Is Atherosclerotic Risk of Cardiovascular Disease Overestimated? Interview with:
Alan S. Go, MD
, chief of Cardiovascular and Metabolic Conditions Research at the Kaiser Permanente Northern California Division of Research

Jamal S. Rana, MD, PhD, cardiologist at Kaiser Permanente Oakland Medical Center and adjunct investigator with the Division of Research What is the background for this study?

Response: In 2013, the American College of Cardiology and American Heart Association published the Pooled Cohort risk equation for estimating the likelihood of atherosclerotic cardiovascular disease events. However, the equation was developed from several groups of enrolled volunteers primarily conducted in the 1990s with limited ethnic diversity and age range, so its accuracy may vary in current community-based populations.

To determine whether the risk equation might be improved by being recalibrated in “real world” clinical care, we examined a large, multi-ethnic, community-based population of Kaiser Permanente members in Northern California whose cholesterol levels and other clinical measures could theoretically trigger a discussion about whether to consider starting cholesterol-lowering therapy based on estimated risk using the ACC/AHA Pooled Cohort tool. The study followed a population of 307,591 men and women aged 40 to 75 years old, including non-Hispanic whites, non-Hispanic blacks, Asian, Pacific Islanders and Hispanics, from 2008 through 2013 and had complete five-year follow-up. The study population did not include patients with diabetes, prior atherosclerotic cardiovascular disease or prior use of lipid-lowering therapy such as statins, as the application of this risk tool is meant for primary prevention of heart disease and stroke. What are the main findings?

Response: We found that the actual incidence of atherosclerotic cardiovascular disease events over five years among study participants was substantially lower than the predicted risk in each category of the ACC/AHA Pooled Cohort equation. From a relative standpoint, the overestimation was approximately five- to six-fold. Among both men and women, there was consistent overestimation of observed five-year atherosclerotic cardiovascular disease incidence in each predicted risk category, with similarly poor calibration in both genders. Researchers also found consistent overestimation of actual atherosclerotic cardiovascular disease risk in each of the major ethnic subgroups. Results were also similar across measures of socioeconomic status. What should readers take away from your report?

Response: We know that statin therapy is a mainstay treatment for millions of Americans, but individual risk for cardiovascular disease should be evaluated over time and as a collaborative process between patients and their doctors. At the same time, everyone can and should adopt a heart-healthy lifestyle and focus on approaches to help prevent heart disease. What recommendations do you have for future research as a result of this study?

Response: Our study provides evidence to support recalibration of the Pooled Cohort Risk Equation in adults without diabetes, especially given the individual and public health implications of widespread application of this risk calculator. Is there anything else you would like to add?

Response: Taking a statin is a lifelong commitment. Another important consideration is that the US Preventive Services Task Force’s (USPSTF) latest recommendations for using the ACC/AHA Pooled Cohort Risk Equation to determine who might be eligible for aspirin for primary prevention. For these reasons, it is crucial that we try to construct the best possible risk estimation tool. Thank you for your contribution to the community.


Jamal S. Rana, Grace H. Tabada, Matthew D. Solomon, Joan C. Lo, Marc G. Jaffe, Sue Hee Sung, Christie M. Ballantyne, Alan S. Go. Accuracy of the Atherosclerotic Cardiovascular Risk Equation in a Large Contemporary, Multiethnic Population. Journal of the American College of Cardiology, 2016; 67 (18): 2118 DOI:10.1016/j.jacc.2016.02.055

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on May 9, 2016 by Marie Benz MD FAAD