Key result
Aggregate ACC/AHA risk enhancers linked to ~21% higher ASCVD risk per additional enhancer.
Why the study?
Limited data exist on the incremental value of the risk enhancers recommended in the 2018 ACC/AHA cholesterol treatment guidelines in addition to the pooled cohort equation.
Do risk enhancers and coronary artery calcium score improve atherosclerotic cardiovascular disease risk prediction over the pooled cohort equation in a general population cohort?
Cohort (n=22,942)
Yes
Do risk enhancers and coronary artery calcium score improve atherosclerotic cardiovascular disease risk prediction over the pooled cohort equation in a general population cohort?
The presence of ≥3 risk enhancers or a positive CAC score provides incremental prognostic value over the pooled cohort equation for identifying intermediate-risk patients who may benefit from statin therapy.
Background Limited data exist on the incremental value of the risk enhancers recommended in the 2018 American Heart Association/American College of Cardiology (ACC/AHA) cholesterol treatment guidelines in addition to the pooled cohort equation. Methods and Results Using pooled individual‐level data from 3 epidemiological cohorts involving 22 942 participants (56% women, mean age 59 years), we evaluated the predictive ability of the risk enhancers and coronary artery calcium (CAC) score for atherosclerotic cardiovascular disease, and determined their incremental utility using the C statistic, net reclassification index, and integrated discrimination index. A total of 1960 (8.5%) atherosclerotic cardiovascular disease events were accrued over 10 years. Of the 10 risk enhancers evaluated, only 6 predicted atherosclerotic cardiovascular disease independent of the pooled cohort equation. However, the individual enhancers demonstrated little or no incremental benefit. There was more incremental value from combining the 6 enhancers into an aggregate score (hazard ratio [HR], 1.21; 95% CI, 1.08–1.37 for each additional enhancer), and having ≥3 enhancers represents an optimum threshold for incremental prediction (C statistic, 0.766; net reclassification index, 0.041; integrated discrimination index, 0.010; P ≤0.007). On the other hand, CAC was superior to individual enhancers (C statistic, 0.774; net reclassification index, 0.073; integrated discrimination index, 0.010; P <0.001), reliably reclassifies intermediate‐risk participants with <3 risk enhancers (event rate, 3.5% if no CAC and 9.8% if positive CAC), but offered no reclassification among participants with ≥3 enhancers. Conclusions The individual risk enhancers evaluated in this study provided no or only marginal incremental information added to the pooled cohort equation. However, the presence of ≥3 risk enhancers reliably identified intermediate‐risk patients that will benefit from statin therapy, and further CAC testing may be considered among those with <3 risk enhancers.
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Akintoye et al. (2021) conducted a cohort in Atherosclerotic cardiovascular disease (ASCVD) (n=22,942). Aggregate ACC/AHA risk enhancer score vs. Pooled cohort equation alone or fewer risk enhancers was evaluated on Incidence of 10-year atherosclerotic cardiovascular disease events (HR 1.21, 95% CI 1.08-1.37, p=0.001). An aggregate score of ACC/AHA risk enhancers predicted 10-year incident ASCVD (HR 1.21 per additional enhancer), with ≥3 enhancers reliably reclassifying intermediate-risk patients.
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