Pooled cohort equations heart failure risk score predicts cardiovascular disease and all-cause mortality in a nationally representative sample of US adults

Association Between Phenotypic Age and the Risk of Mortality in Patients With Heart Failure: A Retrospective Cohort Study

BACKGROUND

Chronological age (CA) is an imperfect proxy for the true biological aging state of the body. As novel measures of biological aging, Phenotypic age (PhenoAge) and Phenotypic age acceleration (PhenoAgeAccel), have been shown to identify morbidity and mortality risks in the general population.

HYPOTHESIS

PhenoAge and PhenoAgeAccel might be associated with mortality in heart failure (HF) patients.

METHODS

This cohort study extracted adult data from the National Health and Nutrition Examination Survey (NHANES) databases. Weighted univariable and multivariable Cox models were performed to analyze the effect of PhenoAge and PhenoAgeAccel on all-cause mortality in HF patients, and hazard ratio (HR) with 95% confidence intervals (CI) was calculated.

RESULTS

In total, 845 HF patients were identified, with 626 all-cause mortality patients. The findings suggested that (1) each 1- and 10-year increase in PhenoAge were associated with a 3% (HR = 1.03, 95% CI: 1.03-1.04) and 41% (HR = 1.41, 95% CI: 1.29-1.54) increased risk of all-cause mortality, respectively; (2) when the PhenoAgeAccel < 0 as reference, the ≥ 0 group was associated with higher risk of all-cause mortality (HR = 1.91, 95% CI = 1.49-2.45). Subgroup analyses showed that (1) older PhenoAge was associated with an increased risk of all-cause mortality in all subgroups; (2) when the PhenoAgeAccel < 0 as a reference, PhenoAgeAccel ≥ 0 was associated with a higher risk of all-cause mortality in all subgroups.

CONCLUSION

Older PhenoAge was associated with an increased risk of all-cause mortality in HF patients. PhenoAge and PhenoAgeAccel can be used as convenient tools to facilitate the identification of at-risk individuals with HF and the evaluation of intervention efficacy.

Validation of Heart Failure-Specific Risk Equations in 1.3 Million Israeli Adults and Usefulness of Combining Ambulatory and Hospitalization Data from a Large Integrated Health Care Organization

Heart failure (HF) prevalence is increasing worldwide and is associated with significant morbidity and mortality. Guidelines emphasize prevention in those at-risk, but HF-specific risk prediction equations developed in United States population-based cohorts lack external validation in large, real-world datasets outside of the United States. The purpose of this study was to assess the model performance of the pooled cohort equations to prevent HF (PCP-HF) within a contemporary electronic health record for 5- and 10-year risk. Using a retrospective cohort study design of Israeli residents between 2008 and 2018 with continuous membership until end of follow-up, HF, or death, we quantified 5- and 10-year estimated risks of HF using the PCP-HF equations, which integrate demographics (age, gender, and race) and risk factors (body mass index, systolic blood pressure, glucose, medication use for hypertension or diabetes, and smoking status). Of 1,394,411 patients included, 56% were women with mean age of 49.6 (SD 13.2) years. Incident HF occurred in 1.2% and 4.5% of participants over 5 and 10 years of follow-up. The PCP-HF model had excellent discrimination for 5- and 10-year predictions of incident HF (C Statistic 0.82 [0.82 to 0.82] and 0.84 [0.84 to 0.84]), respectively. In conclusion, HF-specific risk equations (PCP-HF) accurately predict the risk of incident HF in ambulatory and hospitalized patients using routinely available clinical data.

Contemporary Review of Risk Scores in Prediction of Coronary and Cardiovascular Deaths

PURPOSE OF REVIEW

Explore the current literature supporting risk stratification scores for prediction of coronary and cardiovascular disease deaths.

RECENT FINDINGS

Accurate risk prediction remains the foundation of management choice in primary prevention. When applied to new populations, the calibration of a predictive model will deteriorate, although discrimination changes minimally. One of the approaches with better performance and validation is the initial use of pooled cohort equation to identify low and high-risk patients, followed by coronary artery calcium scoring in those with borderline to intermediate risk. It is important to utilize a risk stratification tool that has been validated in a patient population that resembles the one used to develop the original tool to maintain adequate calibration. It is likely that the future of mortality risk prediction will develop in combined clinical risk predictors and cardiovascular imaging, such coronary artery calcium (CAC) scoring that renders the highest predictive accuracy.

Absolute Cardiovascular Disease Risk Assessed in Old Age Predicts Disability and Mortality: A Retrospective Cohort Study of Community-Dwelling Older Adults

Background

Evidence is limited on the predictive validity of absolute cardiovascular disease (CVD) risk, estimated by multivariable assessments in old age, for disability and mortality. We aimed to examine the longitudinal associations of absolute CVD risk assessed using region‐specific risk estimation charts with disability and mortality among community‐dwelling people aged ≥65 years.

Methods and Results

This retrospective cohort study included 7456 community‐dwelling people aged ≥65 years (mean age, 73.7 years) without CVD and functional decline at baseline. They lived in either Obu City or Midori Ward of Nagoya City, Aichi Prefecture, Japan. We estimated absolute CVD risk using the revised World Health Organization CVD risk estimation charts and stratified risk levels into 3 categories: low (<10%), mid (10% to <20%), and high (≥20%). We followed up the functional disability incidence and all‐cause mortality monthly for 5 years. The prevalence of each CVD risk level based on the laboratory‐based model was as follows: low CVD risk, 1096 (14.7%); mid CVD risk, 5510 (73.9%); and high CVD risk, 850 (11.4%). During follow‐up, the incidence rates of disability and mortality were 33.4 per 1000 and 12.4 per 1000 person‐years, respectively. Cox regression analysis showed that the adjusted hazard ratios (95% CIs) for disability incidence were 1.32 (1.13–1.56) and 1.44 (1.18–1.77) in mid and high CVD risk levels, respectively (reference: low CVD risk level); for mortality incidence, they were 1.53 (1.16–2.01) and 2.02 (1.45–2.80) in mid and high CVD risk levels, respectively (reference: low CVD risk level).

Conclusions

Absolute CVD risk was associated with both disability and mortality in people aged ≥65 years. Estimated CVD risk levels may be useful surrogate markers for disability and mortality risks even when assessed in old age.

Distribution and Correlates of Incident Heart Failure Risk in South Asian Americans: The MASALA Study

BACKGROUND

South Asian Americans experience disproportionately high burden of cardiovascular diseases. Estimating predicted heart failure (HF) risk distribution may facilitate targeted prevention. We estimated the distribution of 10-year predicted risk of incident HF in South Asian Americans and evaluated the associations with social determinants of health and clinical risk factors.

METHODS AND RESULTS

In the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, we calculated 10-year predicted HF risk using the Pooled Cohort Equations to Prevent Heart Failure multivariable model. Distributions of low (<1%), intermediate (1%-5%), and high (≥5%) HF risk, identified overall and by demographic and clinical characteristics, were compared. We evaluated age- and sex-adjusted associations of demographic characteristics and coronary artery calcium with predicted HF risk category using ordinal logistic regression. In 1159 participants (48% women), with a mean age of 57 ± 9 years, 40% had a low, 37% had an intermediate, and 24% had a high HF risk. Significant differences in HF risk distribution existed across demographic (income, education, birthplace) and clinical (diabetes, hypertension, body mass index, coronary artery calcium) groups (P < .01). Significant associations with high predicted HF risk were observed for a family of income 75,000/year or more (adjusted odds ratio 0.5 [95% confidence interval (CI) 0.4-0.7]), college education (0.6 [95% CI 0.4-0.9]), birthplace in another South Asian country (1.9 [95% CI 1.2-3.2], vs. born in India), and prevalent coronary artery calcium (2.6 [95% CI 1.9-3.6]).

CONCLUSIONS

Almost two-thirds of South Asian Americans in the MASALA cohort are at intermediate or high predicted 10-year HF risk, with varying risk across demographic and clinical characteristics.

Heart Failure Risk Distribution and Trends in the United States Population, NHANES 1999-2016

BACKGROUND

Implementation of effective preventive interventions requires identification of high-risk individuals. We sought to define the distribution and trends of heart failure risk in the US population.

METHODS

We calculated 10-year predicted heart failure risk among a representative sample of US adults aged 30-79 years, without baseline cardiovascular disease, from the National Health and Nutrition Examination Surveys (NHANES) 1999-2016. We used the published Pooled Cohort Equations to Prevent Heart Failure (PCP-HF) model, which integrates demographic and risk factor data, to estimate 10-year heart failure risk. Participants were stratified by NHANES cycle, sex, age, and race/ethnicity and by 10-year heart failure risk, defined as low (<1%), intermediate (1% to <5%), and high (≥5%).

RESULTS

From 1999-2000 to 2015-2016, mean predicted 10-year heart failure risk increased significantly from 2.0% to 3.0% (P < .05) in the population, most notably among non-Hispanic black (2.1% to 3.7%) and non-Hispanic white (2.4% to 3.6%) men. In 2013-2016, 17.6% of the studied population was at high predicted 10-year heart failure risk. The prevalence of high predicted heart failure risk was highest among non-Hispanic black men (23.1%), followed by non-Hispanic white men (19.2%) and non-Hispanic white women (17.9%).

DISCUSSION

Mean population risk of heart failure increased significantly from 1999-2016. A substantial proportion of US adults are at high 10-year heart failure risk (≥5%), particularly non-Hispanic black men. These data underscore the importance of identifiying individuals at increased heart failure risk for targeted prevention measures to reduce the future burden of heart failure.