An International Model to Predict Recurrent Cardiovascular Disease

Study Questions:

What are prediction models for cardiovascular events and cardiovascular death in patients with established cardiovascular disease?


Participants from the prospective REduction of Atherothrombosis for Continued Health (REACH) Registry provided a global outpatient population with known cardiovascular disease at entry. Cardiovascular prediction models were estimated from the 2-year follow-up data of 49,689 participants from around the world (36% from North America, 37% from Europe).


A developmental prediction model was estimated from 33,419 randomly selected participants (2,394 cardiovascular events with 1,029 cardiovascular deaths) from the pool of 49,689. Mean age was 68 years, 67% were male, and 37% had diabetics, 72% coronary disease, 34% cerebrovascular disease, 15% peripheral vascular disease, 15% heart failure; 69% were on statins, and 71% were on aspirin. The number of vascular beds with clinical disease, diabetes, smoking, low body mass index, history of atrial fibrillation, cardiac failure, and history of cardiovascular event(s) 1 year before baseline examination increased risk of a subsequent cardiovascular event. Statin (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.69-0.82) and aspirin (HR, 0.90; 95% CI, 0.83-0.99) also were significantly associated with reduced risk of cardiovascular events. The prediction model was validated in the remaining 16,270 REACH subjects (1,172 cardiovascular events, 494 cardiovascular deaths). Risk of cardiovascular death was similarly estimated with the same set of risk factors. Simple algorithms were developed for prediction of overall cardiovascular events and for cardiovascular death.


This study establishes and validates a risk model to predict secondary cardiovascular events and cardiovascular death in outpatients with established atherothrombotic disease. Traditional risk factors, burden of disease, lack of treatment, and geographic location all are related to an increased risk of subsequent cardiovascular morbidity and cardiovascular mortality.


This is a well-designed contemporary investigator-initiated population study that assessed risk of future cardiovascular events among patients with one or more vascular disease event types. Follow-up was obtained by self-reporting and medical records without adjudication of nonfatal ischemic event endpoints. The individual risk factor weighting is intuitive, but the body mass index of <20 kg/m2, which increases risk comparable to a cardiovascular event in the past year and diabetes. As with other tools, age is the most important predictor of events. The tool is simple to use and should be useful to all health care practitioners.

Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Smoking

Keywords: North America, Follow-Up Studies, Chronic Disease, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Coronary Disease, Risk Factors, Europe, Medical Records, Peripheral Vascular Diseases, Smoking, Registries, Body Mass Index, Outpatients, Heart Failure, Cardiovascular Diseases, Atrial Fibrillation, Confidence Intervals, Diabetes Mellitus

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