Cardiovascular Disease Prognostic Models in Latin America and the Caribbean: A Systematic Review

Abstract

Background: Cardiovascular prognostic models guide treatment allocation and support clinical decisions. Whether there are valid models for Latin American and Caribbean (LAC) populations is unknown.

Objective: This study sought to identify and critically appraise cardiovascular prognostic models developed, tested, or recalibrated in LAC populations.

Methods: The systematic review followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) framework (PROSPERO [International Prospective Register of Systemic Reviews]: CRD42018096553). Reports were included if they followed a prospective design and presented a multivariable prognostic model; reports were excluded if they studied symptomatic individuals or patients. The following search engines were used: EMBASE, MEDLINE, Scopus, SciELO, and LILACS. Risk of bias assessment was conducted with PROBAST (Prediction model Risk Of Bias ASsessment Tool). No quantitative summary was conducted due to large heterogeneity.

Results: From 2,506 search results, 8 studies (N = 130,482 participants) were included for qualitative synthesis. We could not identify any cardiovascular prognostic model developed for LAC populations; reviewed reports evaluated available models or conducted a recalibration analysis. Only 1 study included a Caribbean population (Puerto Rico); 3 studies were retrieved from Chile; 2 from Argentina, Brazil, Colombia, and Uruguay; and 1 from Mexico. Four studies included population-based samples, and the other 4 included people affiliated to a health facility (e.g., prevention clinics). Most studied participants were older than 50 years, and there were more women in 5 reports. The Framingham model was assessed 6 times, and the American College of Cardiology/American Heart Association pooled equation was assessed twice. Across the prognostic models assessed, calibration varied widely from one population to another, showing great overestimation particularly in some subgroups (e.g., highest risk). Discrimination (e.g., C-statistic) was acceptable for most models; for Framingham it ranged from 0.66 to 0.76. The American College of Cardiology/American Heart Association pooled equation showed the best discrimination (0.78). That there were few outcome events was the most important methodological limitation of the identified studies.

Conclusions: No cardiovascular prognostic models have been developed in LAC, hampering key evidence to inform public health and clinical practice. Validation studies need to improve methodological issues.

Figure 1

Discrimination estimates for each prognostic model by country. Confidence intervals, when reported, are presented in Online Table 1. In Acevedo , the outcome was cardiovascular mortality (did not include nonfatal events). Brown dots represent studies conducted with populations in 1 country alone, and orange dots are for multicountry studies. PROCAM is a prognostic model for men, the “PROCAM (sex)” indicates the adjusted model so that it can be used for men and women. Figure template from http://yourfreetemplates.com (see “Details for preparation of Figure 1” in the Online Appendix). ACC/AHA, American College of Cardiology/American Heart Association; CHA₂DS₂VASc, Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex; CUORE, Continuous Ultrafiltration for Congestive Heart Failure; FC-IHRS, fasting cholesterol INTERHEART risk score; INTERHEART, Effect of Potentially Modifiable Risk Factors Associated With Myocardial Infarction in 52 Countries; NL-IHRS, nonlaboratory INTERHEART risk score; PROCAM, Prospective Cardiovascular Münster.