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. 2022 Jan 4;2(1):33-43.
doi: 10.1016/j.jacasi.2021.10.007. eCollection 2022 Feb.

Evaluation of Atherosclerotic Cardiovascular Risk Prediction Models in China: Results From the CHERRY Study

Xiaofei Liu  1   2 , Peng Shen  3 , Dudan Zhang  4 , Yexiang Sun  3 , Yi Chen  1 , Jingyuan Liang  1 , Jinguo Wu  5 , Jingyi Zhang  5 , Ping Lu  5 , Hongbo Lin  3 , Xun Tang  1 , Pei Gao  1   2   6
Affiliations

Evaluation of Atherosclerotic Cardiovascular Risk Prediction Models in China: Results From the CHERRY Study

Xiaofei Liu et al. JACC Asia. .

Abstract

Background: Updated American or Chinese guidelines recommended calculating atherosclerotic cardiovascular disease (ASCVD) risk using the Pooled Cohort Equations (PCE) or Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) models; however, evidence on performance of both models in Asian populations is limited.

Objectives: The authors aimed to evaluate the accuracy of the PCE or China-PAR models in a Chinese contemporary cohort.

Methods: Data were extracted from the CHERRY (CHinese Electronic health Records Research in Yinzhou) study. Participants aged 40 to 79 years without prior ASCVD at baseline from 2010 to 2016 were included. ASCVD was defined as nonfatal or fatal stroke, nonfatal myocardial infarction, and cardiovascular death. Models were assessed for discrimination and calibration.

Results: Among 226,406 participants, 5362 (2.37%) adults developed a first ASCVD event during a median of 4.60 years of follow-up. Both models had good discrimination: C-statistics in men were 0.763 (95% confidence interval [CI]: 0.754-0.773) for PCE and 0.758 (95% CI: 0.749-0.767) for China-PAR; C-statistics in women were 0.820 (95% CI: 0.812-0.829) for PCE and 0.811 (95% CI: 0.802-0.819) for China-PAR. The China-PAR model underpredicted risk by 20% in men and by 40% in women, especially in the highest-risk groups. However, PCE overestimated by 63% in men and inversely underestimated the risk by 34% in women with poor calibration (both P < 0.001). After recalibration, observed and predicted risks by recalibrated PCE were better aligned.

Conclusions: In this large-scale population-based study, both PCE and China-PAR had good discrimination in 5-year ASCVD risk prediction. China-PAR outperformed PCE in calibration, whereas recalibration equalized the performance of PCE and China-PAR. Further specific models are needed to improve accuracy in the highest-risk groups.

Keywords: ACC/AHA, American College of Cardiology/American Heart Association; ASCVD, atherosclerotic cardiovascular disease; Chinese; EHR, electronic health record; EMR, electronic medical record; PCE, pooled cohort equations; atherosclerotic cardiovascular disease; electronic health records; primary prevention; risk assessment.

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Conflict of interest statement

This study was supported by the Chinese Ministry of Science and Technology (grant number 2020YFC2003503), the National Natural Science Foundation of China (grant numbers 81973132, 81961128006, 91846112), and the Beijing Natural Science Foundation (grant number 7182084). All authors have followed the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals formulated by the International Committee of Medical Journal Editors (ICMJE). Dr Tang has served as a consultant for Medtronic. Dr Gao has served as a consultant for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Flowchart of Inclusion of Participants in the CHERRY Study Flowchart of participants eligible for risk prediction using the PCE and China-PAR models. ASCVD = atherosclerotic cardiovascular disease; CHERRY = CHinese Electronic health Records Research in Yinzhou; China-PAR = Prediction for ASCVD Risk in China; HDL-C = high-density lipoprotein cholesterol; PCE = Pooled Cohort Equations.
Figure 2
Figure 2
Observed and Predicted Risk Using PCE and China-PAR Models Predicted 5-year ASCVD risk was calculated using original PCE (A, B), recalibrated PCE (C, D), and China-PAR (E, F) for men and women in the CHERRY study, respectively. Observed risk (95% confidence interval) was calculated after Kaplan-Meier adjustment. Abbreviations as in Figure 1.
Central Illustration
Central Illustration
Performance of the Pooled Cohort Equation and Prediction for Atherosclerotic Cardiovascular Disease Risk in China Models for 5-Year Risk Prediction in a Chinese Population Calibration of original PCE, recalibrated PCE, and China-PAR by sex was visualized by plotting the predicted 5-year risk against the observed risk for each decile of the predicted risk. Both PCE and China-PAR models provided adequate discrimination in the Chinese population. Recalibrated PCE to the local population showed similar calibration to China-PAR, whereas both models underestimated risk for the highest-risk groups. ASCVD = atherosclerotic cardiovascular disease; CHERRY = CHinese Electronic health Records Research in Yinzhou; China-PAR = Prediction for ASCVD Risk in China; PCE = Pooled Cohort Equations.
See this image and copyright information in PMC

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