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. 2022 May 7;43(18):1715-1727.
doi: 10.1093/eurheartj/ehac056.

Estimation of recurrent atherosclerotic cardiovascular event risk in patients with established cardiovascular disease: the updated SMART2 algorithm

Steven H J Hageman  1 , Ailsa J McKay  2 , Peter Ueda  3 , Laura H Gunn  2   4 , Tomas Jernberg  5 , Emil Hagström  6 , Deepak L Bhatt  7 , Ph Gabriel Steg  8 , Kristi Läll  9 , Reedik Mägi  9 , Mari Nordbø Gynnild  10   11 , Hanne Ellekjær  10   11 , Ingvild Saltvedt  10   12 , José Tuñón  13   14 , Ignacio Mahíllo  15 , Álvaro Aceña  13 , Karol Kaminski  16 , Malgorzata Chlabicz  16   17 , Emilia Sawicka  16   18 , Taavi Tillman  19 , John W McEvoy  20   21 , Emanuele Di Angelantonio  22 , Ian Graham  23 , Dirk De Bacquer  24 , Kausik K Ray  2 , Jannick A N Dorresteijn  1 , Frank L J Visseren  1
Affiliations

Estimation of recurrent atherosclerotic cardiovascular event risk in patients with established cardiovascular disease: the updated SMART2 algorithm

Steven H J Hageman et al. Eur Heart J. .

Abstract

Aims: The 10-year risk of recurrent atherosclerotic cardiovascular disease (ASCVD) events in patients with established ASCVD can be estimated with the Secondary Manifestations of ARTerial disease (SMART) risk score, and may help refine clinical management. To broaden generalizability across regions, we updated the existing tool (SMART2 risk score) and recalibrated it with regional incidence rates and assessed its performance in external populations.

Methods and results: Individuals with coronary artery disease, cerebrovascular disease, peripheral artery disease, or abdominal aortic aneurysms were included from the Utrecht Cardiovascular Cohort-SMART cohort [n = 8355; 1706 ASCVD events during a median follow-up of 8.2 years (interquartile range 4.2-12.5)] to derive a 10-year risk prediction model for recurrent ASCVD events (non-fatal myocardial infarction, non-fatal stroke, or cardiovascular mortality) using a Fine and Gray competing risk-adjusted model. The model was recalibrated to four regions across Europe, and to Asia (excluding Japan), Japan, Australia, North America, and Latin America using contemporary cohort data from each target region. External validation used data from seven cohorts [Clinical Practice Research Datalink, SWEDEHEART, the international REduction of Atherothrombosis for Continued Health (REACH) Registry, Estonian Biobank, Spanish Biomarkers in Acute Coronary Syndrome and Biomarkers in Acute Myocardial Infarction (BACS/BAMI), the Norwegian COgnitive Impairment After STroke, and Bialystok PLUS/Polaspire] and included 369 044 individuals with established ASCVD of whom 62 807 experienced an ASCVD event. C-statistics ranged from 0.605 [95% confidence interval (CI) 0.547-0.664] in BACS/BAMI to 0.772 (95% CI 0.659-0.886) in REACH Europe high-risk region. The clinical utility of the model was demonstrated across a range of clinically relevant treatment thresholds for intensified treatment options.

Conclusion: The SMART2 risk score provides an updated, validated tool for the prediction of recurrent ASCVD events in patients with established ASCVD across European and non-European populations. The use of this tool could allow for a more personalized approach to secondary prevention based upon quantitative rather than qualitative estimates of residual risk.

Keywords: Established ASCVD; Personalized treatment; Recurrent risk; Residual risk; Risk prediction; Secondary prevention.

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Figures

Structured Graphical Abstract
Structured Graphical Abstract
The updated and geographically recalibrated SMART2 risk score.
Figure 1
Figure 1
Discrimination in the external validation cohorts. Discrimination in all external validation cohorts based on Harrell’s C-statistic.
Figure 2
Figure 2
Calibration in external validation cohorts from Western Europe.
Figure 3
Figure 3
Calibration in external validation cohorts from Eastern Europe.
Figure 4
Figure 4
Calibration in non-European external validation cohorts.
See this image and copyright information in PMC

Comment in

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