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Comparing Risk Scores in Prediction of Coronary and CV Deaths
Quick Takes
- The study supports the ACC/AHA guideline recommending Pooled Cohort Equation (PCE) be utilized, which was derived from a very broad sample of the US population rather than a “modern cohort” with less diversity.
- PCE should be utilized to first identify low- and high-risk cases, followed by use of CAC testing in those at borderline to intermediate risk.
Study Questions:
What is the relative risk discrimination for the prediction of coronary heart disease (CHD) and cardiovascular disease (CVD) deaths for the Pooled Cohort Equations (PCE), the MESA (Multi-Ethnic Study of Atherosclerosis) Risk Score (with and without coronary artery calcium [CAC]), and of simple addition of CAC to the PCE?
Methods:
The study included 53,487 patients (ages 45-79 years) from the CAC Consortium, a retrospective cohort study of asymptomatic individuals referred for clinical CAC scoring. Risk discrimination was measured using C-statistics.
Results:
Mean age was 57 years, 35% were women, and 39% had CAC of 0. There were 421 CHD and 775 CVD deaths over a mean 12-year follow-up. In the overall population, discrimination with the MESA Risk Score with CAC and the PCE was almost identical for both outcomes (C-statistics: 0.80 and 0.79 for CHD death, 0.77 and 0.78 for CVD death, respectively). Addition of CAC to the PCE improved risk discrimination, yielding the largest C-statistics. The MESA Risk Score with CAC and the PCE plus CAC showed the best discrimination among the 45% of patients with 5-20% estimated risk. Secondary analyses by estimated CVD risk strata showed modestly improved risk discrimination with CAC also among low- and high-estimated risk groups.
Conclusions:
The findings support the current American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendation to use the PCE for initial risk assessment and to use CAC for further risk assessment in a broad borderline and intermediate-risk group. Also, in select individuals at low or high estimated risk, CAC modestly improved discrimination.
Perspective:
The CAC Consortium patients had no history of CHD, physician referred, and clinically indicated. The authors suggested that unselected populations will lead to further understanding of the potential value of tools combining risk scores and CAC for optimal risk assessment. Importantly, this analysis did not address risk of CV events, but rather CHD deaths and other CVD deaths.
Clinical Topics: Noninvasive Imaging, Prevention, Computed Tomography, Nuclear Imaging
Keywords: Atherosclerosis, Cardiovascular Diseases, Coronary Disease, Diagnostic Imaging, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors, Tomography, X-Ray Computed
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