Implications of the US Cholesterol Guidelines on Eligibility for Statin Therapy in the Community: Comparison of Observed and Predicted Risks in the Framingham Heart Study Offspring Cohort

Andersson, Charlotte; Enserro, Danielle; Larson, Martin G.; Xanthakis, Vanessa; Vasan, Ramachandran S.

doi:10.1161/jaha.115.001888

Cited by 44 publications

(14 citation statements)

References 21 publications

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“…Some of these differences might be explained by our population being more similar to the cohorts used in constructing the FRS and PCE than MESA. Our finding that the recently proposed PCE had worse calibration than the FRS is consistent with some recent literature that has shown mixed results in validating the PCE in diverse populations . The PCE may suffer somewhat from being overfitted to the longitudinal cohort study data from which it was derived, which negatively affects its calibration in new settings.…”

Section: Discussionsupporting

confidence: 82%

Use and Customization of Risk Scores for Predicting Cardiovascular Events Using Electronic Health Record Data

Wolfson

Vock

Bandyopadhyay³

et al. 2017

JAHA

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BackgroundClinicians who are using the Framingham Risk Score (FRS) or the American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) to estimate risk for their patients based on electronic health data (EHD) face 4 questions. (1) Do published risk scores applied to EHD yield accurate estimates of cardiovascular risk? (2) Are FRS risk estimates, which are based on data that are up to 45 years old, valid for a contemporary patient population seeking routine care? (3) Do the PCE make the FRS obsolete? (4) Does refitting the risk score using EHD improve the accuracy of risk estimates?Methods and ResultsData were extracted from the EHD of 84 116 adults aged 40 to 79 years who received care at a large healthcare delivery and insurance organization between 2001 and 2011. We assessed calibration and discrimination for 4 risk scores: published versions of FRS and PCE and versions obtained by refitting models using a subset of the available EHD. The published FRS was well calibrated (calibration statistic K=9.1, miscalibration ranging from 0% to 17% across risk groups), but the PCE displayed modest evidence of miscalibration (calibration statistic K=43.7, miscalibration from 9% to 31%). Discrimination was similar in both models (C‐index=0.740 for FRS, 0.747 for PCE). Refitting the published models using EHD did not substantially improve calibration or discrimination.ConclusionsWe conclude that published cardiovascular risk models can be successfully applied to EHD to estimate cardiovascular risk; the FRS remains valid and is not obsolete; and model refitting does not meaningfully improve the accuracy of risk estimates.

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Section: Discussionsupporting

confidence: 82%

Use and Customization of Risk Scores for Predicting Cardiovascular Events Using Electronic Health Record Data

Wolfson

Vock

Bandyopadhyay³

et al. 2017

JAHA

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“…Predicted ASCVD risk using the equation was reported to be systematically higher than observed risk in some highly selected cohorts (3,4), but not in others (5). Importantly, however, these studies included persons screened for participation or enrolled in clinical trials, or in much earlier time periods, with limited generalizability to contemporary and diverse populations that are more representative of eligible patients treated in typical clinical practice (6,7).…”

Section: Introductionmentioning

confidence: 78%

Accuracy of the Atherosclerotic Cardiovascular Risk Equation in a Large Contemporary, Multiethnic Population

Rana

Tabada

Solomon

et al. 2016

Journal of the American College of Cardiology

256

141

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Background The accuracy of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) risk equation for atherosclerotic cardiovascular disease (ASCVD) events in contemporary and ethnically diverse populations is not well understood. Objectives We sought to evaluate the accuracy of the 2013 ACC/AHA risk equation within a large, multiethnic population in clinical care. Methods The target population for consideration of cholesterol-lowering therapy in a large, integrated health care delivery system population was identified in 2008 and followed through 2013. The main analyses excluded those with known ASCVD, diabetes mellitus, low-density lipoprotein cholesterol levels <70 or ≥190 mg/dl, prior statin use, or incomplete 5-year follow-up. Patient characteristics were obtained from electronic medical records and ASCVD events were ascertained using validated algorithms for hospitalization databases and death certificates. We compared predicted versus observed 5-year ASCVD risk, overall and by sex and race/ethnicity. We additionally examined predicted versus observed risk in patients with diabetes mellitus. Results Among 307,591 eligible adults without diabetes between 40 and 75 years of age, 22,283 were black, 52,917 Asian/Pacific Islander, and 18,745 Hispanic. We observed 2,061 ASCVD events during 1,515,142 person-years. In each 5-year predicted ASCVD risk category, observed 5-year ASCVD risk was substantially lower: 0.20% for predicted risk <2.50%; 0.65% for predicted risk 2.50 to 3.74%; 0.90% for predicted risk 3.75 to 4.99%; and 1.85% for predicted risk ≥5.00%, with C: 0.74. Similar ASCVD risk overestimation and poor calibration with moderate discrimination (C: 0.68 to 0.74) was observed in sex, racial/ethnic, and socioeconomic status subgroups, and in sensitivity analyses among patients receiving statins for primary prevention. Calibration among 4,242 eligible adults with diabetes was improved, but discrimination was worse (C: 0.64). Conclusions In a large, contemporary “real-world” population, the ACC/AHA Pooled Cohort risk equation substantially overestimated actual 5-year risk in adults without diabetes, overall and across sociodemographic subgroups.

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“…Therefore, secular trends in statin use, revascularization procedures, or treatment of other risk factors such as hypertension and diabetes, may account for the lower rates of CVD observed in more contemporary cohorts. 27–29 Underascertainment of clinically relevant events in the validation cohorts may also explain the apparent overestimation. In fact, when investigators used Medicare claims data to improve outcome ascertainment for the REGARDS study, they demonstrated improved performance of the pooled cohort equations.…”

Section: Guidelines For the Treatment Of Blood Cholesterolmentioning

confidence: 99%

Recent Update to the US Cholesterol Treatment Guidelines

2016

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The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Guideline advocated several changes from the previous Adult Treatment Panel III (ATP III) Guidelines. Assuming full implementation, the 2013 ACC/AHA Guideline would identify approximately 13 million Americans to be newly eligible for consideration of statin therapy. Three features of the 2013 ACC/AHA Guideline primarily responsible for these differences are the specific risk assessment tool endorsed, the risk threshold considered sufficient to warrant primary prevention statin therapy, and the decision to not include cholesterol treatment targets. There is no consensus among international guidelines regarding the optimal approach to these three components. The 2013 ACC/AHA Guideline recommends assessing absolute risk with the pooled cohort equations, which were developed to improve upon previous risk assessment models by including stroke as an outcome and by broadening racial and geographic diversity. Leading international guidelines each recommend a different equation for absolute risk assessment. The 2013 ACC/AHA Guideline advises consideration of statin therapy for an estimated 10-year risk of atherosclerotic vascular disease of ≥7.5%, which is lower than the thresholds recommended by other leading international guidelines. Lastly, the 2013 ACC/AHA Guideline does not endorse a treat-to-target strategy, but instead specifies the appropriate intensity of statin for each risk category. This approach is shared by the National Institute for Health and Care Excellence (NICE) Guidelines but differs from other international guidelines. In this review, we summarize the 2013 ACC/AHA Cholesterol Guideline recommendations and compare them with recommendations from ATP III and other leading international guidelines.

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Implications of the US Cholesterol Guidelines on Eligibility for Statin Therapy in the Community: Comparison of Observed and Predicted Risks in the Framingham Heart Study Offspring Cohort

Cited by 44 publications

References 21 publications

Use and Customization of Risk Scores for Predicting Cardiovascular Events Using Electronic Health Record Data

Use and Customization of Risk Scores for Predicting Cardiovascular Events Using Electronic Health Record Data

Accuracy of the Atherosclerotic Cardiovascular Risk Equation in a Large Contemporary, Multiethnic Population

Recent Update to the US Cholesterol Treatment Guidelines

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