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Original Investigation |

Comparison of Application of the ACC/AHA Guidelines, Adult Treatment Panel III Guidelines, and European Society of Cardiology Guidelines for Cardiovascular Disease Prevention in a European Cohort

Maryam Kavousi, MD, PhD1; Maarten J. G. Leening, MD, MSc1,2; David Nanchen, MD, MSc3; Philip Greenland, MD4,5; Ian M. Graham, MD6; Ewout W. Steyerberg, PhD7; M. Arfan Ikram, MD, PhD1,8,9; Bruno H. Stricker, MMed, PhD1,10,11; Albert Hofman, MD, PhD1; Oscar H. Franco, MD, PhD1
[+] Author Affiliations
1Department of Epidemiology, Erasmus MC–University Medical Center Rotterdam, Rotterdam, the Netherlands
2Department of Cardiology, Erasmus MC–University Medical Center Rotterdam, Rotterdam, the Netherlands
3Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
4Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
5Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
6Trinity College, Dublin, Ireland
7Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, the Netherlands
8Department of Radiology, Erasmus MC–University Medical Center Rotterdam, Rotterdam, the Netherlands
9Department of Neurology, Erasmus MC–University Medical Center, Rotterdam, the Netherlands
10Department of Internal Medicine, Erasmus MC–University Medical Center Rotterdam, Rotterdam, the Netherlands
11Inspectorate for Health Care, the Hague, the Netherlands
JAMA. 2014;311(14):1416-1423. doi:10.1001/jama.2014.2632.
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Importance  The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines introduced a prediction model and lowered the threshold for treatment with statins to a 7.5% 10-year hard atherosclerotic cardiovascular disease (ASCVD) risk. Implications of the new guideline’s threshold and model have not been addressed in non-US populations or compared with previous guidelines.

Objective  To determine population-wide implications of the ACC/AHA, the Adult Treatment Panel III (ATP-III), and the European Society of Cardiology (ESC) guidelines using a cohort of Dutch individuals aged 55 years or older.

Design, Setting, and Participants  We included 4854 Rotterdam Study participants recruited in 1997-2001. We calculated 10-year risks for “hard” ASCVD events (including fatal and nonfatal coronary heart disease [CHD] and stroke) (ACC/AHA), hard CHD events (fatal and nonfatal myocardial infarction, CHD mortality) (ATP-III), and atherosclerotic CVD mortality (ESC).

Main Outcomes and Measures  Events were assessed until January 1, 2012. Per guideline, we calculated proportions of individuals for whom statins would be recommended and determined calibration and discrimination of risk models.

Results  The mean age was 65.5 (SD, 5.2) years. Statins would be recommended for 96.4% (95% CI, 95.4%-97.1%; n = 1825) of men and 65.8% (95% CI, 63.8%-67.7%; n = 1523) of women by the ACC/AHA, 52.0% (95% CI, 49.8%-54.3%; n = 985) of men and 35.5% (95% CI, 33.5%-37.5%; n = 821) of women by the ATP-III, and 66.1% (95% CI, 64.0%-68.3%; n = 1253) of men and 39.1% (95% CI, 37.1%-41.2%; n = 906) of women by ESC guidelines. With the ACC/AHA model, average predicted risk vs observed cumulative incidence of hard ASCVD events was 21.5% (95% CI, 20.9%-22.1%) vs 12.7% (95% CI, 11.1%-14.5%) for men (192 events) and 11.6% (95% CI, 11.2%-12.0%) vs 7.9% (95% CI, 6.7%-9.2%) for women (151 events). Similar overestimation occurred with the ATP-III model (98 events in men and 62 events in women) and ESC model (50 events in men and 37 events in women). The C statistic was 0.67 (95% CI, 0.63-0.71) in men and 0.68 (95% CI, 0.64-0.73) in women for hard ASCVD (ACC/AHA), 0.67 (95% CI, 0.62-0.72) in men and 0.69 (95% CI, 0.63-0.75) in women for hard CHD (ATP-III), and 0.76 (95% CI, 0.70-0.82) in men and 0.77 (95% CI, 0.71-0.83) in women for CVD mortality (ESC).

Conclusions and Relevance  In this European population aged 55 years or older, proportions of individuals eligible for statins differed substantially among the guidelines. The ACC/AHA guideline would recommend statins for nearly all men and two-thirds of women, proportions exceeding those with the ATP-III or ESC guidelines. All 3 risk models provided poor calibration and moderate to good discrimination. Improving risk predictions and setting appropriate population-wide thresholds are necessary to facilitate better clinical decision making.

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Figure 1.
Inclusion/Exclusion Criteria for Rotterdam Study Participants for Assessment of Different Guideline Recommendations and Risk Prediction Models

ACC/AHA indicates American College of Cardiology/American Heart Association; ASCVD, atherosclerotic cardiovascular disease; ATP-III, Adult Treatment Panel III; CHD, coronary heart disease; CKD, chronic kidney disease; CVD, cardiovascular disease; DM, diabetes mellitus; ESC, European Society of Cardiology; LDL-C, low-density lipoprotein cholesterol; and MI, myocardial infarction.aHard ASCVD includes fatal CHD, nonfatal CHD, and stroke.bHard CHD includes fatal myocardial infarction, nonfatal MI, and CHD mortality.

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Figure 2.
Observed vs Predicted Risks by the ACC/AHA Risk Model, ATP-III Risk Model, and SCORE Equation Among Rotterdam Study Participants

A, Comparison of average observed hard atherosclerotic cardiovascular disease (ASCVD) risk over 10-year follow-up (ie, cumulative incidence of hard ASCVD) vs average predicted 10-year hard ASCVD risk by the American College of Cardiology/American Heart Association (ACC/AHA) risk prediction model7 across categories of risk for men (n = 1513) and women (n = 1920). Individuals receiving statin treatment at baseline, with prevalent CVD, or with low-density lipoprotein cholesterol levels >190 mg/dL were excluded. B, Comparison of average observed hard coronary heart disease (CHD) risk over 10-year follow-up (ie, cumulative incidence of hard CHD) vs average predicted 10-year hard CHD risk by the Adult Treatment Panel III (ATP-III) risk prediction model16 across categories of risk for men (n = 1431) and women (n = 1976). Individuals receiving statin treatment at baseline and those with prevalent CVD or diabetes mellitus were excluded. C, Comparison of average observed CVD mortality risk over 10-year follow-up (ie, cumulative incidence of CVD mortality) vs average predicted 10-year CVD mortality risk by the SCORE equation17 across categories of risk for men (n = 1366) and women (n = 1816). Individuals receiving statin treatment at baseline and those with prevalent CVD, diabetes mellitus, or chronic kidney disease were excluded.

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