Center for Cardiovascular Disease Prevention, Divisions of Preventive Medicine and Cardiology, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Intern Med. 2014 Dec;174(12):1964-71. doi: 10.1001/jamainternmed.2014.5336.
While the pooled cohort equations from the recent American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Assessment of Cardiovascular Risk have overestimated cardiovascular risk in multiple external cohorts, the reasons for the discrepancy are unclear.
To determine whether increased use of statins over time, incident coronary revascularization procedures, or underascertainment of vascular events explain overestimation of risk in a more contemporary population.
DESIGN, SETTING, AND PARTICIPANTS: The Women's Health Study (WHS) is a nationwide cohort of US women free of cardiovascular disease, cancer, or other major illness at baseline from 1992 to 1995. A total of 27 542 women ages 45 to 79 years with complete ascertainment of plasma lipids and other risk factors were followed for a median of 10 years.
Atherosclerotic cardiovascular disease (ASCVD), defined as any myocardial infarction, any stroke, or death due to cardiovascular cause.
A total of 632 women experienced an ASCVD event over the course of the follow-up. The average predicted risk from the pooled cohort equations was 3.6% over 10 years, compared with an actual observed risk of 2.2%. Ratios of predicted to observed rates were 1.90 or higher in the groups with 0 to less than 5.0% and 5.0% to less than 7.5% risk and were over 1.40 in the groups with 7.5% to less than 10.0% and 10.0% or higher risk. Rates of statin use and revascularizations increased over follow-up time and by risk group, and in sensitivity analyses, we estimated the hypothetical rates if no women were prescribed statins or underwent revascularization procedures. After adjustment for intervention effects of statins and revascularization as well as hypothetical confounding by indication, ratios of predicted to observed rates remained 1.80 or higher in the lower 2 risk groups and over 1.30 higher in the upper 2 risk groups. Underascertainment is unlikely since follow-up rates in the WHS were 97.2%, and overall we would need approximately 60% more events to match the numbers predicted using the pooled cohort equations.
Statin use, revascularization procedures, and underascertainment of events do not explain the discrepancy between observed rates of ASCVD in the WHS and those predicted by the ACC/AHA pooled cohort equations. Other explanations include changing patterns of risk within more contemporary populations.
尽管最近美国心脏病学会/美国心脏协会（ACC/AHA）心血管风险评估指南中的汇总队列方程在多个外部队列中高估了心血管风险，但造成差异的原因尚不清楚。
确定随着时间的推移他汀类药物使用的增加、新发冠状动脉血运重建手术或血管事件的漏诊是否可以解释在更具现代性的人群中风险的高估。
研究设计、地点和参与者：妇女健康研究（WHS）是一项全美范围内的队列研究，纳入了 1992 年至 1995 年期间无心血管疾病、癌症或其他重大疾病的美国女性。共有 27542 名年龄在 45 至 79 岁之间的女性入组，她们的血脂和其他危险因素均完整可查。中位随访时间为 10 年。
动脉粥样硬化性心血管疾病（ASCVD），定义为任何心肌梗死、任何卒中和任何心血管原因导致的死亡。
在随访期间，共有 632 名女性发生 ASCVD 事件。在 10 年内，汇总队列方程预测的平均风险为 3.6%，而实际观察到的风险为 2.2%。在风险为 0 至＜5.0%和＜5.0%至＜7.5%的组中，预测率与观察率的比值为 1.90 或更高，在风险为 7.5%至＜10.0%和≥10.0%的组中，比值大于 1.40。他汀类药物使用率和血运重建率随随访时间和风险组而增加，在敏感性分析中，如果没有女性接受他汀类药物治疗或进行血运重建手术，我们估计了假设的发生率。在调整了他汀类药物和血运重建的干预效果以及假设的按适应证混杂因素后，在较低的 2 个风险组中，预测率与观察率的比值仍保持在 1.80 或更高，在较高的 2 个风险组中，比值仍保持在 1.30 或更高。漏诊的可能性不大，因为 WHS 的随访率为 97.2%，而且我们总体上需要大约 60%的更多事件才能与使用汇总队列方程预测的数字相匹配。
他汀类药物的使用、血运重建手术以及事件的漏诊并不能解释 WHS 中 ASCVD 的观察发生率与 ACC/AHA 汇总队列方程预测值之间的差异。其他解释包括在更具现代性的人群中风险模式的变化。
