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Cho SMJ, Rivera R, Koyama S, Kim MS, Ganesh S, Bhattacharya R, Paruchuri K, Masson P, Honigberg MC, Allen NB, Hornsby W, Natarajan P. Improving Cardiovascular Disease Primary Prevention Treatment Thresholds in a New England Health Care System. JACC. ADVANCES 2024; 3:101257. [PMID: 39290815 PMCID: PMC11406032 DOI: 10.1016/j.jacadv.2024.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 08/12/2024] [Accepted: 08/15/2024] [Indexed: 09/19/2024]
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD) risk estimation based on the pooled cohort equation (PCE) overestimates in population-based cohorts. Whether it performs equally across disaggregated demographics in health care populations is less known. Objectives The purpose of the study was to recalibrate PCE and rederive prevention thresholds in a contemporary health care system and evaluate its performance across sociodemographics. Methods We retrospectively inspected electronic health records between 2010 to 2012 and 2020 to 2022 within Mass General Brigham health care in New England region. We compared performance of the original vs recalibrated PCE measured by calibration, discrimination, reclassification rate, and net benefit among 160,926 patients aged 40 to 79 years and without prior ASCVD or lipid-lowering medication. Results Of the 160,926 patients (mean age: 54.6 ± 8.6 years; 61.4% female), 20,373 (12.7%) developed ASCVD over 10 years. The original PCE globally underestimated ASCVD risk (observed vs predicted incidence rate: 0.13 vs 0.05). Recalibration upclassified risk primarily among individuals with low-to-borderline risk by the original PCE and additionally identified 40% of patients who had undergone ASCVD events yet deemed statin-ineligible based on the original PCE. Treatment thresholds yielding the greatest net benefit were ≥24.0% for women (+23.3%) vs ≥26.0% for men (+18.7%), whereas ≥26.0% for White or other race (+24.7%) vs ≥14.0% Black or African American (+12.5%), respectively. Specifically, Hispanic or Latino and non-Hispanic Black patients conferred the greatest sensitivity improvement at ≥12.3% threshold compared to higher ≥23.6% among non-Hispanic Asian or Pacific Islanders. Generally, lower thresholds earlier in life were optimal. Conclusions Recalibration and personalized treatment thresholds derived within a health system may improve prevention treatment allocation efficiency.
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Affiliation(s)
- So Mi Jemma Cho
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Rachel Rivera
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Satoshi Koyama
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Min Seo Kim
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shriienidhie Ganesh
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Romit Bhattacharya
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kaavya Paruchuri
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patricia Masson
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Disease Prevention Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael C Honigberg
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Norrina B Allen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Whitney Hornsby
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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García-Perea A, Fernández-Cruz E, de la O-Pascual V, Gonzalez-Zorzano E, Moreno-Aliaga MJ, Tur JA, Martinez JA. Nutritional and Lifestyle Features in a Mediterranean Cohort: An Epidemiological Instrument for Categorizing Metabotypes Based on a Computational Algorithm. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:610. [PMID: 38674256 PMCID: PMC11051796 DOI: 10.3390/medicina60040610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Modern classification and categorization of individuals' health requires personalized variables such as nutrition, physical activity, lifestyle, and medical data through advanced analysis and clustering methods involving machine learning tools. The objective of this project was to categorize Mediterranean dwellers' health factors and design metabotypes to provide personalized well-being in order to develop professional implementation tools in addition to characterizing nutritional and lifestyle features in such populations. Materials and Methods: A two-phase observational study was conducted by the Pharmacists Council to identify Spanish nutritional and lifestyle characteristics. Adults over 18 years of age completed questionnaires on general lifestyle habits, dietary patterns (FFQ, MEDAS-17 p), physical activity (IPAQ), quality of life (SF-12), and validated well-being indices (LS7, MEDLIFE, HHS, MHL). Subsequently, exploratory factor, clustering, and random forest analysis methods were conducted to objectively define the metabotypes considering population determinants. Results: A total of 46.4% of the sample (n = 5496) had moderate-to-high adherence to the Mediterranean diet (>8 points), while 71% of the participants declared that they had moderate physical activity. Almost half of the volunteers had a good self-perception of health (49.9%). Regarding lifestyle index, population LS7 showed a fair cardiovascular health status (7.9 ± 1.7), as well as moderate quality of life by MEDLIFE (9.3 ± 2.6) and MHL scores (2.4 ± 0.8). In addition, five metabotype models were developed based on 26 variables: Westernized Millennial (28.6%), healthy (25.1%), active Mediterranean (16.5%), dysmetabolic/pre-morbid (11.5%), and metabolically vulnerable/pro-morbid (18.3%). Conclusions: The support of tools related to precision nutrition and lifestyle integrates well-being characteristics and contributes to reducing the impact of unhealthy lifestyle habits with practical implications for primary care. Combining lifestyle, metabolic, and quality of life traits will facilitate personalized precision interventions and the implementation of targeted public health policies.
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Affiliation(s)
| | - Edwin Fernández-Cruz
- IMDEA-Food Institute (Madrid Institute for Advances Studies), 28049 Madrid, Spain
- Faculty of Health Sciences, International University of La Rioja (UNIR), 26006 Logroño, Spain
| | - Victor de la O-Pascual
- IMDEA-Food Institute (Madrid Institute for Advances Studies), 28049 Madrid, Spain
- Faculty of Health Sciences, International University of La Rioja (UNIR), 26006 Logroño, Spain
| | | | - María J. Moreno-Aliaga
- CIBEROBN (Pathophysiology of Obesity and Nutrition), Carlos III Health Institute, 28029 Madrid, Spain
- Center for Nutrition Research and Department of Nutrition, Food Sciences and Physiology, University of Navarra, 31008 Pamplona, Spain
- IdISNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - Josep A. Tur
- CIBEROBN (Pathophysiology of Obesity and Nutrition), Carlos III Health Institute, 28029 Madrid, Spain
- Research Group on Community Nutrition and Oxidative Stress, University of the Balearic Islands-IUNICS, 07122 Palma de Mallorca, Spain
- IDISBA, Health Research Institute of the Balearic Islands, 07120 Palma de Mallorca, Spain
| | - J. Alfredo Martinez
- IMDEA-Food Institute (Madrid Institute for Advances Studies), 28049 Madrid, Spain
- CIBEROBN (Pathophysiology of Obesity and Nutrition), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Medicine, Dermatology, and Toxicology, University of Valladolid, 47005 Valladolid, Spain
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Wu R, Williams C, Zhou J, Schlackow I, Emberson J, Reith C, Keech A, Robson J, Armitage J, Gray A, Simes J, Baigent C, Mihaylova B. Long-term cardiovascular risks and the impact of statin treatment on socioeconomic inequalities: a microsimulation model. Br J Gen Pract 2024; 74:e189-e198. [PMID: 38373851 PMCID: PMC10904120 DOI: 10.3399/bjgp.2023.0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/19/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND UK cardiovascular disease (CVD) incidence and mortality have declined in recent decades but socioeconomic inequalities persist. AIM To present a new CVD model, and project health outcomes and the impact of guideline-recommended statin treatment across quintiles of socioeconomic deprivation in the UK. DESIGN AND SETTING A lifetime microsimulation model was developed using 117 896 participants in 16 statin trials, 501 854 UK Biobank (UKB) participants, and quality-of-life data from national health surveys. METHOD A CVD microsimulation model was developed using risk equations for myocardial infarction, stroke, coronary revascularisation, cancer, and vascular and non-vascular death, estimated using trial data. The authors calibrated and further developed this model in the UKB cohort, including further characteristics and a diabetes risk equation, and validated the model in UKB and Whitehall II cohorts. The model was used to predict CVD incidence, life expectancy, quality-adjusted life years (QALYs), and the impact of UK guideline-recommended statin treatment across socioeconomic deprivation quintiles. RESULTS Age, sex, socioeconomic deprivation, smoking, hypertension, diabetes, and cardiovascular events were key CVD risk determinants. Model-predicted event rates corresponded well to observed rates across participant categories. The model projected strong gradients in remaining life expectancy, with 4-5-year (5-8 QALYs) gaps between the least and most socioeconomically deprived quintiles. Guideline-recommended statin treatment was projected to increase QALYs, with larger gains in quintiles of higher deprivation. CONCLUSION The study demonstrated the potential of guideline-recommended statin treatment to reduce socioeconomic inequalities. This CVD model is a novel resource for individualised long-term projections of health outcomes of CVD treatments.
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Affiliation(s)
- Runguo Wu
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Claire Williams
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Junwen Zhou
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Nuffield Department of Population Health and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Christina Reith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anthony Keech
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - John Robson
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jane Armitage
- Nuffield Department of Population Health and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Colin Baigent
- Nuffield Department of Population Health and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London; associate professor and senior health economist, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Yu J, Yang X, Deng Y, Krefman AE, Pool LR, Zhao L, Mi X, Ning H, Wilkins J, Lloyd-Jones DM, Petito LC, Allen NB. Incorporating longitudinal history of risk factors into atherosclerotic cardiovascular disease risk prediction using deep learning. Sci Rep 2024; 14:2554. [PMID: 38296982 PMCID: PMC10830564 DOI: 10.1038/s41598-024-51685-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
It is increasingly clear that longitudinal risk factor levels and trajectories are related to risk for atherosclerotic cardiovascular disease (ASCVD) above and beyond single measures. Currently used in clinical care, the Pooled Cohort Equations (PCE) are based on regression methods that predict ASCVD risk based on cross-sectional risk factor levels. Deep learning (DL) models have been developed to incorporate longitudinal data for risk prediction but its benefit for ASCVD risk prediction relative to the traditional Pooled Cohort Equations (PCE) remain unknown. Our study included 15,565 participants from four cardiovascular disease cohorts free of baseline ASCVD who were followed for adjudicated ASCVD. Ten-year ASCVD risk was calculated in the training set using our benchmark, the PCE, and a longitudinal DL model, Dynamic-DeepHit. Predictors included those incorporated in the PCE: sex, race, age, total cholesterol, high density lipid cholesterol, systolic and diastolic blood pressure, diabetes, hypertension treatment and smoking. The discrimination and calibration performance of the two models were evaluated in an overall hold-out testing dataset. Of the 15,565 participants in our dataset, 2170 (13.9%) developed ASCVD. The performance of the longitudinal DL model that incorporated 8 years of longitudinal risk factor data improved upon that of the PCE [AUROC: 0.815 (CI 0.782-0.844) vs 0.792 (CI 0.760-0.825)] and the net reclassification index was 0.385. The brier score for the DL model was 0.0514 compared with 0.0542 in the PCE. Incorporating longitudinal risk factors in ASCVD risk prediction using DL can improve model discrimination and calibration.
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Affiliation(s)
- Jingzhi Yu
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Xiaoyun Yang
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Yu Deng
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amy E Krefman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lindsay R Pool
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lihui Zhao
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Xinlei Mi
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hongyan Ning
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John Wilkins
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lucia C Petito
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Norrina B Allen
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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5
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Yu J, Yang X, Deng Y, Krefman AE, Pool LR, Zhao L, Mi X, Ning H, Wilkins J, Lloyd-Jones DM, Petito LC, Allen NB. Incorporating longitudinal history of risk factors into atherosclerotic cardiovascular disease risk prediction using deep learning. RESEARCH SQUARE 2023:rs.3.rs-3405388. [PMID: 37886463 PMCID: PMC10602136 DOI: 10.21203/rs.3.rs-3405388/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background It is increasingly clear that longitudinal risk factor levels and trajectories are related to risk for atherosclerotic cardiovascular disease (ASCVD) above and beyond single measures. Currently used in clinical care, the Pooled Cohort Equations (PCE) are based on regression methods that predict ASCVD risk based on cross-sectional risk factor levels. Deep learning (DL) models have been developed to incorporate longitudinal data for risk prediction but its benefit for ASCVD risk prediction relative to the traditional Pooled Cohort Equations (PCE) remain unknown. Objective To develop a ASCVD risk prediction model that incorporates longitudinal risk factors using deep learning. Methods Our study included 15,565 participants from four cardiovascular disease cohorts free of baseline ASCVD who were followed for adjudicated ASCVD. Ten-year ASCVD risk was calculated in the training set using our benchmark, the PCE, and a longitudinal DL model, Dynamic-DeepHit. Predictors included those incorporated in the PCE: sex, race, age, total cholesterol, high density lipid cholesterol, systolic and diastolic blood pressure, diabetes, hypertension treatment and smoking. The discrimination and calibration performance of the two models were evaluated in an overall hold-out testing dataset. Results Of the 15,565 participants in our dataset, 2,170 (13.9%) developed ASCVD. The performance of the longitudinal DL model that incorporated 8 years of longitudinal risk factor data improved upon that of the PCE [AUROC: 0.815 (CI: 0.782-0.844) vs 0.792 (CI: 0.760-0.825)] and the net reclassification index was 0.385. The brier score for the DL model was 0.0514 compared with 0.0542 in the PCE. Conclusion Incorporating longitudinal risk factors in ASCVD risk prediction using DL can improve model discrimination and calibration.
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Xu Y, Foryciarz A, Steinberg E, Shah NH. Clinical utility gains from incorporating comorbidity and geographic location information into risk estimation equations for atherosclerotic cardiovascular disease. J Am Med Inform Assoc 2023; 30:878-887. [PMID: 36795076 PMCID: PMC10114071 DOI: 10.1093/jamia/ocad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/17/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE There are over 363 customized risk models of the American College of Cardiology and the American Heart Association (ACC/AHA) pooled cohort equations (PCE) in the literature, but their gains in clinical utility are rarely evaluated. We build new risk models for patients with specific comorbidities and geographic locations and evaluate whether performance improvements translate to gains in clinical utility. MATERIALS AND METHODS We retrain a baseline PCE using the ACC/AHA PCE variables and revise it to incorporate subject-level information of geographic location and 2 comorbidity conditions. We apply fixed effects, random effects, and extreme gradient boosting (XGB) models to handle the correlation and heterogeneity induced by locations. Models are trained using 2 464 522 claims records from Optum©'s Clinformatics® Data Mart and validated in the hold-out set (N = 1 056 224). We evaluate models' performance overall and across subgroups defined by the presence or absence of chronic kidney disease (CKD) or rheumatoid arthritis (RA) and geographic locations. We evaluate models' expected utility using net benefit and models' statistical properties using several discrimination and calibration metrics. RESULTS The revised fixed effects and XGB models yielded improved discrimination, compared to baseline PCE, overall and in all comorbidity subgroups. XGB improved calibration for the subgroups with CKD or RA. However, the gains in net benefit are negligible, especially under low exchange rates. CONCLUSIONS Common approaches to revising risk calculators incorporating extra information or applying flexible models may enhance statistical performance; however, such improvement does not necessarily translate to higher clinical utility. Thus, we recommend future works to quantify the consequences of using risk calculators to guide clinical decisions.
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Affiliation(s)
- Yizhe Xu
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Agata Foryciarz
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Ethan Steinberg
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Nigam H Shah
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA
- Clinical Excellence Research Center, Department of Medicine, Stanford University, Stanford, California, USA
- Technology and Digital Solutions, Stanford Healthcare, Stanford, California, USA
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Rylance RT, Wagner P, Olesen KKW, Carlson J, Alfredsson J, Jernberg T, Leosdottir M, Johansson P, Vasko P, Maeng M, Mohammed MA, Erlinge D. Patient-oriented risk score for predicting death 1 year after myocardial infarction: the SweDen risk score. Open Heart 2022; 9:openhrt-2022-002143. [PMID: 36460308 PMCID: PMC9723953 DOI: 10.1136/openhrt-2022-002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Our aim was to derive, based on the SWEDEHEART registry, and validate, using the Western Denmark Heart registry, a patient-oriented risk score, the SweDen score, which could calculate the risk of 1-year mortality following a myocardial infarction (MI). METHODS The factors included in the SweDen score were age, sex, smoking, diabetes, heart failure and statin use. These were chosen a priori by the SWEDEHEART steering group based on the premise that the factors were information known by the patients themselves. The score was evaluated using various statistical methods such as time-dependent receiver operating characteristics curves of the linear predictor, area under the curve metrics, Kaplan-Meier survivor curves and the calibration slope. RESULTS The area under the curve values were 0.81 in the derivation data and 0.76 in the validation data. The Kaplan-Meier curves showed similar patient profiles across datasets. The calibration slope was 1.03 (95% CI 0.99 to 1.08) in the validation data using the linear predictor from the derivation data. CONCLUSIONS The SweDen risk score is a novel tool created for patient use. The risk score calculator will be available online and presents mortality risk on a colour scale to simplify interpretation and to avoid exact life span expectancies. It provides a validated patient-oriented risk score predicting the risk of death within 1 year after suffering an MI, which visualises the benefit of statin use and smoking cessation in a simple way.
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Affiliation(s)
- Rebecca Tremain Rylance
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Philippe Wagner
- Center for Clinical Research, Uppsala University, Uppsala, Sweden
| | - Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Karolinska University Hospital, Linkoping, Sweden
| | - Tomas Jernberg
- The Swedish Heart and Lung Association, Stockholm, Sweden
| | - Margret Leosdottir
- Department of Clinical Sciences, Skåne University Hospital Lund, Malmö, Sweden,Department of Clinical Sciences, Lund University, Malmo, Sweden
| | | | - Peter Vasko
- Department of Cardiology, Karolinska University Hospital, Linkoping, Sweden
| | - Michael Maeng
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Moman Aladdin Mohammed
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
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Sun XY, Ma RL, He J, Ding YS, Rui DS, Li Y, Yan YZ, Mao YD, Liao SY, He X, Guo SX, Guo H. Updating Framingham CVD risk score using waist circumference and estimated cardiopulmonary function: a cohort study based on a southern Xinjiang population. BMC Public Health 2022; 22:1715. [PMID: 36085029 PMCID: PMC9463829 DOI: 10.1186/s12889-022-14110-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose To explore the association between waist circumference (WC), estimated cardiopulmonary function (eCRF), and cardiovascular disease (CVD) risk in southern Xinjiang. Update the Framingham model to make it more suitable for the southern Xinjiang population. Methods Data were collected from 7705 subjects aged 30–74 years old in Tumushuke City, the 51st Regiment of Xinjiang Production and Construction Corps. CVD was defined as an individual's first diagnosis of non-fatal acute myocardial infarction, death from coronary heart disease, and fatal or non-fatal stroke. The Cox proportional hazards regression analysis was used to analyze the association between WC, eCRF and CVD risk. Restricted cubic spline plots were drawn to describe the association of the two indicators with CVD risk. We update the model by incorporating the new variables into the Framingham model and re-estimating the coefficients. The discrimination of the model is evaluated using AUC, NRI, and IDI metrics. Model calibration is evaluated using pseudo R2 values. Results WC was an independent risk factor for CVD (multivariate HR: 1.603 (1.323, 1.942)), eCRF was an independent protective factor for CVD (multivariate HR: 0.499 (0.369, 0.674)). There was a nonlinear relationship between WC and CVD risk (nonlinear χ2 = 12.43, P = 0.002). There was a linear association between eCRF and CVD risk (non-linear χ2 = 0.27, P = 0.6027). In the male, the best risk prediction effect was obtained when WC and eCRF were added to the model (AUC = 0.763((0.734,0.792)); pseudo R2 = 0.069). In the female, the best risk prediction effect was obtained by adding eCRF to the model (AUC = 0.757 (0.734,0.779); pseudo R2 = 0.107). Conclusion In southern Xinjiang, WC is an independent risk factor for CVD. eCRF is an independent protective factor for CVD. We recommended adding WC and eCRF in the male model and only eCRF in the female model for better risk prediction. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14110-y.
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Wallisch C, Agibetov A, Dunkler D, Haller M, Samwald M, Dorffner G, Heinze G. The roles of predictors in cardiovascular risk models - a question of modeling culture? BMC Med Res Methodol 2021; 21:284. [PMID: 34922459 PMCID: PMC8684157 DOI: 10.1186/s12874-021-01487-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND While machine learning (ML) algorithms may predict cardiovascular outcomes more accurately than statistical models, their result is usually not representable by a transparent formula. Hence, it is often unclear how specific values of predictors lead to the predictions. We aimed to demonstrate with graphical tools how predictor-risk relations in cardiovascular risk prediction models fitted by ML algorithms and by statistical approaches may differ, and how sample size affects the stability of the estimated relations. METHODS We reanalyzed data from a large registry of 1.5 million participants in a national health screening program. Three data analysts developed analytical strategies to predict cardiovascular events within 1 year from health screening. This was done for the full data set and with gradually reduced sample sizes, and each data analyst followed their favorite modeling approach. Predictor-risk relations were visualized by partial dependence and individual conditional expectation plots. RESULTS When comparing the modeling algorithms, we found some similarities between these visualizations but also occasional divergence. The smaller the sample size, the more the predictor-risk relation depended on the modeling algorithm used, and also sampling variability played an increased role. Predictive performance was similar if the models were derived on the full data set, whereas smaller sample sizes favored simpler models. CONCLUSION Predictor-risk relations from ML models may differ from those obtained by statistical models, even with large sample sizes. Hence, predictors may assume different roles in risk prediction models. As long as sample size is sufficient, predictive accuracy is not largely affected by the choice of algorithm.
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Affiliation(s)
- Christine Wallisch
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Asan Agibetov
- Section for Artificial Intelligence and Decision Support, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Maria Haller
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
- Department of Nephrology, Ordensklinikum Linz, Hospital Elisabethinen, Linz, Austria
| | - Matthias Samwald
- Section for Artificial Intelligence and Decision Support, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Georg Dorffner
- Section for Artificial Intelligence and Decision Support, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Georg Heinze
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
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Wang Q, Li W, Wang Y, Li H, Zhai D, Wu W. Prediction of coronary heart disease in rural Chinese adults: a cross sectional study. PeerJ 2021; 9:e12259. [PMID: 34721974 PMCID: PMC8515995 DOI: 10.7717/peerj.12259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022] Open
Abstract
Background Coronary heart disease (CHD) is a common cardiovascular disease with high morbidity and mortality in China. The CHD risk prediction model has a great value in early prevention and diagnosis. Methods In this study, CHD risk prediction models among rural residents in Xinxiang County were constructed using Random Forest (RF), Support Vector Machine (SVM), and the least absolute shrinkage and selection operator (LASSO) regression algorithms with identified 16 influencing factors. Results Results demonstrated that the CHD model using the RF classifier performed best both on the training set and test set, with the highest area under the curve (AUC = 1 and 0.9711), accuracy (one and 0.9389), sensitivity (one and 0.8725), specificity (one and 0.9771), precision (one and 0.9563), F1-score (one and 0.9125), and Matthews correlation coefficient (MCC = one and 0.8678), followed by the SVM (AUC = 0.9860 and 0.9589) and the LASSO classifier (AUC = 0.9733 and 0.9587). Besides, the RF model also had an increase in the net reclassification index (NRI) and integrated discrimination improvement (IDI) values, and achieved a greater net benefit in the decision curve analysis (DCA) compared with the SVM and LASSO models. Conclusion The CHD risk prediction model constructed by the RF algorithm in this study is conducive to the early diagnosis of CHD in rural residents of Xinxiang County, Henan Province.
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Affiliation(s)
- Qian Wang
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Wenxing Li
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Yongbin Wang
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Huijun Li
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Desheng Zhai
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
| | - Weidong Wu
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, China
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Wallisch C, Dunkler D, Rauch G, de Bin R, Heinze G. Selection of variables for multivariable models: Opportunities and limitations in quantifying model stability by resampling. Stat Med 2020; 40:369-381. [PMID: 33089538 PMCID: PMC7820988 DOI: 10.1002/sim.8779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/02/2020] [Accepted: 09/29/2020] [Indexed: 12/14/2022]
Abstract
Statistical models are often fitted to obtain a concise description of the association of an outcome variable with some covariates. Even if background knowledge is available to guide preselection of covariates, stepwise variable selection is commonly applied to remove irrelevant ones. This practice may introduce additional variability and selection is rarely certain. However, these issues are often ignored and model stability is not questioned. Several resampling-based measures were proposed to describe model stability, including variable inclusion frequencies (VIFs), model selection frequencies, relative conditional bias (RCB), and root mean squared difference ratio (RMSDR). The latter two were recently proposed to assess bias and variance inflation induced by variable selection. Here, we study the consistency and accuracy of resampling estimates of these measures and the optimal choice of the resampling technique. In particular, we compare subsampling and bootstrapping for assessing stability of linear, logistic, and Cox models obtained by backward elimination in a simulation study. Moreover, we exemplify the estimation and interpretation of all suggested measures in a study on cardiovascular risk. The VIF and the model selection frequency are only consistently estimated in the subsampling approach. By contrast, the bootstrap is advantageous in terms of bias and precision for estimating the RCB as well as the RMSDR. Though, unbiased estimation of the latter quantity requires independence of covariates, which is rarely encountered in practice. Our study stresses the importance of addressing model stability after variable selection and shows how to cope with it.
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Affiliation(s)
- Christine Wallisch
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | | | - Georg Heinze
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
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