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
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
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DOI：
10.1001/jama.2014.2632
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发表时间：
2014-04-09
影响因子：
120.7
通讯作者：
Franco, Oscar H.
中科院分区：
文献类型：
--
作者：
Kavousi, Maryam;Leening, Maarten J. G.;Franco, Oscar H.
重要性2013年美国心脏病学会/美国心脏协会(ACC/AHA)指南引入了一个预测模型，并将他汀类药物的治疗门槛降低到7.5%的10年硬性动脉粥样硬化性心血管疾病(ASCVD)风险。新指南的阈值和模型的含义还没有在非美国人群中得到解决，也没有与以前的指南进行比较。目的通过使用55岁或55岁以上的荷兰人队列，确定ACC/AHA、成人治疗小组III(ATP-III)和欧洲心脏病学会(ESC)指南对整个人群的影响。设计、设置和参与者我们包括在1997-2001年招募的4854名鹿特丹研究参与者。我们计算了“硬”ASCVD事件(包括致命性和非致命性冠心病[CHD]和中风)(ACC/AHA)、硬CHD事件(致命性和非致命性心肌梗死、CHD死亡率)(ATP-III)和动脉粥样硬化性心血管疾病死亡率(ESC)的10年风险。MAIN结果和测量事件评估到2012年1月1日。根据指南，我们计算了推荐服用他汀类药物的个体比例，并确定了风险模型的校正和区分。结果平均年龄为65.5(SD，5.2)岁。ACC/AHA将他汀类药物推荐给96.4%(95%CI，95.4%-97.1%；n=1825)的男性和65.8%(95%CI，63.8%-67.7%；n=1523)的女性，52.0%(95%CI，49.8%-54.3%；n=985)的男性和35.5%(95%CI，33.5%-37.5%)的男性和35.5%(95%CI，33.5%-37.5%；n=1523)的男性和35.5%(95%CI，33.5%-37.5%；n=1523)的男性和35.5%(95%CI，49.8%-54.3%；n=985)的男性和35.5%(95%CI，33.5%-37.根据ATP-III，女性821人)，而根据ESC指南，男性66.1%(95%CI，64.0%~68.3%；n=1253)，女性39.1%(95%CI，37.1%~41.2%；n=906)。在ACC/AHA模型中，男性(192个事件)硬ASCVD事件的平均预测风险与观察累积发生率分别为21.5%(95%CI，20.9%~22.1%)和12.7%(95%CI，11.1%~14.5%)；女性(151个事件)分别为11.6%(95%CI，11.2%~12.0%)和7.9%(95%CI，6.7%~9.2%)。ATP-III模型(男性98个事件，女性62个事件)和ESC模型(男性50个事件，女性37个事件)也出现了类似的高估。硬性ASCVD(ACC/AHA)男性0.67(95%CI，0.63-0.71)，女性0.68(95%CI，0.64-0.73)；硬性冠心病(ATP-III)男性0.67(95%CI，0.62-0.72)，女性0.69(95%CI，0.63-0.75)；男性0.76(95%CI，0.70-0.82)，男性0.77(95%CI，0.70-0.82)，女性心血管疾病死亡率(ESC)为0.71-0.83)。结论在55岁或以上的欧洲人群中，有资格服用他汀类药物的个体比例在指南中有很大差异。ACC/AHA指南将建议几乎所有男性和三分之二的女性服用他汀类药物，比例超过ATP-III或ESC指南。所有3个风险模型都提供了较差的校准和中等到良好的区分度。改善风险预测和设置适当的全人群阈值对于促进更好的临床决策是必要的。
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.