Evaluation of the Pooled Cohort Equations for Prediction of Cardiovascular Risk in a Contemporary Prospective Cohort

Published:December 17, 2016DOI:
      Most guidelines suggest a baseline risk assessment to guide atherosclerotic cardiovascular disease (ASCVD) prevention strategies. The American Heart Association/American College of Cardiology Pooled Cohort Equations (PCEs) is one tool to assess baseline risk; however, the accuracy of this tool has been called into question. We aimed to examine the calibration and discrimination of the PCEs in the BioImage study, a contemporary multiethnic cohort of asymptomatic adults enrolled from 2008 to 2009 in the Humana Health System in Chicago, Illinois, and Fort Lauderdale, Florida. Our primary end point was hard ASCVD, defined as cardiovascular death, myocardial infarction, and stroke. A total of 3,635 adults who were not on lipid-lowering therapy at baseline were followed for a maximum of 4.6 years. The mean age was 68.6 years; 2000 (55%) participants were women and 935 patients reported being of non-white race (26%). Although 74 ASCVD events were observed over a median follow-up of 2.7 years, 198 events were predicted by the PCEs. The observed event rate was 7.9 per 1,000 participant-years (95% confidence interval [CI] 6.1 to 9.8), whereas the predicted rate by the PCEs was 21 per 1,000 participant-years (95% CI 20.7 to 21.8). This represents an overestimation of 167% (Hosmer–Lemeshow chi-square = 173; p <0.001). With regard to discrimination, the C-statistic of the PCEs was 0.65 (CI 0.58 to 0.71). In an analysis restricted to 3,080 participants without diabetes mellitus and with low-density lipoprotein cholesterol between 70 and 189 mg/dl, the PCEs similarly overestimated risk by 181% (152 predicted events vs 54 observed events; p <0.001). The PCEs substantially overestimate ASCVD risk in this middle-aged adult insured population. Refinement of existing risk prediction functions may be warranted.
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        • Goff D.C.
        • Lloyd-Jones D.M.
        • Bennett G.
        • Coady S.
        • D'Agostino R.B.
        • Gibbons R.
        • Greenland P.
        • Lackland D.T.
        • Levy D.
        • O'Donnell C.J.
        • Robinson J.G.
        • Schwartz J.S.
        • Shero S.T.
        • Smith S.C.
        • Sorlie P.
        • Stone N.J.
        • Wilson P.W.F.
        • American College of Cardiology/American Heart association Task Force on Practice Guidelines
        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
        • DeFilippis A.P.
        • Young R.
        • Carrubba C.J.
        • McEvoy J.W.
        • Budoff M.J.
        • Blumenthal R.S.
        • Kronmal R.A.
        • McClelland R.L.
        • Nasir K.
        • Blaha M.J.
        An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort.
        Ann Intern Med. 2015; 162: 266-275
        • Cook N.R.
        • Ridker P.M.
        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
        • Muntner P.
        • Colantonio L.D.
        • Cushman M.
        • Goff D.C.
        • Howard G.
        • Howard V.J.
        • Kissela B.
        • Levitan E.B.
        • Lloyd-Jones D.M.
        • Safford M.M.
        Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations.
        JAMA. 2014; 311: 1406-1415
        • Baber U.
        • Mehran R.
        • Sartori S.
        • Schoos M.M.
        • Sillesen H.
        • Muntendam P.
        • Garcia M.J.
        • Gregson J.
        • Pocock S.
        • Falk E.
        • Fuster V.
        Prevalence, impact, and predictive value of detecting subclinical coronary and carotid atherosclerosis in asymptomatic adults: the BioImage study.
        J Am Coll Cardiol. 2015; 65: 1065-1074
        • Agatston A.S.
        • Janowitz W.R.
        • Hildner F.J.
        • Zusmer N.R.
        • Viamonte M.
        • Detrano R.
        Quantification of coronary artery calcium using ultrafast computed tomography.
        J Am Coll Cardiol. 1990; 15: 827-832
        • Lemeshow S.
        • Hosmer D.W.
        A review of goodness of fit statistics for use in the development of logistic regression models.
        Am J Epidemiol. 1982; 115: 92-106
        • Stone N.J.
        • Robinson J.G.
        • Lichtenstein A.H.
        • Bairey Merz C.N.
        • Blum C.B.
        • Eckel R.H.
        • Goldberg A.C.
        • Gordon D.
        • Levy D.
        • Lloyd-Jones D.M.
        • McBride P.
        • Schwartz J.S.
        • Shero S.T.
        • Smith S.C.
        • Watson K.
        • Wilson P.W.F.
        • Eddleman K.M.
        • Jarrett N.M.
        • LaBresh K.
        • Nevo L.
        • Wnek J.
        • Anderson J.L.
        • Halperin J.L.
        • Albert N.M.
        • Bozkurt B.
        • Brindis R.G.
        • Curtis L.H.
        • DeMets D.
        • Hochman J.S.
        • Kovacs R.J.
        • Ohman E.M.
        • Pressler S.J.
        • Sellke F.W.
        • Shen W.-K.
        • Tomaselli G.F.
        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.
        Circulation. 2014; 129: S1-S45
        • Ridker P.M.
        • Cook N.R.
        Statins: new American guidelines for prevention of cardiovascular disease.
        Lancet. 2013; 382: 1762-1765
        • Kavousi M.
        • Leening M.J.G.
        • Nanchen D.
        • Greenland P.
        • Graham I.M.
        • Steyerberg E.W.
        • Ikram M.A.
        • Stricker B.H.
        • Hofman A.
        • Franco O.H.
        Comparison of Application of the ACC/AHA Guidelines, Adult Treatment Panel III Guidelines, and European Society of Cardiology Guidelines for Cardiovascular Disease Prevention in a European cohort.
        JAMA. 2014; 311: 1416-1423
        • Rana J.S.
        • Tabada G.H.
        • Solomon M.D.
        • Lo J.C.
        • Jaffe M.G.
        • Sung S.H.
        • Ballantyne C.M.
        • Go A.S.
        Accuracy of the atherosclerotic cardiovascular risk equation in a large contemporary, multiethnic population.
        J Am Coll Cardiol. 2016; 67: 2118-2130
        • DeFilippis A.P.
        • Young R.
        • McEvoy J.W.
        • Michos E.D.
        • Sandfort V.
        • Kronmal R.A.
        • McClelland R.L.
        • Blaha M.J.
        Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort.
        Eur Heart J. 2016; (ehw301)
        • Blaha M.J.
        The critical importance of risk score calibration: time for transformative approach to risk score validation?.
        J Am Coll Cardiol. 2016; 67: 2131-2134
        • Baigent C.
        • Blackwell L.
        • Collins R.
        • Emberson J.
        • Godwin J.
        • Peto R.
        • Buring J.
        • Hennekens C.
        • Kearney P.
        • Meade T.
        • Patrono C.
        • Roncaglioni M.C.
        • Zanchetti A.
        • Antithrombotic Trialists' (ATT) Collaboration
        Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials.
        Lancet. 2009; 373: 1849-1860