Psychological factors beyond the SMART2 model for predicting recurrent events in atherosclerotic cardiovascular disease patients

Background Guidelines recommend using cardiovascular (CV) risk prediction models to support treatment decisions. Psychological factors such as depression, anxiety, and insomnia may affect CV risk. Aim Evaluating the added value of psychological factors on top of the SMART2 model for estimating 10-year risk of recurrent CV events in patients with atherosclerotic CV disease. Methods Patients aged 40–80 with atherosclerotic CV disease were included from the UCC-SMART, HUNT3, HUNT4, NORCOR, and Nor-COAST cohorts. Potential added value of (self-reported) symptoms, diagnoses, and treatment for depression, anxiety, and insomnia on top of the SMART2 was investigated using Fine and Gray models, with SMART2 coefficients as an offset. Added value was assessed by change (Δ) in C-statistic and calibration. Results 20,050 patients were eligible, with 2,987 experiencing recurrent CV events. Psychological factors were present in 3-9%, 3-45% and 10-14% of patients for diagnosis, self-reported symptoms and prescribed treatment, respectively. No psychological factors were significantly associated with recurrent CV events on top of SMART2 and performance in patients with psychological factors was adequate (C-statistics 0.61 to 0.70). Added value of psychological factors was minimal, with the ΔC-statistic ranging from -0.0003 [95% confidence interval: -0.0005–0.0001] for symptoms of depression, to 0.0011 [0.0011–0.0011] for prescribed treatment with anxiolytics. There was no relevant difference in calibration. Conclusions SMART2 model reliably estimates recurrent CV event risk in patients with psychological factors. Psychological factors have no added value to CV risk prediction when integrated on top of the SMART2 risk score.