282 PMCID: PMC9015037 DOI: 10.1161/circoutcomes.121.008487] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: While clinical prediction models (CPMs) are used increasingly commonly to guide patient care, the performance and clinical utility of these CPMs in new patient cohorts is poorly understood. Methods: We performed 158 external validations of 104 unique CPMs across 3 domains of cardiovascular disease (primary prevention, acute coronary syndrome, and heart failure). Validations were performed in publicly available clinical trial cohorts and model performance was assessed using measures of discrimination, calibration, and net benefit. To explore potential reasons for poor model performance, CPM-clinical trial cohort pairs were stratified based on relatedness, a domain-specific set of characteristics to qualitatively grade the similarity of derivation and validation patient populations. We also examined the model-based C-statistic to assess whether changes in discrimination were because of differences in case-mix between the derivation and validation samples. The impact of model updating on model performance was also assessed. Results: Discrimination decreased significantly between model derivation (0.76 [interquartile range 0.73–0.78]) and validation (0.64 [interquartile range 0.60–0.67], P<0.001), but approximately half of this decrease was because of narrower case-mix in the validation samples. CPMs had better discrimination when tested in related compared with distantly related trial cohorts. Calibration slope was also significantly higher in related trial cohorts (0.77 [interquartile range, 0.59–0.90]) than distantly related cohorts (0.59 [interquartile range 0.43–0.73], P=0.001). When considering the full range of possible decision thresholds between half and twice the outcome incidence, 91% of models had a risk of harm (net benefit below default strategy) at some threshold; this risk could be reduced substantially via updating model intercept, calibration slope, or complete re-estimation. Conclusions: There are significant decreases in model performance when applying cardiovascular disease CPMs to new patient populations, resulting in substantial risk of harm. Model updating can mitigate these risks. Care should be taken when using CPMs to guide clinical decision-making.
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Affiliation(s)
- Gaurav Gulati
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Division of Cardiology, Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W.)
| | - Jenica Upshaw
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Division of Cardiology, Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W.)
| | - Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Division of Cardiology, Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W.)
| | - Riley J Brazil
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - David van Klaveren
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Department of Biomedical Data Sciences, Leiden University Medical Centre, Netherlands (D.v.K., E.W.S., B.V.C.)
| | - Christine M Lundquist
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Jinny G Park
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Hannah McGinnes
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Netherlands (D.v.K., E.W.S., B.V.C.)
| | - Ben Van Calster
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Netherlands (D.v.K., E.W.S., B.V.C.).,KU Leuven, Department of Development and Regeneration, Belgium (B.V.C.).,EPI-Center, KU Leuven, Belgium (B.V.C.)
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
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Tea V, Bonaca M, Chamandi C, Iliou MC, Lhermusier T, Aissaoui N, Cayla G, Angoulvant D, Ferrières J, Schiele F, Simon T, Danchin N, Puymirat E. Appropriate secondary prevention and clinical outcomes after acute myocardial infarction according to atherothrombotic risk stratification: The FAST-MI 2010 registry. Eur J Prev Cardiol 2018; 26:411-419. [PMID: 30354737 DOI: 10.1177/2047487318808638] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Full secondary prevention medication regimen is often under-prescribed after acute myocardial infarction. DESIGN The purpose of this study was to analyse the relationship between prescription of appropriate secondary prevention treatment at discharge and long-term clinical outcomes according to risk level defined by the Thrombolysis In Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS-2P) after acute myocardial infarction. METHODS We used data from the 2010 French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI) registry, including 4169 consecutive acute myocardial infarction patients admitted to cardiac intensive care units in France. Level of risk was stratified in three groups using the TRS-2P score: group 1 (low-risk; TRS-2P=0/1); group 2 (intermediate-risk; TRS-2P=2); and group 3 (high-risk; TRS-2P≥3). Appropriate secondary prevention treatment was defined according to the latest guidelines (dual antiplatelet therapy and moderate/high dose statins for all; new-P2Y12 inhibitors, angiotensin-converting-enzyme inhibitor/angiotensin-receptor-blockers and beta-blockers as indicated). RESULTS Prevalence of groups 1, 2 and 3 was 46%, 25% and 29% respectively. Appropriate secondary prevention treatment at discharge was used in 39.5%, 37% and 28% of each group, respectively. After multivariate adjustment, evidence-based treatments at discharge were associated with lower rates of major adverse cardiovascular events (death, re-myocardial infarction or stroke) at five years especially in high-risk patients: hazard ratio = 0.82 (95% confidence interval: 0.59-1.12, p = 0.21) in group 1, 0.74 (0.54-1.01; p = 0.06) in group 2, and 0.64 (0.52-0.79, p < 0.001) in group 3. CONCLUSIONS Use of appropriate secondary prevention treatment at discharge was inversely correlated with patient risk. The increased hazard related to lack of prescription of recommended medications was much larger in high-risk patients. Specific efforts should be directed at better prescription of recommended treatment, particularly in high-risk patients.
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Affiliation(s)
- Victoria Tea
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
| | - Marc Bonaca
- 2 Division of Cardiovascular Medicine, Brigham and Women's Hospital, USA
| | - Chekrallah Chamandi
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
| | | | | | | | - Guillaume Cayla
- 6 Department of Cardiology, University Hospital of Nimes, France
| | - Denis Angoulvant
- 7 Department of Cardiology, CHU Tours & Tours University, France
| | | | - François Schiele
- 8 Department of Cardiology, University Hospital Jean Minjoz, France
| | - Tabassome Simon
- 9 Department of Clinical Pharmacology, Hôpital Saint Antoine, France.,10 Université Pierre et Marie Curie, France
| | - Nicolas Danchin
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
| | - Etienne Puymirat
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
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Bloch Thomsen PE, Jons C, Raatikainen MP, Moerch Joergensen R, Hartikainen J, Virtanen V, Boland J, Anttonen O, Gang UJ, Hoest N, Boersma LV, Platou ES, Becker D, Messier MD, Huikuri HV. Long-Term Recording of Cardiac Arrhythmias With an Implantable Cardiac Monitor in Patients With Reduced Ejection Fraction After Acute Myocardial Infarction. Circulation 2010; 122:1258-64. [DOI: 10.1161/circulationaha.109.902148] [Citation(s) in RCA: 193] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Poul Erik Bloch Thomsen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Christian Jons
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - M.J. Pekka Raatikainen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Rikke Moerch Joergensen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Juha Hartikainen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Vesa Virtanen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - J. Boland
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Olli Anttonen
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Uffe Jakob Gang
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Nis Hoest
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Lucas V.A. Boersma
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Eivin S. Platou
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Daniel Becker
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Marc D. Messier
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
| | - Heikki V. Huikuri
- From the Gentofte University Hospital, Copenhagen, Denmark (P.E.B.T., C.J., R.M.J., U.J.G.); Department of Internal Medicine, University of Oulu, Oulu, Finland (H.V.H., M.J.P.R.); Department of Internal Medicine, University of Kuopio, Kuopio, Finland (J.H.); Department of Cardiology, University of Tampere, Tampere, Finland (V.V.); Department of Internal Medicine, Hopital Citadelle, Liege, Belgium (J.B.); Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (O.A.); Glostrup
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