Failure of Traditional Risk Factors to Adequately Predict Cardiovascular Events in Older Populations
Failure of Traditional Risk Factors to Adequately Predict Cardiovascular Events in Older Populations
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DOI：
10.1111/jgs.16329
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发表时间：
2020-01-20
影响因子：
6.3
通讯作者：
Perzynski, Adam T.
中科院分区：
文献类型：
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作者：
Dalton, Jarrod E.;Rothberg, Michael B.;Perzynski, Adam T.
准确评估异质人群中动脉粥样硬化性心血管疾病（ASCVD）的风险是有效的一级预防所必需的。关于标准心血管危险因素在老年人中的表现知之甚少。目的评价美国心脏病学会/美国心脏协会合并队列方程（PCE）风险模型的性能，以及潜在的心血管危险因素，在65岁以上的成年人。设计与设置回顾性队列研究来自一个地区转诊系统的电子病历。参与者研究基线时（2007年至2010年间首次门诊血脂检查的日期），共有25349名65岁或以上的患者。如PCE模型中所定义的，感兴趣的暴露是传统的心血管危险因素。主要结局是主要ASCVD事件，定义为心肌梗死、卒中和心血管死亡的复合事件。结果PCE模型和内部估计模型对65 ~ 74岁的白色男性产生了相似的风险分布。对于所有其他群体，PCE预测普遍低于内部模型，特别是对非洲裔美国人。所有年龄组的PCE区分度均较差，65 - 74岁、75 - 84岁和85岁及以上患者的一致性指数（95%置信区间）估计值分别为0.62（0.60-0.64）、0.56（0.54-0.57）和0.52（0.49-0.54）。重新估计这些年龄组内的关系导致了更好的校准，但在歧视方面的改善微不足道。在老年组中，血压、总胆固醇和糖尿病要么完全不相关，要么呈负相关。结论：传统的心血管疾病临床危险因素不能准确地描述当代老年医保患者人群的风险。在85岁及以上的患者中，一些传统的风险因素与ASCVD事件无关。需要更好的风险模型来适当地为不断增长的老年人群体的治疗决策提供信息。
BACKGROUND Accurate assessment of atherosclerotic cardiovascular disease (ASCVD) risk across heterogeneous populations is needed for effective primary prevention. Little is known about the performance of standard cardiovascular risk factors in older adults. OBJECTIVE To evaluate the performance of the American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) risk model, as well as the underlying cardiovascular risk factors, among adults older than 65 years. DESIGN AND SETTING Retrospective cohort derived from a regional referral system's electronic medical records. PARTICIPANTS A total of 25 349 patients who were 65 years or older at study baseline (date of the first outpatient lipid panel taken between 2007 and 2010). MEASUREMENTS Exposures of interest were traditional cardiovascular risk factors, as defined by inclusion in the PCE model. The primary outcome was major ASCVD events, defined as a composite of myocardial infarctions, stroke, and cardiovascular death. RESULTS The PCE and internally estimated models produced similar risk distributions for white men aged 65 to 74 years. For all other groups, PCE predictions were generally lower than those of the internal models, particularly for African Americans. Discrimination of the PCE was poor for all age groups, with concordance index (95% confidence interval) estimates of 0.62 (0.60-0.64), 0.56 (0.54-0.57), and 0.52 (0.49-0.54) among patients aged 65 to 74, 75 to 84, and 85 years and older, respectively. Reestimating relationships within these age groups resulted in better calibration but negligible improvements in discrimination. Blood pressure, total cholesterol, and diabetes either were not associated at all or had inverse associations in the older age groups. CONCLUSION Traditional clinical risk factors for cardiovascular disease failed to accurately characterize risk in a contemporary population of Medicare-aged patients. Among those aged 85 years and older, some traditional risk factors were not associated with ASCVD events. Better risk models are needed to appropriately inform treatment decision making for the growing population of older adults.