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J Am Coll Cardiol. 2016 May 10;67(18):2118-2130. doi: 10.1016/j.jacc.2016.02.055.

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

Author information

1
Division of Cardiology, Kaiser Permanente Northern California, Oakland, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, University of California, San Francisco, San Francisco, California.
2
Division of Research, Kaiser Permanente Northern California, Oakland, California.
3
Division of Cardiology, Kaiser Permanente Northern California, Oakland, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, Stanford University, Stanford, California.
4
Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, University of California, San Francisco, San Francisco, California; Division of Endocrinology, Kaiser Permanente Oakland Medical Center, Oakland, California.
5
Department of Medicine, University of California, San Francisco, San Francisco, California; Division of Endocrinology, Kaiser Permanente South San Francisco Medical Center, South San Francisco, California.
6
Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, and Center for Cardiovascular Disease Prevention, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
7
Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, University of California, San Francisco, San Francisco, California; Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California. Electronic address: alan.s.go@kp.org.

Abstract

BACKGROUND:

The accuracy of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equation for atherosclerotic cardiovascular disease (ASCVD) events in contemporary and ethnically diverse populations is not well understood.

OBJECTIVES:

The goal of this study was to evaluate the accuracy of the 2013 ACC/AHA Pooled Cohort 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 up through 2013. The main analyses excluded those with known ASCVD, diabetes mellitus, low-density lipoprotein cholesterol levels <70 or ≥190 mg/dl, prior lipid-lowering therapy use, or incomplete 5-year follow-up. Patient characteristics were obtained from electronic medical records, and ASCVD events were ascertained by using validated algorithms for hospitalization databases and death certificates. We compared predicted versus observed 5-year ASCVD risk, overall and according to 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 were Asian/Pacific Islander, and 18,745 were 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 <3.75%; 0.90% for predicted risk 3.75% to <5.00%; and 1.85% for predicted risk ≥5.00% (C statistic: 0.74). Similar ASCVD risk overestimation and poor calibration with moderate discrimination (C statistic: 0.68 to 0.74) were 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 statistic: 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.

KEYWORDS:

cardiovascular; diabetes mellitus; prediction; race/ethnicity; risk factor

PMID:
27151343
PMCID:
PMC5097466
DOI:
10.1016/j.jacc.2016.02.055
[Indexed for MEDLINE]
Free PMC Article

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