The SMART2 model predicted recurrent cardiovascular risk with moderate discrimination (AUC 0.63) and good overall calibration (OE ratio 0.96) but underestimated risk by 9-29% in socioeconomically deprived, non-Western ethnicity, and psychiatric vulnerable subgroups.
Observational (n=15,528)
Yes
Does the SMART2 model accurately predict 10-year recurrent cardiovascular risk in socioeconomic, ethnic, and psychiatric subgroups of patients with established ASCVD?
While the SMART2 model is well-calibrated in the general ASCVD population, it systematically underestimates recurrent cardiovascular risk in patients with low socioeconomic status, non-Western ethnicity, and psychiatric disorders, indicating these groups may require intensified monitoring.
Effect estimate: AUC 0.63 (95% CI 0.61 to 0.65); Observed/Expected (OE) ratio 0.96 (95% CI 0.92 to 1.00) in entire cohort (95% CI 95% CI AUC 0.61 to 0.65, OE ratio 0.92 to 1.00)
Background Secondary prevention is critical for patients with established atherosclerotic cardiovascular diseases (ASCVD). The SMART2 model predicts recurrent ASCVD risk but does not account for psychiatric disorders, socioeconomic deprivation or ethnicity. We aimed to evaluate SMART2 model performance overall and in subgroups defined by these factors. Methods SMART2 was externally validated using electronic health records of patients aged 40–80 in the Leiden-The Hague region. Patients hospitalised for cardiovascular disease or coronary interventions between 1 January 2010 and 31 December 2021 were included. Model performance was assessed using discrimination (10-year area under ROC curve (AUC)) and calibration (observed/expected (OE) ratios and plots, adjusted for competing risks), both overall and in subgroups defined by three factors: psychiatric history, socioeconomic status (SES) and ethnicity. Results Among 15 528 patients (66% male, mean age 65) with established ASCVD, median follow-up was 6.0 years. Recurrent cardiovascular events occurred in 2220 patients, and 1820 had competing events. Overall AUC was 0.63 (95% CI 0.61 to 0.65). OE ratio was 0.96 (95% CI 0.92 to 1.00). The model underestimated risk in patients with low SES (OE 1.09, 95% CI 1.02 to 1.17) and in non-Western patients (OE 1.16, 95% CI 1.02 to 1.31). Calibration was adequate in patients with psychiatric history, but the model was substantially underestimating for patients with multiple vulnerabilities—combinations of low SES, non-Western ethnicity and psychiatric history—with OE ranging from 1.19 to 1.29, depending on the combination. Conclusion The SMART2 model is well-calibrated in the general population but underestimates risk, especially in subgroups with multiple vulnerabilities. Patients in these vulnerable subgroups may require intensified monitoring. Clinicians should consider social, ethnic and psychiatric factors when interpreting risk estimates.
Egeraat et al. (Thu,) conducted a observational in Adults aged 40-80 years with stable, established atherosclerotic cardiovascular disease (prior hospitalization for coronary artery disease, cerebrovascular disease, peripheral artery disease, or abdominal aortic aneurysm) in an ethnically and socioeconomically diverse Dutch urban population (n=15,528). SMART2 model risk prediction vs. Observed outcomes was evaluated on 10-year recurrent cardiovascular events (composite of non-fatal myocardial infarction, non-fatal stroke and vascular death) risk prediction by SMART2 model versus observed events (AUC 0.63 (95% CI 0.61 to 0.65); Observed/Expected (OE) ratio 0.96 (95% CI 0.92 to 1.00) in entire cohort, 95% CI 95% CI AUC 0.61 to 0.65, OE ratio 0.92 to 1.00). The SMART2 model predicted recurrent cardiovascular risk with moderate discrimination (AUC 0.63) and good overall calibration (OE ratio 0.96) but underestimated risk by 9-29% in socioeconomically deprived, non-Western ethnicity, and psychiatric vulnerable subgroups.