Estimation of recurrent atherosclerotic cardiovascular event risk in patients with established cardiovascular disease: the updated SMART2 algorithm

Abstract

Aims The 10-year risk of recurrent atherosclerotic cardiovascular disease (ASCVD) events in patients with established ASCVD can be estimated with the Secondary Manifestations of ARTerial disease (SMART) risk score, and may help refine clinical management. To broaden generalizability across regions, we updated the existing tool (SMART2 risk score) and recalibrated it with regional incidence rates and assessed its performance in external populations. Methods and results Individuals with coronary artery disease, cerebrovascular disease, peripheral artery disease, or abdominal aortic aneurysms were included from the Utrecht Cardiovascular Cohort-SMART cohort [n = 8355; 1706 ASCVD events during a median follow-up of 8.2 years (interquartile range 4.2–12.5)] to derive a 10-year risk prediction model for recurrent ASCVD events (non-fatal myocardial infarction, non-fatal stroke, or cardiovascular mortality) using a Fine and Gray competing risk-adjusted model. The model was recalibrated to four regions across Europe, and to Asia (excluding Japan), Japan, Australia, North America, and Latin America using contemporary cohort data from each target region. External validation used data from seven cohorts [Clinical Practice Research Datalink, SWEDEHEART, the international REduction of Atherothrombosis for Continued Health (REACH) Registry, Estonian Biobank, Spanish Biomarkers in Acute Coronary Syndrome and Biomarkers in Acute Myocardial Infarction (BACS/BAMI), the Norwegian COgnitive Impairment After STroke, and Bialystok PLUS/Polaspire] and included 369 044 individuals with established ASCVD of whom 62 807 experienced an ASCVD event. C-statistics ranged from 0.605 [95% confidence interval (CI) 0.547–0.664] in BACS/BAMI to 0.772 (95% CI 0.659–0.886) in REACH Europe high-risk region. The clinical utility of the model was demonstrated across a range of clinically relevant treatment thresholds for intensified treatment options. Conclusion The SMART2 risk score provides an updated, validated tool for the prediction of recurrent ASCVD events in patients with established ASCVD across European and non-European populations. The use of this tool could allow for a more personalized approach to secondary prevention based upon quantitative rather than qualitative estimates of residual risk. Key objective To improve upon prediction of 10-year residual atherosclerotic cardiovascular disease (ASCVD) event risk in individuals with established ASCVD, by taking into account competing risks and geographical differences in ASCVD incidence. Key findings Derivation in 8355 individuals with established ASCVD from the Utrecht Cardiovascular Cohort-Secondary Manifestations of ARTerial disease (SMART) cohort. C-statistics ranged from 0.605 [95% confidence interval (CI) 0.547–0.664] to 0.772 (95% CI 0.659–0.886). Clinical utility was demonstrated across a range of treatment thresholds relevant to therapy intensification. Take-home messages The SMART2 risk score can be used to estimate 10-year residual risk of fatal and non-fatal ASCVD in individuals with established ASCVD. Adapted to the CVD incidence in several global regions. Facilitates shared decision-making on Step 2 prevention goals as recommended by the 2021 ESC Guidelines on cardiovascular prevention.

World Heart Federation Cholesterol Roadmap 2022

“…Although newer add on therapies are available, their cost and uncertainties in everyday practice as to who benefits most when healthcare resources are scarce have impacted their widespread use. In this regard, estimation of 10-year risk with the SMART risk equation is globally the most validated tool for assessing absolute risk and thus allows estimation of absolute benefit [46,49]. A schematic shows how among 13 patients with ASCVD, risk varies based on demographics and comorbidities, Absolute benefits of anti-coagulants depends upon the starting global risk.…”

Effect of dual residual risk of cholesterol and inflammation on all-cause mortality in patients with cardiovascular disease

“…Taking into account the effect of statin adherence and degree of lipid-lowering on the outcome, we calculated the percentage decrease in LDL-C using the LDL-C level before medication and LDL-C at baseline, stratified according to whether adherence was good and 75% of the percentage of LDL-C decline, respectively, and we repeated the main analysis. To explore the effect of residual risk on all-cause mortality according to different degrees of CVD recurrence risk, we stratified participants by whether they had a high Secondary Manifestations of ARTerial disease (SMART) 2 risk score [ 21 ] and whether blood pressure and blood glucose were at normal levels.…”

Cohort profile: the Utrecht Cardiovascular Cohort–Second Manifestations of Arterial Disease (UCC-SMART) Study–an ongoing prospective cohort study of patients at high cardiovascular risk in the Netherlands

“…The large database of observational data has been used for over 350 aetiological and prognostic studies so far, and the coverage of a wide age range and long follow-up provides opportunity to develop and validate prediction models. This has been done with the SMART risk score,42 43 the SMART-REACH lifetime model for patients with previous CVD3 and the DIAL lifetime model44 for patients with type 2 diabetes (to be found at https://u-prevent.com and the European Society of Cardiology ‘CVD risk calculation’ app). These estimates serve clinical practice by providing insight into risk and thus supporting patient education and shared decision-making.…”