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JAMA. 2014 Apr 9;311(14):1416-23. doi: 10.1001/jama.2014.2632.

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.

Author information

1
Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
2
Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands2Department of Cardiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
3
Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
4
Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois5Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
5
Trinity College, Dublin, Ireland.
6
Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
7
Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands8Department of Radiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands9Department of Neurology, Erasmus MC-University Medic.
8
Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands10Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands11Inspectorate for Health Care, the Hague, t.

Abstract

IMPORTANCE:

The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines introduced a prediction model and lowered the threshold for treatment with statins to a 7.5% 10-year hard atherosclerotic cardiovascular disease (ASCVD) risk. Implications of the new guideline's threshold and model have not been addressed in non-US populations or compared with previous guidelines.

OBJECTIVE:

To determine population-wide implications of the ACC/AHA, the Adult Treatment Panel III (ATP-III), and the European Society of Cardiology (ESC) guidelines using a cohort of Dutch individuals aged 55 years or older.

DESIGN, SETTING, AND PARTICIPANTS:

We included 4854 Rotterdam Study participants recruited in 1997-2001. We calculated 10-year risks for "hard" ASCVD events (including fatal and nonfatal coronary heart disease [CHD] and stroke) (ACC/AHA), hard CHD events (fatal and nonfatal myocardial infarction, CHD mortality) (ATP-III), and atherosclerotic CVD mortality (ESC).

MAIN OUTCOMES AND MEASURES:

Events were assessed until January 1, 2012. Per guideline, we calculated proportions of individuals for whom statins would be recommended and determined calibration and discrimination of risk models.

RESULTS:

The mean age was 65.5 (SD, 5.2) years. Statins would be recommended for 96.4% (95% CI, 95.4%-97.1%; n = 1825) of men and 65.8% (95% CI, 63.8%-67.7%; n = 1523) of women by the ACC/AHA, 52.0% (95% CI, 49.8%-54.3%; n = 985) of men and 35.5% (95% CI, 33.5%-37.5%; n = 821) of women by the ATP-III, and 66.1% (95% CI, 64.0%-68.3%; n = 1253) of men and 39.1% (95% CI, 37.1%-41.2%; n = 906) of women by ESC guidelines. With the ACC/AHA model, average predicted risk vs observed cumulative incidence of hard ASCVD events was 21.5% (95% CI, 20.9%-22.1%) vs 12.7% (95% CI, 11.1%-14.5%) for men (192 events) and 11.6% (95% CI, 11.2%-12.0%) vs 7.9% (95% CI, 6.7%-9.2%) for women (151 events). Similar overestimation occurred with the ATP-III model (98 events in men and 62 events in women) and ESC model (50 events in men and 37 events in women). The C statistic was 0.67 (95% CI, 0.63-0.71) in men and 0.68 (95% CI, 0.64-0.73) in women for hard ASCVD (ACC/AHA), 0.67 (95% CI, 0.62-0.72) in men and 0.69 (95% CI, 0.63-0.75) in women for hard CHD (ATP-III), and 0.76 (95% CI, 0.70-0.82) in men and 0.77 (95% CI, 0.71-0.83) in women for CVD mortality (ESC).

CONCLUSIONS AND RELEVANCE:

In this European population aged 55 years or older, proportions of individuals eligible for statins differed substantially among the guidelines. The ACC/AHA guideline would recommend statins for nearly all men and two-thirds of women, proportions exceeding those with the ATP-III or ESC guidelines. All 3 risk models provided poor calibration and moderate to good discrimination. Improving risk predictions and setting appropriate population-wide thresholds are necessary to facilitate better clinical decision making.

PMID:
24681960
DOI:
10.1001/jama.2014.2632
[Indexed for MEDLINE]
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