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Canadian Journal of Cardiology

Comparison of Cardiovascular Risk Assessment Algorithms to Determine Eligibility for Statin Therapy: Implications for Practice in Canada

  • G.B. John Mancini
    Correspondence
    Corresponding author: Dr G.B. John Mancini, Vancouver Hospital Research Pavilion, Room 489, 828 West 10th Ave, Vancouver, British Columbia V5Z 1M9, Canada. Tel.: +1-604-875-5477; fax: +1-604-875-5471.
    Affiliations
    Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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  • Arnold Ryomoto
    Affiliations
    Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Published:April 07, 2014DOI:https://doi.org/10.1016/j.cjca.2014.04.001

      Abstract

      Background

      New lipid management guidelines in the United States have created controversy regarding risk assessment using the new Pooled Cohort Equations (PCE) which might overestimate cardiovascular risk and identify an excessive number of patients as new candidates for statin therapy.

      Methods

      We compared the Framingham Risk Score (FRS) used in Canada with PCE, the FRS version used in Adult Treatment Panel III (ATP III), Reynolds Risk Score (RRS), and Systematic Coronary Risk Evaluation (SCORE) using patient profile simulation of 10 cohorts of 100,000 each (total n = 1,000,000 for each comparison). Patients with diabetes, established cardiovascular disease, or family history of premature cardiovascular disease were not considered, mimicking uncomplicated primary prevention. Analyses were performed separately for men and women and for black individuals when feasible.

      Results

      SCORE (high-risk version) was most concordant with FRS in men, whereas PCE was most concordant in black women. Compared with FRS, all other algorithms except SCORE (high-risk version) identified more simulations as low risk. Reclassification from low FRS to a higher risk was not seen using RRS or ATP III and seen in < 5% of simulations using PCE, affecting predominantly black subject simulations.

      Conclusions

      Choice of risk calculator leads to systematic differences in risk categorization that can influence eligibility for lipid-lowering therapy. Compared with FRS, an isolated switch to PCE, RRS, or ATP III is unlikely to lead to substantial reclassification from low to higher risk categories in Canada.

      Résumé

      Introduction

      Les nouvelles lignes directrices sur la prise en charge des lipides aux États-Unis ont suscité la controverse concernant l’évaluation des risques à l’aide des nouvelles PCE (Pooled Cohort Equations), qui pourraient surestimer le risque cardiovasculaire et identifier à titre de nouveaux candidats au traitement par statine un trop grand nombre de patients.

      Méthodes

      Nous avons comparé le score de risque de Framingham (SRF) utilisé au Canada avec les PCE, la version du SRF utilisé par l’ATP III (Adult Treatment Panel III), le score de risque de Reynolds (SRR) et le SCORE (Systematic Coronary Risk Evaluation) en utilisant la simulation des profils de patients de 10 cohortes de 100 000 patients chacune (n total = 1 000 000 pour chaque comparaison). Les patients souffrant de diabète qui avaient une maladie cardiovasculaire établie ou des antécédents familiaux de maladie cardiovasculaire prématurée n’ont pas été pris en considération pour simuler la prévention primaire de cas non compliqués. Les analyses des femmes et des hommes, ainsi que des individus noirs lorsque cela a été possible, ont été réalisées séparément.

      Résultats

      Le SCORE (version risque élevé) a montré une meilleure concordance avec le SRF chez les hommes, tandis que les PCE ont montré une meilleure concordance chez les femmes noires. Comparativement au SRF, les autres algorithmes excepté le SCORE (version risque élevé) ont identifié plus de simulations comme étant de faible risque. La reclassification du SRF de faible à plus élevé n’a pas été observée en utilisant le SRR ou l’ATP III et observée dans < 5 % des simulations par le PCE, touchant principalement les simulations de sujets noirs.

      Conclusions

      Le choix du calculateur de risque entraîne des différences systématiques dans la classification du risque, qui peuvent influencer l’admissibilité au traitement hypolipémiant. Comparativement au SRF, un changement isolé vers le PCE, le SRR ou l’ATP III n’est pas susceptible d’entraîner une importante reclassification des catégories de risque de faible à plus élevé au Canada.
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