Identifying Patients at Very High Risk for Recurrent Atherosclerotic Events

Study Questions:

What is the ability of the current American College of Cardiology (ACC)/American Heart Association (AHA) very high risk (VHR) criteria for identifying persons with recurrent clinical arterial disease?


Data were used from the SMART study (n = 7,216) and REACH registry (n = 48,322), two prospective cohorts of patients with manifest atherosclerotic arterial disease. Prevalence and incidence rates of recurrent major adverse cardiac events (MACE) were calculated, according to the ACC/AHA VHR criteria (cardiovascular disease combined with diabetes, smoking, dyslipidemia, and/or recent recurrent coronary events). Performance of the ACC/AHA criteria was compared with single very high risk factors in terms of C-statistics and Net Reclassification Index.


All patients were at VHR according to the European Society of Cardiology guidelines (incidence of recurrent MACE in the SMART study was 2.4/100 person-years [PY], and in the REACH registry, was 5.1/100 PY). In the SMART study, 57% of the patients were at VHR, according to the ACC/AHA criteria (incidence of recurrent MACE, 2.7/100 PY) and in the REACH registry, this was 64% (5.9/100 PY). The C-statistic for the ACC/AHA VHR criteria was 0.53 in REACH and 0.54 in SMART. VHR factors with comparable or slightly better performance were estimated glomerular filtration rate (eGFR) <45, polyvascular disease, and age >70 years. Nearly 70% of the patients meeting the ACC/AHA VHR criteria had a predicted 10-year risk of recurrent MACE <30%.


The ACC/AHA VHR criteria have limited discriminative power. Identifying patients with clinically manifest arterial disease at VHR for recurrent vascular events using eGFR <45, polyvascular disease, or age >70 years performs as well as the ACC/AHA VHR criteria.


Considering the low cost of aspirin and the availability of low-cost generic drugs for hypertension, diabetes, and hyperlipidemia, the findings are not of clinical import. But that may not be the case in countries with limited resources. And as novel more effective, but expensive treatments become available, studies like this will help decide cost-effective strategies.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Hypertension, Smoking

Keywords: Aspirin, Atherosclerosis, Cost-Benefit Analysis, Diabetes Mellitus, Dyslipidemias, Glomerular Filtration Rate, Hyperlipidemias, Hypertension, Incidence, Risk Factors, Secondary Prevention, Smoking, Vascular Diseases

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