Key result
Adding CAC score to calibrated PCE modestly improves ASCVD risk prediction C-statistic to 0.76.
Why the study?
The improvement in discrimination gained by adding nontraditional cardiovascular risk markers to the ASCVD risk estimator (PCE) was untested.
Does the addition of nontraditional risk markers (CAC, ABI, hsCRP, FH) improve ASCVD risk prediction over the Pooled Cohort Equations in adults without known CVD?
Cohort (n=5,185)
Yes
Does the addition of nontraditional risk markers (CAC, ABI, hsCRP, FH) improve ASCVD risk prediction over the Pooled Cohort Equations in adults without known CVD?
Absolute Event Rate: 0.76% vs 0.74%
p-value: p=0.04
Coronary artery calcium (CAC) score provides the most significant, though modest, improvement in ASCVD risk discrimination when added to the Pooled Cohort Equations compared to other nontraditional risk markers.
Modest C-statistic gain with CAC should not yet change practice; leaves open whether reclassification improves outcomes in statin-naive adults.
Background The improvement in discrimination gained by adding nontraditional cardiovascular risk markers cited in the 2013 American College of Cardiology/American Heart Association cholesterol guidelines to the atherosclerotic cardiovascular disease (ASCVD) risk estimator (pooled cohort equation [PCE]) is untested. Objectives We assessed the predictive accuracy and improvement in reclassification gained by the addition of coronary artery calcium (CAC) score, ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP), and family history (FH) of ASCVD to the PCE in participants of the MESA (Multi Ethnic Study of Atherosclerosis). Methods The PCE was calibrated (cPCE) and used for this analysis. Cox proportional hazard model, Harrell's C-statistics, and net reclassification improvement analyses were used. ASCVD was defined as myocardial infarction, coronary heart disease death, or fatal or nonfatal stroke. Results Of 6,814 MESA participants not on statins at baseline, 5,185 had complete data and were included in this analysis. Mean age was 61years; 53.1% were women, 9.8% diabetic, and 13.6% current smokers. After 10 years of follow-up, 320 (6.2%) ASCVD events occurred. CAC, ABI, and FH were independent predictors of ASCVD events in the multivariable Cox models. CAC modestly improved the Harrell's C-statistic (0.74 vs. 0.76; p = 0.04) while ABI, hsCRP, and FH showed no improvement in Harrell's C-statistic when added to the cPCE. Conclusions CAC, ABI, and FH are independent predictors of ASCVD events. CAC modestly improved the discriminative ability of the cPCE best compared with other nontraditional risk markers.
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Yeboah et al. (2016) conducted a cohort in Atherosclerotic cardiovascular disease (ASCVD) risk assessment (n=5,185). Coronary artery calcium (CAC) score vs. Calibrated Pooled Cohort Equation (cPCE) alone was evaluated on Harrell's C-statistic for incident ASCVD (myocardial infarction, coronary heart disease death, or fatal or nonfatal stroke) (p=0.04). The addition of coronary artery calcium (CAC) score to the calibrated Pooled Cohort Equation modestly improved the Harrell's C-statistic for predicting incident ASCVD from 0.74 to 0.76.
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