Combining ≥3 risk enhancers provided incremental predictive value for atherosclerotic cardiovascular disease over the pooled cohort equation (HR 1.21 per additional enhancer; 95% CI 1.08-1.37).
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.
Hazard Ratio: 1.21 (95% CI 1.08–1.37)
p-value: p=≤0.007
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.
Akintoye et al. (Mon,) conducted a cohort in Atherosclerotic cardiovascular disease (n=22,942). Risk enhancers and coronary artery calcium (CAC) score vs. Pooled cohort equation alone was evaluated on Atherosclerotic cardiovascular disease events (HR 1.21, 95% CI 1.08-1.37, p=≤0.007). Combining ≥3 risk enhancers provided incremental predictive value for atherosclerotic cardiovascular disease over the pooled cohort equation (HR 1.21 per additional enhancer; 95% CI 1.08-1.37).