Improving Cardiovascular Disease Primary Prevention Treatment Thresholds in a New England Health Care System

Abstract

BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) risk estimation based on the pooled cohort equation (PCE) overestimates in population-based cohorts. Whether it performs equally across disaggregated demographics in health care populations is less known. OBJECTIVES The purpose of the study was to recalibrate PCE and rederive prevention thresholds in a contemporary health care system and evaluate its performance across sociodemographics. METHODS We retrospectively inspected electronic health records between 2010 to 2012 and 2020 to 2022 within Mass General Brigham health care in New England region. We compared performance of the original vs recalibrated PCE measured by calibration, discrimination, reclassification rate, and net benefit among 160,926 patients aged 40 to 79 years and without prior ASCVD or lipid-lowering medication. RESULTS Of the 160,926 patients (mean age: 54.6 + 8.6 years; 61.4% female), 20,373 (12.7%) developed ASCVD over 10 years. The original PCE globally underestimated ASCVD risk (observed vs predicted incidence rate: 0.13 vs 0.05). Recalibration upclassified risk primarily among individuals with low-to-borderline risk by the original PCE and additionally identified 40% of patients who had undergone ASCVD events yet deemed statin-ineligible based on the original PCE. Treatment thresholds yielding the greatest net benefit were >= 24.0% for women (+23.3%) vs >= 26.0% for men (+18.7%), whereas >= 26.0% for White or other race (+24.7%) vs >= 14.0% Black or African American (+12.5%), respectively. Specifically, Hispanic or Latino and non-Hispanic Black patients conferred the greatest sensitivity improvement at >= 12.3% threshold compared to higher >= 23.6% among non-Hispanic Asian or Pacific Islanders. Generally, lower thresholds earlier in life were optimal. CONCLUSIONS Recalibration and personalized treatment thresholds derived within a health system may improve prevention treatment allocation efficiency. (JACC Adv. 2024;3:101257) (c) 2024 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).