Comparison of Application of the ACC/AHA Guidelines, Adult Treatment Panel III Guidelines, and European Society of Cardiology Guidelines for Cardiovascular Disease Prevention in a European Cohort

Study Questions:

What are implications of the American College of Cardiology (ACC)/American Heart Association (AHA), the Adult Treatment Panel (ATP) III, and the European Society of Cardiology (ESC) guidelines in a prospective cohort of healthy European men and women ages ≥55 years and without previous cardiovascular disease (CVD)?


This was a population-based, prospective cohort study of 4,854 participants from the Rotterdam Study, among persons ages ≥55 years in the Netherlands. Participants were free of CVD at baseline (i.e., this was a primary prevention study). The authors calculated 10-year risk for atherosclerotic CVD (ASCVD; ACC/AHA), coronary heart disease (CHD) events (ATP III), and atherosclerotic CVD mortality (ESC); events were assessed until 2012. For each guideline and following the assessment of 10-year risk, the authors created three categories of treatment (“treatment recommended,” “treatment considered,” and “no treatment”) to characterize what proportion of the population would be treated. The discrimination and calibration of each risk prediction model was assessed.


Treatment would be recommended for 96.4% (95% confidence interval [CI], 95.4%-97.1%; n = 1,825) of men and 65.8% (95% CI, 63.8%-67.7%; n = 1,523) of women by the ACC/AHA Pooled Cohort equations; 52.0% (95% CI, 49.8%-54.3%; n = 985) of men and 35.5% (95% CI, 33.5%-37.5%; n = 821) of women by the ATP III risk prediction model; and 66.1% (95% CI, 64.0%-68.3%; n = 1,253) of men and 39.1% (95% CI, 37.1%-41.2%; n = 906) of women by the SCORE equation for low-risk European countries. The C statistic for the three risk prediction models ranged from 0.67 to 0.77 (the SCORE equation provided the highest discrimination). Calibration was poor for all three risk prediction models with an overestimation of 10-year risk among men and women across all categories (e.g., with the ACC/AHA Pooled Cohort equations, average predicted risk vs. observed cumulative incidence of ASCVD events was 21.5% [95% CI, 20.9%-22.1%] vs. 12.7% [95% CI, 11.1%-14.5%] for men and 11.6% [95% CI, 11.2%-12.0] vs. 7.9% [95% CI, 6.7%-9.2%] for women).


In a European cohort of older healthy men and women, there was substantial variation in the proportion of individuals for whom statin therapy was recommended based on application of the ACC/AHA, ATP III, and ESC guidelines. Based on the recent ACC/AHA guideline and Pooled Cohort equations, nearly all men and nearly two-thirds of women in this Dutch cohort would have qualified for statin therapy. Although the risk prediction tools all had modest discrimination ability, all three had poor calibration and overestimated 10-year risk.


The 2013 ACC/AHA CVD prevention guidelines differ significantly from the ATP III and ESC guidelines. The new guidelines have broadened the definition of adverse outcomes to include all ASCVD (including CHD and stroke), introduced the Pooled Cohort equations for risk stratification, and lowered the risk threshold for treatment. The authors highlight the modest discrimination and poor calibration of the ACC/AHA risk prediction model and opine that the ‘choice of treatment threshold becomes central.’ It should be noted that the patients included in this observational study were ≥55 years. One of the benefits of the new ACC/AHA guidelines may be the ability to identify younger patients (with low short-term risk, but higher lifetime risks) who would benefit from therapy. Nonetheless, treatment thresholds that are evidence-based and population-specific are important to facilitate clinical decision-making for primary prevention.

Keywords: Stroke, Cardiovascular Diseases, Netherlands, ACC Annual Scientific Session

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