Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA, USA; Department of Medicine, School of Medicine, Boston University, Boston, MA, USA; Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA.
Department of Medicine, School of Medicine, Boston University, Boston, MA, USA; Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, Netherlands.
Lancet Digit Health. 2022 Jan;4(1):e55-e63. doi: 10.1016/S2589-7500(21)00236-3.
Sex-specific and race-specific pooled cohort equations (PCEs) are recommended for estimating the 10-year risk of cardiovascular disease, with an absolute risk of more than 7·5% indicating a clinical decision threshold. We compared differences between Black and White individuals in PCE-estimated absolute cardiovascular disease risk across various plausible risk factor combinations with the aim of evaluating if using the PCE might result in different clinical decisions in Black versus White individuals with identical risk profiles.
We generated in silico patient risk profiles by combining numerical risk factors (age [5-year intervals], total cholesterol [20-mg/dl intervals], HDL cholesterol [5-mg/dl intervals], systolic blood pressure [10-mm Hg intervals]) and binary risk factors (smoking, diabetes, and antihypertensive treatment). We compared PCE-estimated 10-year cardiovascular disease risk in Black versus White individuals with identical risk profiles. We did similar comparisons using eligible participants in the Framingham Heart Study (FHS) third generation cohort and the National Health and Nutrition Examination Survey (NHANES) 2017-18.
For our in silico analysis, we evaluated 29 515 risk factor combinations for women and 30 565 for men, after excluding profiles that generated 10-year cardiovascular disease risk estimates below 1% or above 30%. There were 6357 risk profiles associated with 10-year cardiovascular disease risk above 7·5% for Black men but not for White men (median risk difference [RD] 6·25%, range 0·15-22·8; median relative risk [RR] 2·40, range 1·02-12·6). There were 391 profiles with 10-year cardiovascular disease risk above 7·5% for White men but not Black men (median RD 2·68%, range 0·07-16·9%; median RR 1·42, range 1·01-3·57). There were 6543 risk profiles associated with 10-year estimated cardiovascular disease risk above 7·5% for Black women but not for White women (median RD 6·14%, range 0·35-26·8%; median RR 2·29, range 1·05-12·6). There were 318 profiles with 10-year cardiovascular disease risk above 7·5% for White women but not Black women (median RD 3·71%, range 0·22-20·1%; median RR 1·66, range 1·03-5·46). For the population-based samples, we calculated the PCE-based 10-year cardiovascular disease risk for 1272 eligible participants (378 women; median age 48 years [IQR 44-52]; 100% White) in the FHS third generation cohort and 550 participants (223 women [36·8% Black] and 327 men [40·4% Black]; median age 61 years [IQR 52-67]) in the NHANES cohort. The population-based samples showed similar risk differences to that of the in silico analyses.
The PCE might generate substantially divergent cardiovascular disease risk estimates for Black versus White individuals with identical risk profiles, which could introduce race-related variations in clinical recommendations for cardiovascular disease prevention.
US National Institutes of Health.
推荐使用基于性别的和基于种族的 pooled cohort 方程（PCE）来估计心血管疾病的 10 年风险，绝对风险超过 7.5%表明存在临床决策阈值。我们比较了不同可能的风险因素组合中 PCE 估计的黑人和白人个体的绝对心血管疾病风险之间的差异，目的是评估在风险特征相同的黑人和白人个体中，使用 PCE 是否会导致不同的临床决策。
我们通过结合数值风险因素（年龄[5 年间隔]、总胆固醇[20mg/dl 间隔]、高密度脂蛋白胆固醇[5mg/dl 间隔]、收缩压[10mmHg 间隔]）和二值风险因素（吸烟、糖尿病和降压治疗）生成虚拟患者风险概况。我们比较了具有相同风险特征的黑人和白人个体的 PCE 估计的 10 年心血管疾病风险。我们使用弗雷明汉心脏研究（FHS）第三代队列和国家健康和营养检查调查（NHANES）2017-18 中符合条件的参与者进行了类似的比较。
对于我们的计算机模拟分析，我们排除了生成的 10 年心血管疾病风险估计值低于 1%或高于 30%的风险概况后，评估了女性的 29515 个风险因素组合和男性的 30565 个风险因素组合。对于黑人男性，有 6357 个风险概况与 10 年心血管疾病风险超过 7.5%相关，但对于白人男性则没有（中位数风险差异[RD]6.25%，范围 0.15-22.8；中位数相对风险[RR]2.40，范围 1.02-12.6）。对于白人男性，有 391 个风险概况与 10 年心血管疾病风险超过 7.5%相关，但对于黑人男性则没有（中位数 RD 2.68%，范围 0.07-16.9%；中位数 RR 1.42，范围 1.01-3.57）。对于黑人女性，有 6543 个风险概况与 10 年心血管疾病风险超过 7.5%相关，但对于白人女性则没有（中位数 RD 6.14%，范围 0.35-26.8%；中位数 RR 2.29，范围 1.05-12.6）。对于白人女性，有 318 个风险概况与 10 年心血管疾病风险超过 7.5%相关，但对于黑人女性则没有（中位数 RD 3.71%，范围 0.22-20.1%；中位数 RR 1.66，范围 1.03-5.46）。对于基于人群的样本，我们计算了 1272 名符合条件的参与者（378 名女性；中位年龄 48 岁[IQR 44-52]；100%白人）在 FHS 第三代队列中的 PCE 估计的 10 年心血管疾病风险和 550 名参与者（223 名女性[36.8%黑人]和 327 名男性[40.4%黑人]；中位年龄 61 岁[IQR 52-67]）在 NHANES 队列中的 PCE 估计的 10 年心血管疾病风险。基于人群的样本显示出与计算机模拟分析相似的风险差异。
PCE 可能为具有相同风险特征的黑人和白人个体生成截然不同的心血管疾病风险估计值，这可能会导致心血管疾病预防的临床建议出现与种族相关的差异。
美国国立卫生研究院。
