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. 2024 Dec 12;4(1):101459.
doi: 10.1016/j.jacadv.2024.101459. eCollection 2025 Jan.

Estimating the Risk of Cardiovascular Events in U.S. Veterans Using the SMART Risk Score

Subhash Banerjee  1   2   3 , Rick A Weideman  3 , David A Jacob  3 , Helene R DiGregorio  4 , Kevin C Kelly  3 , Avantika Banerjee  5 , Milan Ravishankar  2 , Patrick T Strickland  2 , Helayna M Abraham  2 , Nicole E Minniefield  3   6 , Bradley R Grimsley  1   2 , Jeffrey M Schussler  1   2 , Rohit J Parmar  1   2 , Robert C Stoler  1   2 , Emmanouil S Brilakis  7 , Bertis B Little  3   8
Affiliations

Estimating the Risk of Cardiovascular Events in U.S. Veterans Using the SMART Risk Score

Subhash Banerjee et al. JACC Adv. .

Abstract

Background: Estimation of long-term risk for cardiovascular events using the SMART (Secondary Manifestations of Arterial Disease) risk score can be potentially valuable in devising risk mitigation strategies.

Objectives: The objective of this study was to apply the SMART risk score to compute the risk for major adverse cardiovascular events (MACE) in the U.S. Veteran patient population.

Methods: We used the Veterans Affairs (VA) informatics and computing infrastructure to identify patients referred for an initial outpatient cardiology evaluation between the years 2003 and 2010 to estimate 10-year risk for composite MACE (all-cause death, ischemic stroke, and nonfatal myocardial infarction). Cox regression and survival curves were used to develop and validate the VA SMART score.

Results: The study population included 472,702 patients (mean age 60 ± 8.9 years, 96% male) who were allocated into development (n = 94,091) and test cohorts (n = 378,611). The median follow-up time was 7.9 years (IQR: 6.0-9.9). The VA-SMART score allowed accurate estimation of MACE. Patients were stratified in low (<10%), moderate (10% to 20%), high (20% to 30%), and very high (≥30%) risk groups with observed events rates of 6.8%, 17.9%, 28.5%, and 49.5%, respectively, in the test cohort (P < 0.0001 for all intergroup comparisons). Most MACE events were all-cause death, with nonfatal myocardial infarction and stroke also being high, especially in the very high-risk group. The VA SMART score performed similar to other established risk prediction models (C-statistic = 0.67).

Conclusions: The VA SMART risk score can estimate the long-term risk of recurrent cardiovascular events in U.S. Veterans and could help implement individualized risk mitigation strategies.

Keywords: cardiovascular disease; risk score; veterans.

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Conflict of interest statement

This study was received research grant support from Esperion Inc, Baylor Research Institute Cardiovascular Research Grant (to Dr Banerjee), and philanthropic support from Bob and Brigitta Smith to the Baylor Heart and Vascular Hospital and from the Paul J. Thomas Research Foundation at Baylor Scott & White, Dallas, Texas, USA. Dr Banerjee is a board member for Elsevier, Cardiovascular Innovations foundation; has received institutional research grant from GE, Esperion, and Novartis; and has received honoraria from Boston Scientific Corporation and Medtronic. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medtronic, and Teleflex; has received research support from Boston Scientific, GE Healthcare; is an owner of Hippocrates LLC; is a shareholder in MHI Ventures, Cleerly Health, Stallion Medical. Dr Stoler is a consultant and advisory board member for Medtronic, Boston Scientific Corporation. 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
Study Cohort Describes development of the study cohort. CPT = current procedural terminology; ICD = International Classification of Diseases (includes ICD-9 and -10).
Central Illustration
Central Illustration
Estimating the Risk of Cardiovascular Events in U.S. Veterans Using the SMART Risk Score MACE = major adverse cardiovascular event.
Figure 2
Figure 2
Performance of VA SMART Risk Score Prediction in Development and Test Cohorts MACE = major adverse cardiovascular event; MI = myocardial infarction; Stroke = ischemic stroke.
Figure 3
Figure 3
Survival Analysis for Major Adverse Cardiovascular Events in Development Cohort and in the Test Cohort (A) survival analysis for major adverse cardiovascular events in development cohort. (B) survival analysis for major adverse cardiovascular events in test cohort. Abbreviation as in Figure 2.
Figure 4
Figure 4
SMART Risk Score Decision Analysis Curve for Major Adverse Cardiovascular Events
See this image and copyright information in PMC

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