Cardiovascular Disease Risk Estimates in the US CKD Population Using the PREVENT Equation

Abstract

Rationale & objective: The 2023 American Heart Association (AHA) Predicting Risk of Cardiovascular Disease (CVD) EVENTs (PREVENT) equations incorporate estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR). We estimated CVD risk in the US chronic kidney disease (CKD) population using PREVENT and compared the estimates to the 2013 American Heart Association/American College of Cardiology pooled cohort equations (PCEs).

Study design: Cross-sectional study.

Setting & participants: Individuals aged 40-75 years with CKD (eGFR<60mL/min/1.73m² and/or UACR≥30mg/g) without CVD were identified from National Health and Nutrition Examination Survey (NHANES) data (2013-2020).

Exposure: Age, sex, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, body mass index, eGFR, diabetes, smoking, antihypertensive use, statin use, urinary albumin-creatinine ratio, hemoglobin A1c.

Outcome: Estimated 10-year CVD, atherosclerotic CVD (ASCVD), and heart failure risks, and guideline-based statin eligibility.

Analytical approach: Survey methods were used to produce cross-sectional estimates representing the US CKD population.

Results: We identified 1,814 eligible individuals, representing 17.5 million people. Their mean age was 59.8 (95% CI, 59.2-60.4) years and 56.2% (95% CI, 52.4%-60.0%) were female. Mean 10-year ASCVD risk in CKD using PREVENT was 8.8% (95% CI, 8.3%-9.4%). This was lower than the risk estimated by PCEs by 5.2 (95% CI, 4.6-5.8) percentage points. The mean estimated 10-year heart failure risk was 11.6% (95% CI, 10.8%-12.3%) and 10-year CVD risk was 15.3% (95% CI, 14.4%-16.1%). The estimated proportion eligible for statin therapy with PREVENT was 63.4% (95% CI, 59.8%-67.0%) using the AHA primary prevention guideline and 85.9% (CI 83.2%-88.6%) using the Kidney Disease Improving Global Outcomes (KDIGO) guideline. Less than half of those eligible for statins for primary prevention based on the PREVENT equation and either the AHA or KDIGO guideline were receiving statin therapy.

Limitations: NHANES survey weights were not derived for this subpopulation, and years dating back to 2013 were included to achieve adequate sample size.

Conclusions: The estimated ASCVD risk was lower with the PREVENT equations compared with the PCEs. Despite the reduced risk estimate, a substantial unmet need for statin therapy in CKD was found.

Plain-language summary: Estimating the risk for developing cardiovascular disease (CVD) can guide prevention. Equations to predict cardiovascular risk are available, but the additional risk due to kidney disease has usually been neglected. The 2023 American Heart Association's Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations include kidney measures. We compared the estimated risk of CVD using PREVENT with that using a prior equation (without kidney measures) in people in the United States with chronic kidney disease. We found that the estimated risk of atherosclerotic CVD with the PREVENT equation was lower than with the prior equation, except for in people with the most advanced kidney disease. Despite the reduction in estimated risk, most individuals whose risk qualifies for statins did not report taking them. This highlights a major opportunity to prevent CVD.

Keywords: Cardiovascular risk; chronic kidney disease; risk prediction; statin use.