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. 2026 Feb;5(2):102508.
doi: 10.1016/j.jacadv.2025.102508. Epub 2026 Jan 2.

Risk of Cardiovascular Events Using the SMART Polyvascular Disease Risk Score

Subhash Banerjee  1 , Anand Gupta  2 , Minseob Jeong  2 , David Fernandez Vazquez  2 , Shuaib Abdullah  3 , Bradley R Grimsley  4 , Rohit J Parmar  4 , Vishal Ahuja  5 , Robert C Stoler  4 , Ambarish Pandey  3
Affiliations

Risk of Cardiovascular Events Using the SMART Polyvascular Disease Risk Score

Subhash Banerjee et al. JACC Adv. 2026 Feb.

Abstract

Background: Secondary Manifestations of Arterial Disease (SMART) risk score-based projection of risk for cardiovascular (CV) events can help devise risk mitigation strategies.

Objectives: The objective of the study was to analyze the use of the SMART polyvascular disease score to compute the risk for major adverse CV events (MACE) in U.S.

Methods: We accessed the Baylor Scott & White EPIC informatics and data warehouse to identify patients at their first outpatient cardiology evaluation between April 2014 and October 2023 to estimate up to 10-year risk of MACE, a composite of all-cause death, ischemic stroke, and nonfatal myocardial infarction (MI). Cox regression, accelerated failure time model, and survival analyses were used to develop and validate the SMART risk score.

Results: The study population of 259,250 patients (mean age 60.9 ± 15.2 years, 48.6% females) were divided into development (60%) and test (40%) cohorts; median follow-up 2.1 years (IQR: 0.54-4.4). The SMART risk score allowed accurate estimation of MACE. Patients in low (<10%), moderate (10%-<20%), high (20%-<30%), and very high (≥30%) SMART risk score groups had observed MACE events rates of 2.9%, 15.0%, 24.5%, and 56.5%, 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, in the very high-risk group. The SMART score outperformed an established risk prediction model (TIMI Risk Score for Secondary Prevention [TRS2°P]; C-statistic = 0.811) in the test cohort.

Conclusions: The SMART polyvascular disease risk score can provide accurate estimation of up to 10-year risk of CV events and could be potentially leveraged to develop individualized risk mitigation strategies.

Keywords: cardiovascular disease; cardiovascular events; risk score.

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Conflict of interest statement

Funding support and author disclosures Dr Banerjee is a board member of Elsevier and Cardiovascular Innovations foundation; and reports receiving institutional research grant from GE, Esperion, and Novartis; reports Honoraria from AngioSafe, Kaneka, and Terumo. Dr Stoler is a consultant and advisory board member of Medtronic and Boston Scientific Corporation. Dr Pandey received research support from the National Institute of Health, American Heart Association, Applied Therapeutics, Roche, Ultromics, Gilead Sciences, Bayer, and AstraZeneca. Honoraria as an advisor/consultant for Tricog Health Inc, Lilly USA, Rivus, Cytokinetics, Roche Diagnostics, Axon Therapies, Medtronic, Edward Lifesciences, Science37, Novo Nordisk, Bayer, Medical AI, Astra Zeneca, Baylor Scott and White Research Institute, Boehringer Ingelheim, iRhythm Technologies, Tourmaline Bio, Merck, Sarfez Pharmaceuticals, Semler Scientific, Ultromics, Encarda, Boehringer Ingelheim, Tenax Pharma, Alnylam, Abbott, Kieele Health, Anumana, Acorai, Novartis, Antlia Biosciences. 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. BSWH = Baylor Scott & White Health; CVD = cardiovascular disease.
Figure 2
Figure 2
Uncalibrated Plot for the Test Cohort MACE = major adverse cardiovascular event.
Figure 3
Figure 3
Cardiovascular Outcomes in the Secondary Manifestations of Arterial Disease Risk Score Groups (A) Entire cohort; (B) development cohort; (C) test cohort. MI = nonfatal myocardial infarction; SMART = Secondary Manifestations of Arterial Disease; other abbreviation as in Figure 2.
Figure 4
Figure 4
Kaplan-Meier Analysis for Major Adverse Cardiovascular Event (A) Development cohort; (B) test cohort. Abbreviation as in Figures 2 and 3.
Figure 5
Figure 5
Secondary Manifestations of Arterial Disease Risk and TRS2°P Score Decision Analysis for Major Adverse Cardiovascular Events For the test cohort. TRS2°P = TIMI Risk Score for Secondary Prevention; other abbreviations as in Figure 3.
Central Illustration
Central Illustration
Estimating the Risk of Cardiovascular Events in U.S. Veterans Using the Secondary Manifestations of Arterial Disease Risk Score AAA = abdominal aortic aneurysm; CAD = coronary artery disease; CeVD = cardiovascular disease; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; HDL = high-density lipoprotein; hsCRP = high-sensitivity C-reactive protein; MACE = major adverse cardiovascular event; PAD = peripheral artery disease; SMART = Secondary Manifestations of Arterial Disease.
See this image and copyright information in PMC

References

    1. Dorresteijn J.A., Visseren F.L., Wassink A.M., et al. Development and test of a prediction rule for recurrent vascular events based on a cohort study of patients with arterial disease: the SMART risk score. Heart. 2013;99(12):866–872. - PubMed
    1. Banerjee S., Weideman R.A., Jacob D.A., et al. Estimating the risk of cardiovascular events in U.S. veterans using the SMART risk score. JACC Adv. 2024;4(1) - PMC - PubMed
    1. Deo S.V., Althouse A., Al-Kindi S., et al. Validating the SMART2 score in a racially diverse high-risk nationwide cohort of patients receiving coronary artery bypass grafting. J Am Heart Assoc. 2023;12(21) - PMC - PubMed
    1. Kaasenbrood L., Bhatt D.L., Dorresteijn J.A.N., et al. Estimated life expectancy without recurrent cardiovascular events in patients with vascular disease: the SMART-REACH model. J Am Heart Assoc. 2018;7(16) - PMC - PubMed
    1. Berg D.D., Moura F.A., Bellavia A., et al. Assessment of atherothrombotic risk in patients with type 2 diabetes mellitus. J Am Coll Cardiol. 2023;81(25):2391–2402. - PMC - PubMed

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