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Canadian Journal of Cardiology

The New Pooled Cohort Equations Risk Calculator

Published:February 03, 2015DOI:https://doi.org/10.1016/j.cjca.2015.02.001

      Abstract

      In the National Cholesterol Education Program Adult Treatment Panel III guidelines published in 2001, estimation of cardiovascular risk was recommended based on the Framingham score for 10-year risk of myocardial infarction and the Canadian Cardiovascular Society currently recommends the Framingham total cardiovascular risk score. During development of joint guidelines released in 2013 by the American College of Cardiology (ACC) and American Heart Association (AHA), the decision was taken to develop a new risk score. This resulted in the ACC/AHA Pooled Cohort Equations Risk Calculator. This risk calculator, based on major National Heart, Lung, and Blood Institute-funded cohort studies, is designed to predict 10-year risk of ‘hard’ atherosclerotic cardiovascular disease (ASCVD) events, namely, nonfatal myocardial infarction, fatal coronary heart disease, nonfatal, or fatal stroke. Considerable strengths are its inclusion of stroke as an end point and race as a characteristic, which allows better risk prediction especially in African-American individuals, plus provision of lifetime ASCVD risk estimates for adults aged 20-59 years. Notable omissions from the risk factors include chronic kidney disease and any measure of social deprivation. An early criticism of the Pooled Cohort Equations Risk Calculator has been its alleged overestimation of ASCVD risk which, if confirmed in the general population, is likely to result in statin therapy being prescribed to many individuals at lower risk than the intended 7.5% 10-year ASCVD risk threshold for treatment in the joint ACC/AHA cholesterol guidelines. In this review we discuss the development of the new risk calculator, its strengths and weaknesses, and potential implications for its routine use.

      Résumé

      Dans les lignes directrices du National Cholesterol Education Program – Adult Treatment Panel III publiées en 2001, l’estimation du risque cardiovasculaire était recommandée selon le score de Framingham pour le risque d’infarctus du myocarde après 10 ans, alors que la Société canadienne de cardiologie recommande actuellement le risque cardiovasculaire global selon le score de Framingham. Durant l’élaboration des lignes directrices conjointes publiées en 2013 par l’American College of Cardiology (ACC) et l’American Heart Association (AHA), la décision d’établir un nouveau score de risque était prise, ce qui a mené à l’outil de prédiction du risque de l’ACC/AHA appelé le Pooled Cohort Equations Risk Calculator. Ce calculateur de risque qui s’appuie sur les études de cohortes majeures du National Heart, Lung, and Blood Institute est conçu pour prédire le risque d’événements « difficiles » liés à la maladie cardiovasculaire athérosclérotique (ASCVD : atherosclerotic cardiovascular disease) après 10 ans, à savoir l’infarctus du myocarde non fatal, la coronaropathie fatale, et l’accident vasculaire cérébral fatal ou non fatal. Ses points forts sont l’inclusion de l’accident vasculaire cérébral comme critère de jugement et la race comme caractéristique, qui permet une meilleure prédiction du risque particulièrement chez les individus afro-américains, ainsi que la mise à disposition d’estimations du risque à vie de l’ASCVD des adultes âgés de 20 à 59 ans. Parmi les importants facteurs de risque omis, notons la maladie rénale chronique et toute mesure d’isolement social. Les critiques initiales du Pooled Cohort Equations Risk Calculator ont porté sur sa présumée surestimation du risque d’ASCVD qui, si cela est confirmé dans la population générale, est susceptible d’entraîner la prescription de traitements par statines chez plusieurs individus exposés à un risque plus faible que le seuil de risque d’ASCVD de 7,5 % prévu après 10 ans pour le traitement dans les lignes directrices conjointes de l’ACC/AHA en matière de cholestérol. Dans cette revue, nous discutons de l’élaboration du nouveau calculateur de risque, de ses forces et de ses faiblesses, ainsi que des conséquences potentielles liées à son utilisation systématique.
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