Which Anthropometric Index Best Signals 10‑Year Cardiovascular Risk? A Sex‑Stratified Analysis From the Shiraz Heart Study

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) remains a major global cause of morbidity and mortality, with obesity as a critical contributor. Traditional measures like body mass index (BMI) do not fully capture fat distribution or composition. Anthropometric and fat indices such as body fat (BF), may offer greater precision in ASCVD risk assessment. METHODS: We analyzed data from 1106 university individuals (26-72 years). The primary analysis included adults 40-70 years (n = 761), for whom 10-year ASCVD risk was estimated using the 2019 ACC/AHA Pooled Cohort Equations (PCE). We modeled continuous risk using sex-adjusted linear regression with each index entered separately and We tested Index × Sex interactions. Discrimination for elevated risk (≥7.5%) was assessed with ROC/AUC. A secondary analysis in participants <40 years assessed discrimination for a composite high risk-factor burden endpoint (≥2 abnormalities among BP, lipids, smoking, diabetes, BMI). RESULTS: The median (IQR) of ASCVD risk score was 1.33 (0.55-3.77), significantly higher in men than women (2.67 vs. 0.65; p < 0.001). Most participants (73.1%) were classified as low-risk, though men had greater representation in higher-risk categories. Furthermore, BF, Waist-to-height ratio (WHtR), and Waist-to-hip ratio (WHR) showed the strongest positive associations with continuous PCE risk, whereas Fat-free mass (FFM) was inversely associated (p < 0.001). For discriminating ≥7.5% risk, WHR performed best, BF and WC were modest and WHtR and BMI provided little to no discriminative ability. CONCLUSION: Anthropometric indices such as WC, WHR, and BF are valuable discriminators of ASCVD risk, surpassing BMI in risk assessment and stratification.