Study Assesses Accuracy of Multiple Cardiovascular Risk Scores

Andrew Paul DeFilippis, MD, MSc Assistant Professor of Medicine University of Louisville Director, Cardiovascular Disease Prevention Medical Director, Cardiovascular Intensive Care Unit Adjunct Assistant Professor of Medicine Johns Hopkins University of Louisville Jewish Hospital Rudd Heart & Lung Center Louisville, KY MedicalResearch.com Interview with:
Andrew Paul DeFilippis, MD, MSc
Assistant Professor of Medicine University of Louisville
Director, Cardiovascular Disease Prevention
Medical Director, Cardiovascular Intensive Care Unit
Adjunct Assistant Professor of Medicine Johns Hopkins
University of Louisville Jewish Hospital Rudd Heart & Lung Center
Louisville, KY

Michael Joseph Blaha, MD MPH Director of Clinical Research Ciccarone Center for the Prevention of Heart Disease Assistant Professor of Medicine John HopkinsMichael Joseph Blaha, MD MPH
Director of Clinical Research
Ciccarone Center for the Prevention of Heart Disease
Assistant Professor of Medicine
John Hopkins

MedicalResearch: What is the background for this study?

Response: Atherosclerotic cardiovascular disease is the leading cause of death worldwide. While multiple therapies are available to prevent this common disease, accurate risk assessment is essential to effectively balance the risks and benefits of therapy in primary prevention. For more than a decade, national guidelines have recommended the use of an objective risk assessment tool based on the Framingham Risk Score (FRS) to guide therapy in primary prevention. Recently, the American Heart Association (AHA) and the American College of Cardiology (ACC) developed a new risk score to guide cardiovascular risk-reducing therapy.

We had two main objectives in our study:

1) To compare the performance of the new AHA-ACC risk score with four other commonly used risk scores in a MODERN DAY gender balanced multi-ethnic population.

2) To explore how the use of modern day preventive therapy (aspirin, statins, BP meds and revascularization) impact the performance of the AHA-ACC score.

MedicalResearch: What are the main findings?

Response:  We found that the new AHA-ACC atherosclerotic cardiovascular disease (ASCVD) risk score and three Framingham-based risk scores, all derived from cohorts’ decade’s old, overestimated cardiovascular events by 25 – 115%, while the Reynolds Risk score, derived from more modern cohorts, accurately predicted the overall event rate in a modern, multi-ethnic cohort free of baseline clinical cardiovascular disease. Overestimation was noted throughout the continuum of risk and does not appear to be secondary to missed events or use of preventive therapies.

MedicalResearch: What should clinicians and patients take away from your report?

Response:  Predicting the future is difficult –this includes trying to predict who will have a heart attack or stroke. We do know that risk is cumulative and is increased by inherited genetic predisposition, poor diet, sedentary life style, dyslipidemia, hypertension, smoking, environmental pollution and many other identified and unidentified factors. More importantly we have many tools to help quantify risk and to prevent and treat many of the factors that lead to cardiovascular disease. No one test or treatment is perfect for every patient, the diagnostic and treatment plan needs to be individualized for each patient.

We recommend using a risk predication scores as a starting point, not a decision maker, for cardiovascular risk prediction therapy. In difficult treatment decision cases, additional testing, like coronary artery calcium, may help guide therapy.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Response:  Our next step is to explore the impact of multiple individual cardiovascular risk factors on risk score accuracy. Such an analysis will generate important insights about which factors need to be recalibrated and what new variables should be considered to develop new, more accurate risk scores for today’s patients.

The next iteration of guidelines should use modern cohorts to derive and validate risk prediction tools. This will require new community based cohorts to keep pace with evolving cardiovascular risk factors and therapies. In addition, these new cohorts will allow researchers to learn how patient’s respond to risk factors and therapies may be changing over time. The inclusion of additional individual preventive therapies, like statins and aspirin, in risk calculators should be explored.

The use of direct measures of subclinical atherosclerosis, like coronary artery calcium, improve risk prediction beyond risk factor based calculators and need to be further explored in randomized controlled trial for how these measures may be used to reduce major adverse cardiovascular events (MACE) in today’s patients.

Citation:

An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort

Andrew P. DeFilippis, MD, MSc*; Rebekah Young, PhD*; Christopher J. Carrubba, MD; John W. McEvoy, MB, BCh, BAO; Matthew J. Budoff, MD; Roger S. Blumenthal, MD; Richard A. Kronmal, PhD; Robyn L. McClelland, PhD; Khurram Nasir, MD, MPH; and Michael J. Blaha, MD, MPH

Ann Intern Med. 2015;162(4):266-275. doi:10.7326/M14-1281

MedicalResearch.com Interview with: Andrew Paul DeFilippis, MD, MSc (2015). Study Assesses Accuracy of Multiple Cardiovascular Risk Scores 

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