Prediction of lifetime cardiovascular risk and individual lifetime treatment benefit in four European risk regions: geographic recalibration of the LIFE-CVD model

Background

The life expectancy free of cardiovascular disease (CVD) in individuals without previous CVD can be estimated with the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model, as recommended by the 2021 ESC CVD prevention guidelines. Our aim was to systematically recalibrate the LIFE-CVD model to four European risk regions using contemporary and representative registry data.

Methods and results

The LIFE-CVD model was systematically recalibrated to four distinct risk regions within Europe, using representative aggregate data on age- and sex-specific expected CVD and non-CVD mortality incidences and risk factor distributions. For external validation, 1,451,077 individuals without previous CVD were included from seven European cohorts, with 53,721 CVD events and 62,902 non-CVD deaths during follow up. After applying the recalibrated risk prediction models to external validation cohorts, C-indices (figure 1) ranged from 0.670 (95% CI 0.650–0.690) to 0.787 (95% CI 0.785–0.789). Predicted risks matched the observed risks in the CPRD data. With the recalibrated LIFE-CVD model, the estimated gain in CVD-free life expectancy from preventive therapy differed per region, for example a 50-year-old smoking women with a systolic blood pressure of 140mm Hg was estimated to gain 0.4 years of CVD-free life from 10 mm Hg SBP reduction in the low risk region, whereas this would be 1.5 years in the very high risk region (figure 2).

Interpretation

By taking into account geographical differences in CVD incidence, the recalibrated LIFE-CVD model provides a more accurate tool for the prediction of lifetime risk and CVD-free life expectancy for individuals without previous CVD, facilitating shared decision-making in cardiovascular prevention options as recommended by the 2021 European Prevention Guidelines.

Funding Acknowledgement

Type of funding sources: None.

Including measures of chronic kidney disease to improve cardiovascular risk prediction by SCORE2 and SCORE2-OP

Background

The 2021 ESC guideline on cardiovascular disease (CVD) prevention qualitatively categorizes moderate and severe chronic kidney disease (CKD) as high and very-high CVD risk status regardless of other factors like age and does not include estimated glomerular filtration rate (eGFR) and albuminuria in its algorithms, SCORE2 and SCORE2-OP, to predict CVD risk.

Purpose

To develop and validate an “Add-on” to incorporate CKD measures into these algorithms, using a validated approach.

Methods

In 3,054,840 participants from 34 datasets, we developed three Add-ons (eGFR only, eGFR + urinary albumin-to-creatinine ratio [ACR] [the primary Add-on], and eGFR + dipstick proteinuria) for SCORE2 and SCORE2-OP. We validated c-statistics and net reclassification improvement (NRI), accounting for competing risk of non-CVD death, in 5,995,067 participants from 33 different datasets.

Results

In the target population of SCORE2 and SCORE2-OP without diabetes, the CKD Add-on (eGFR only) and CKD Add-on (eGFR + ACR) improved c-statistic by 0.006 (95% CI 0.005–0.008) and 0.018 (0.012–0.024), respectively, for SCORE2 and 0.012 (0.009–0.015) and 0.023 (0.013–0.032), respectively, for SCORE2-OP. Similar results were seen when we included individuals with diabetes and tested the CKD Add-on (eGFR + dipstick). In 57,485 European participants with CKD, SCORE2 or SCORE2-OP with a CKD Add-on showed a significant NRI (e.g., 0.100 [0.062–0.138] for SCORE2) compared to the qualitative approach in the ESC guideline.

Conclusion

Our Add-ons with CKD measures improved CVD risk prediction beyond SCORE2 and SCORE2-OP. This approach will help clinicians and patients with CKD refine risk prediction and further personalize preventive therapies for CVD.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): US National Kidney Foundation funding as well as US NIDDK

The value of additional risk factors for improving 10-year cardiovascular risk prediction in apparently healthy people

Background

In clinical practice, factors known to be associated with cardiovascular disease (CVD) like albuminuria, education level, or coronary calcium score are not directly incorporated in cardiovascular risk prediction models. The aim of the current study was to quantify the added value of potential risk modifying characteristics when added to the SCORE2 algorithm for individuals without diabetes mellitus (DM) or prior CVD.

Methods and results

Individuals without previous CVD or DM were included from the ARIC, MESA, EPIC-NL and HNR studies (n=46,285) in whom 2,177 CVD events and 2,062 non-cardiovascular deaths were observed over exactly 10.0 years of follow-up. The effect of each possible risk modifying characteristic was derived using Fine and Gray models that included an offset term for the SCORE2 linear predictor. The risk modifying characteristics were applied to individual predictions using the “naïve approach”, which modifies predicted risks based on the population prevalence and the SHR of the relevant predictor. Subdistribution hazard ratios are presented in the table. External validation was performed in the CPRD cohort (UK, n=518,015, 12,675 CVD events). In the external validation, adjustment of SCORE2 predicted risks with both single and with all available risk modifiers did not negatively affect calibration (see figure) and led to a modest increase in discrimination (C-index 0.742 [95% CI 0.737–0.746] versus unimproved SCORE2 risk C-index 0.737 [95% CI 0.732–0.741]). The net reclassification index or adding all these predictors was +0.032 (95% CI 0.025; 0.028) for future events and −0.008 (95% CI −0.009; −0.007) for future non-events. The coronary calcium score was found to the single strongest added predictor.

Interpretation

The current analysis presents a method on how to integrate possible risk modifying characteristics that are not included in existing CVD risk models for the prediction of CVD event risk in apparently healthy people. This flexible methodology improves the accuracy of predicted risks and increases applicability of prediction models for individuals with additional risk known modifiers

Funding Acknowledgement

Type of funding sources: None.

Overall benefits of smoking cessation in patients with ASCVD are underestimated

Funding Acknowledgements

Type of funding sources: None.

Introduction

New risk prediction models estimate and employ individual ‘treatment benefit’, which can be used to motivate patients with atherosclerotic cardiovascular disease (ASCVD) to quit smoking and to adhere to beneficial pharmacological interventions. However, this treatment benefit is usually calculated for a limited set of cardiovascular outcomes, i.e. years gained without myocardial infarction or stroke, while ignoring non-cardiovascular health benefits and pharmacological side- and adverse effects. Importantly, treatment effect size of medication is smaller in persistent smokers compared to non-smokers, because of the higher overall mortality of the smokers. By disregarding non-cardiovascular outcomes, the overall benefit of smoking cessation will be underestimated.

Purpose

We estimated and compared the treatment benefits – expressed as ‘gain in years without major cardiovascular events’ – of smoking cessation versus persistent smoking with targeted pharmaceutical interventions in patients with established ASCVD treated with anti-platelet agents, statins and anti-hypertensive drugs.

Methods

We pooled individual-level risk factors data from six large, recent prospective studies: RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS. We included patients aged ≥45 years who persisted in smoking ≥6 months after acute coronary syndrome or revascularisation. The primary outcome was SMART-REACH estimated treatment benefit expressed as gain in years without a myocardial infarction or stroke. We compared the cardiovascular treatment benefit of smoking cessation versus the use of one or more pharmaceutical treatments: bempedoic acid, colchicine and PCSK9 inhibitors.

Results

We included 989 smokers with established ASCVD (23% female), with mean age of 60 (SD 8) years at median 1.2 (IQR 1.0-2.0) years post-index event. A mean of 4.81 (95%CI 4.73-4.89) event-free years would be gained through smoking cessation. Persistent smoking with maximal pharmaceutical treatment resulted in a comparable gain of 4.83 (95% CI 4.72-4.93) event-free years.(Figure)

Conclusion

The estimated lifetime treatment benefit of smoking cessation appeared to be comparable to the use of several pharmaceutical treatments combined, even when the analysis was limited to major cardiovascular events. This substantial health benefit underscores smoking cessation to be one of the most important actions to improve the overall health of patients with established ASCVD. To accurately compare treatment options, overall benefits and harms should be considered, in addition to the patients’ preferences, in a shared decision making process.

Lifetime versus 10-year risk of recurrent events in patients with cardiovascular disease: impact of age

Funding Acknowledgements

Type of funding sources: None.

Introduction

Most risk models for patients with established atherosclerotic cardiovascular disease (ASCVD) calculate short-term risk of recurrent events and death, typically for a duration of 10 years. However, lifetime risk estimates may better support the healthcare professional in selecting patients for intensified preventive treatment (1). Also, a cross-sectional study suggested that communicating lifetime risk to ASCVD patients enhances risk perception and willingness for therapy (2). In the new ESC prevention guideline, however, 10-year risk estimates remain standard for ASCVD patients but the additional use of lifetime risk is recommended for communication in the shared decision-making process (3).

Purpose

We therefore aimed to compare estimates of 10-year with lifetime risk of recurrent ASCVD events or death, stratified by age.

Methods

We pooled individual-level data on risk factors from six large, recent prospective studies (RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS). We included Dutch patients aged ≥45 years with a follow-up of ≥6 months after acute coronary syndrome or revascularisation. The SMART-REACH models were used to estimate the difference between 10-year and lifetime risk of recurrent myocardial infarction, stroke, or cardiovascular death, stratified by age (<55, 55-65, 65-75, ≥75 years).

Results

In 3,230 ASCVD patients (24% women), mean age 61±8 years, at median follow-up 1.1 (IQR 1.0-1.8) years after index event, SMART-REACH 10-year risk was 23±11% versus lifetime 56±11%. (Figure 1) We found a considerable difference between 10-year and lifetime risk in patients aged 45-55 years (18±8% vs. 61±10%). Discrepancies decreased with increasing age, with similar estimates in the highest (75-85) age group. (Figure 2).

Conclusion

Lifetime risk of a limited set of cardiovascular outcomes rather than 10-year risk may provide a more complete estimate of future ASCVD disease burden, as especially in younger patients 10-year risk is usually low, even in the presence of risk factors.

Modifiable lifetime risk for recurrent major cardiovascular events: observations in a contemporary pooled cohort

Introduction

The major modifiable risk factors for atherosclerosis – lifestyle, hypertension, diabetes and cholesterol – collectively account for 80 to 90% of disease burden. Currently, the majority of coronary patients does not meet the guideline-directed treatment targets for these risk factors, resulting in high levels of residual risk. An increasing number of novel preventive drugs aims to reduce this residual risk, but are not considered cost-effective when added routinely to all patients. Quantifying the potential lifetime risk reduction one year after an acute coronary syndrome (ACS) may aid in optimum use of available treatment and value-based use of novel drugs.

Purpose

The purpose of this analysis was to quantify the loss of lifetime risk reduction due to suboptimal modifiable risk factor control in patients with prior ACS or revascularisation.

Methods

We pooled six recent prospective studies (Response 1 [1] and 2 [2], Opticare [3], EuroAspire IV [4] and V [5] and HELIUS [6]) with Dutch patients (n=3,230, 24% women) at mean age 61±8 years and follow-up at median 1.1 [IQR 1.0–1.8] years after an ACS or revascularisation. We investigated individual lifestyle- and drug-modifiable risk factors at guideline-directed targets. Using the SMART-REACH model [7], we calculated % reduction of individual residual lifetime risk for myocardial infarction, stroke, or cardiovascular death and event free years gained by the change from current treatment to a (simulated) guideline-directed optimal situation.

Results

Risk factor control was far from optimal: only 7% met all lifestyle-related risk targets, whereas 10% met none: 30% persist smoking, 79% was overweight (BMI ≥25 kg/m2), of which 40% obese (BMI ≥30 kg/m2), and 45% reported insufficient physical activity (<150 minutes per week). Systolic blood pressure ≥140 mmHg was found in 40%, and LDL-cholesterol ≥1.8 mmol/L or ≥2.5 mmol/L (depending on the target at that time) in 65%. Basic preventive medication use was, however, common: 87% used antithrombotic agents, 85% lipid lowering drugs and 86% any blood pressure lowering drugs. By the change from current to optimal guideline-directed treatment, residual lifetime risk for cardiovascular events and cardiovascular death would decrease from a mean of 54±11% to 25±10% (Figure 1), and a median of 7.4 [IQR 5.2–10.6] event free years would be gained (Figure 2).

Conclusion

Suboptimal risk factor control resulted in avoidable high residual lifetime risk of myocardial infarction, stroke, or cardiovascular death and loss of event free years in patients with prior ACS or revascularisation. This finding highlights the unexploited potential of optimised use of available lifestyle- and drug treatment to significantly reduce residual lifetime risk.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Modifiable residual lifetime riskFigure 2. Lifetime benefit in CVD event free years

P1540Major adverse limb events (MALE) and the relation with classical risk factors in patients with symptomatic cardiovascular disease

Background

Patients with symptomatic cardiovascular disease are at high risk for recurrent major adverse cardiovascular events (MACE). Major adverse limb events (MALE) are only rarely reported as a (primary) outcome in trials and cohorts although MALE often lead to significant morbidity and disability.

Purpose

The aim of this study was to determine the incidence of MALE in patients with coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD) or abdominal aortic aneurysm (AAA) and to assess to what extent the classical modifiable risk factors systolic blood pressure (SBP), smoking and non-high density lipoprotein cholesterol (non-HDL-c) affect the risk of MALE.

Methods

Patients with symptomatic vascular disease were included from the ongoing UCC-SMART cohort (1996–2017, n=8139). MALE was defined as a major amputation, peripheral revascularization or thrombolysis of the lower limb. A major amputation included all amputations at the level of the forefoot or higher due to a vascular cause. For non-HDL-c, smoking (per category: non-smoking, former smoking and current smoking) and SBP, the risk for MALE was analyzed with Cox proportional hazard models adjusted for potential confounders. All results were stratified for the presence of PAD/AAA or CAD/CVD at baseline. To calculate the population attributable fraction, non-HDL-c was dichotomized at 1.8 mmol/L and SBP at 140 mmHg.

Results

A total of 577 MALE were observed in 65,402 person-years (median follow up 7.6 years, IQR 3.9–11.7 years) (figure 1A), of which 32 major amputations. In PAD/AAA patients 413 MALE were observed (incidence rate 24.9/1000 person-years). In the CAD/CVD patients 164 MALE were observed (incidence rate 3.4/1000 person-years). The MALE risk per 1 mmol/L higher non-HDL-c was not elevated: HR 1.01 (95% CI 0.94–1.09) for patients with PAD/AAA and HR 1.03 (95% CI 0.91–1.18) for patients with CAD/CVD (figure 1B). The MALE risk per 10mmHg higher SBP was HR 1.10 (95% CI 1.05–1.15) for PAD/AAA patients and HR 1.14 (95% CI 1.06–1.22) for CAD/CVD patients. In patients with PAD/AAA the risk for MALE by former smoking was HR 1.34 (95% CI 0.92–1.97) and for current smoking HR 1.66 (95% CI 1.14–2.44). In CAD/CVD patients, this was for former smoking HR 2.98 (95% CI 1.65–5.39) and for current smoking HR 6.81 (95% CI 3.72–12.45). The population attributable fraction was 0.13 (95% CI −0.07–0.32) for non-HDL-c, 0.21 (95% CI 0.13–0.28) for SBP and 0.28 (95% CI 0.22–0.33) for current smoking.

Figure 1

Conclusions

The incidence of MALE is high in patients with PAD/AAA, and much lower in patients with CAD or CVD. Systolic blood pressure and smoking increase the risk of MALE in PAD/AAA and CAD/CVD patients, Non-HDL-c was not related to the risk of MALE. These findings confirm the importance of MALE as an outcome in patients with clinical manifest vascular disease and underline the importance of the management of classical risk factors to prevent these disabling clinical events.

Acknowledgement/Funding

None