PREVENT and PCE Models for Estimating ASCVD Risk Stratified by Statin Exposure.

IMPORTANCE

The Predicting Risk of Cardiovascular Disease Events (PREVENT) equations are an updated model developed to improve on the Pooled Cohort Equation (PCE) for estimating 10-year atherosclerotic cardiovascular disease (ASCVD) risk. These equations facilitate patient-clinician discussions on initiating statin therapy and are used to estimate risk without treatment. However, statin exposure during follow-up was not fully accounted for in the development of these equations.

OBJECTIVE

To assess the performance of the PCE and PREVENT equations in estimating ASCVD, accounting for statin exposure during follow-up.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included adults from an integrated health care system with 10-year follow-up data. Adults without diabetes or ASCVD were identified in 2013 and followed-up through December 31, 2023, with analyses performed in January 2025.

MAIN OUTCOMES AND MEASURES

The primary outcome was incident ASCVD. Estimated risks from PCE and PREVENT equations were compared with observed risks, with discrimination assessed via C statistics. The performance of these equations was evaluated in patient populations stratified by statin exposure during follow-up.

RESULTS

Among 193 885 adults (median [IQR] age, 55 [48-63] years; 113 400 [58.5%] women), 6528 experienced an ASCVD event. The C statistic was 0.725 (95% CI, 0.719-0.731) for PCE and 0.723 (95% CI, 0.716-0.729) for PREVENT. In the overall population, regardless of statin exposure, the observed 10-year ASCVD risk was lower than estimated by PCE: 3.6% for individuals with estimated risk of 5% to less than 7.5%, 4.5% for those with estimated risk of 7.5% to less than 10%, and 8.0% for those with estimated risk of 10% or greater. The observed risk more closely aligned with the estimated risk from PREVENT: 5.2% for individuals with estimated risk of 5% to 7.5%, 8.1% for those with estimated risk 7.5% to less than 10%, and 11.6% for those with estimated risk of 10% or greater. In contrast, among patients not exposed to statin therapy during follow-up, PREVENT underestimated risk: observed risk was 8.2% for individuals with estimated risk of 5% to less than 7.5%, and 13.5% for those with estimated risk of 7.5% to less than 10%, while PCE-estimated risk more closely approximated the observed risk.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, the PREVENT model underestimated risk in patients not treated with statins, whereas the PCE estimates more closely reflected what a patient's risk would be without statin therapy.