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. 2021 Feb;14(2):411-421.
doi: 10.1016/j.jcmg.2019.12.010. Epub 2020 Jan 15.

Comparing Risk Scores in the Prediction of Coronary and Cardiovascular Deaths: Coronary Artery Calcium Consortium

Michael J Blaha  1 , Seamus P Whelton  2 , Mahmoud Al Rifai  3 , Zeina Dardari  2 , Leslee J Shaw  4 , Mouaz H Al-Mallah  5 , Kunihiro Matsushita  6 , Alan Rozanski  7 , John A Rumberger  8 , Daniel S Berman  9 , Matthew J Budoff  10 , Michael D Miedema  11 , Khurram Nasir  12 , Miguel Cainzos-Achirica  2
Affiliations

Comparing Risk Scores in the Prediction of Coronary and Cardiovascular Deaths: Coronary Artery Calcium Consortium

Michael J Blaha et al. JACC Cardiovasc Imaging. 2021 Feb.

Abstract

Objectives: This study compared 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.

Background: The PCE predict 10-year risk of atherosclerotic CVD events, and the MESA Risk Score predicts risk of CHD. Their comparative performance for the prediction of fatal events is poorly understood.

Methods: We evaluated 53,487 patients ages 45 to 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 study 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% to 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: Our findings support the current guideline recommendation to use, among available risk scores, 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. Studies in unselected populations will lead to further understanding of the potential value of tools combining risk scores and CAC for optimal risk assessment.

Keywords: cardiovascular disease; coronary artery calcium; mortality; risk; score.

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Conflict of interest statement

Funding Support and Author Disclosures Dr. Blaha was supported by National Institutes of Health award L30 HL110027 for this project. Dr. Budoff has received grant support from General Electric. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1.
Figure 1.. Flow of the population included in the study.
CAC Consortium participants included in the present analysis. *Defined as a 5–20% 10-year estimated ASCVD risk using the PCE. *Defined as a 5 – 20% 10-year estimated ASCVD risk using the PCE ASCVD = atherosclerotic cardiovascular disease; CAC = coronary artery calcium; MHI = Minneapolis Heart Institute; OH = Ohio; UCLA = University of California, Los Angeles; PCE = Pooled Cohort Equations
Figure 2.
Figure 2.. Discriminative ability for the prediction of CHD death events, by 5%-ASCVD risk strata.
Results are presented using the C-statistic. ASCVD = atherosclerotic cardiovascular disease events; CAC = coronary artery calcium; CHD = coronary heart disease; MESA = Multi-Ethnic Study of Atherosclerosis; PCE = Pooled Cohort Equations
Figure 3.
Figure 3.. Discriminative ability for the prediction of CVD death events, by 5%-ASCVD risk strata.
Results are presented using the C-statistic. ASCVD = atherosclerotic cardiovascular disease events; CAC = coronary artery calcium; CVD = cardiovascular disease; MESA = Multi-Ethnic Study of Atherosclerosis; PCE = Pooled Cohort Equations
Figure 4.
Figure 4.. Improvement in the C-statistics for CHD death events and for CVD death events comparing the MESA Risk Score with CAC and the PCE (Panel A), and comparing the PCE plus CAC and the PCE alone (Panel B).
Results are presented as difference in the C-statistic. ASCVD = atherosclerotic cardiovascular disease events; CAC = coronary artery calcium; CHD = coronary heart disease; CVD = cardiovascular disease; MESA = Multi-Ethnic Study of Atherosclerosis; PCE = Pooled Cohort Equations
Central Illustration.
Central Illustration.. Discriminative ability of the PCE, the MESA Risk Score (with and without CAC), and of the PCE plus CAC, for the prediction of CHD death and CVD death events in the CAC Consortium.
Results are presented using the C-statistic. On the upper panels, results for all CAC Consortium participants included (overall), for participants at borderline/intermediate estimated ASCVD risk, and for participants ages 45 to 65 years at baseline. On the lower panels, results are presented for all CAC Consortium participants by estimated 10-year ASCVD risk strata. ASCVD = atherosclerotic cardiovascular disease events; CAC = coronary artery calcium; CHD = coronary heart disease; CVD = cardiovascular disease; MESA = Multi-Ethnic Study of Atherosclerosis; PCE = Pooled Cohort Equations
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