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Development and Validation of a Coronary Risk Prediction Model for Older U.S. and European Persons in the Cardiovascular Health Study and the Rotterdam Study

Michael T. Koller, MD, MSc; Maarten J.G. Leening, MD, MSc; Marcel Wolbers, PhD; Ewout W. Steyerberg, PhD; M.G. Myriam Hunink, MD, PhD; Rotraut Schoop, PhD; Albert Hofman, MD, PhD; Heiner C. Bucher, MD, MPH; Bruce M. Psaty, MD, PhD; Donald M. Lloyd-Jones, MD, ScM; and Jacqueline C.M. Witteman, PhD
[+] Article and Author Information

From University Hospital Basel, Basel, Switzerland; Erasmus Medical Center, Rotterdam, the Netherlands; Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Harvard School of Public Health, Boston, Massachusetts; University of Freiburg, Freiburg, Germany; University of Washington and Group Health Cooperative, Seattle, Washington; and Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Acknowledgment: The authors thank the CHS and RS participants and staff, as well as Ramon T. Saccilotto, MD, for setting up the risk calculator.

Grant Support: By the University of Basel research foundation (Dr. Koller); Santésuisse and the Gottfried and Julia Bangerter-Rhyner-Foundation (Drs. Koller and Bucher); the Wellcome Trust (Dr. Wolbers); contracts N01-HC-80007, N01-HC-85079 through N01-HC-85086, N01-HC-35129, N01 HC-15103, N01 HC-55222, N01-HC-75150, and N01-HC-45133 and grant U01 HL080295 from the National Heart, Lung, and Blood Institute, with additional contributions from the National Institute of Neurological Disorders and Stroke, the Netherlands Organisation for Scientific Research and the Netherlands Organisation for Health Research and Development (ZonMW grant 80-82500-98-10208 and Vici grant 918-76-619). The RS is supported by the Erasmus Medical Center and Erasmus University Rotterdam; the Netherlands Organisation for Scientific Research; the Netherlands Organisation for Health Research and Development; the Research Institute for Diseases in the Elderly; the Ministry of Education, Culture, and Science; the Ministry of Health, Welfare, and Sports; the European Commission (DG XII); and the Municipality of Rotterdam, the Netherlands.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1132.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Koller (e-mail, mkoller@uhbs.ch).

Requests for Single Reprints: Michael T. Koller, MD, MSc, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Hebelstrasse 10, Petersgraben 4, CH-4031 Basel, Basel-Stadt, Switzerland; e-mail, mkoller@uhbs.ch.

Current Author Addresses: Drs. Koller and Bucher: Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Hebelstrasse 10, Petersgraben 4, CH-4031 Basel, Basel-Stadt, Switzerland.

Drs. Leening, Hunink, Hofman, and Witteman: Department of Epidemiology, Erasmus Medical Center, Box 2040, 3000 CA, Rotterdam, the Netherlands.

Dr. Wolbers: Centre for Tropical Medicine, Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, 764 Vo Van Kiet Street, Ward 1, District 5, Ho Chi Minh City, Vietnam.

Dr. Steyerberg: Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Box 2040, 3000 CA, Rotterdam, the Netherlands.

Dr. Schoop: Department of Medical Biometry and Statistics, Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany.

Dr. Psaty: Cardiovascular Health Research Unit, University of Washington, Metropolitan Park East, 1730 Minor Avenue, Campus Box 358085, Seattle, WA 98101.

Dr. Lloyd-Jones: Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 North Lake Shore, Chicago, IL 60611.

Author Contributions: Conception and design: M.T. Koller, M. Wolbers, E.W. Steyerberg, A. Hofman, B.M. Psaty, D.M. Lloyd-Jones, J.C.M. Witteman.

Analysis and interpretation of the data: M.T. Koller, M.J.G. Leening, M. Wolbers, E.W. Steyerberg, M.G.M. Hunink, R. Schoop, A. Hofman, J.C.M. Witteman.

Drafting of the article: M.T. Koller, M.J.G. Leening, D.M. Lloyd-Jones.

Critical revision of the article for important intellectual content: M.T. Koller, M.J.G. Leening, M. Wolbers, E.W. Steyerberg, M.G.M. Hunink, A. Hofman, H.C. Bucher, B.M. Psaty, D.M. Lloyd-Jones, J.C.M. Witteman.

Final approval of the article: M.T. Koller, M.J.G. Leening, M. Wolbers, E.W. Steyerberg, M.G.M. Hunink, H.C. Bucher, B.M. Psaty, D.M. Lloyd-Jones, J.C.M. Witteman.

Provision of study materials or patients: B.M. Psaty, J.C.M. Witteman.

Statistical expertise: E.W. Steyerberg, R. Schoop, J.C.M. Witteman.

Obtaining of funding: M.T. Koller, A. Hofman, B.M. Psaty, J.C.M. Witteman.

Administrative, technical, or logistic support: M.J.G. Leening, B.M. Psaty.

Collection and assembly of data: M.J.G. Leening, B.M. Psaty, J.C.M. Witteman.


Ann Intern Med. 2012;157(6):389-397. doi:10.7326/0003-4819-157-6-201209180-00002
Text Size: A A A

Background: Risk scores for prediction of coronary heart disease (CHD) in older adults are needed.

Objective: To develop a sex-specific CHD risk prediction model for older adults that accounts for competing risks for death.

Design: 2 observational cohort studies, using data from 4946 participants in the Cardiovascular Health Study (CHS) and 4303 participants in the Rotterdam Study (RS).

Setting: Community settings in the United States (CHS) and Rotterdam, the Netherlands (RS).

Participants: Persons aged 65 years or older who were free of cardiovascular disease.

Measurements: A composite of nonfatal myocardial infarction and coronary death.

Results: During a median follow-up of 16.5 and 14.9 years, 1166 CHS and 698 RS participants had CHD events, respectively. Deaths from noncoronary causes largely exceeded the number of CHD events, complicating accurate CHD risk predictions. The prediction model had moderate ability to discriminate between events and nonevents (c-statistic, 0.63 in both U.S. and European men and 0.67 and 0.68 in U.S. and European women). The model was well-calibrated; predicted risks were in good agreement with observed risks. Compared with the Framingham point scores, the prediction model classified elderly U.S. persons into higher risk categories but elderly European persons into lower risk categories. Differences in classification accuracy were not consistent and depended on cohort and sex. Adding newer cardiovascular risk markers to the model did not substantially improve performance.

Limitation: The model may be less applicable in nonwhite populations, and the comparison Framingham model was not designed for adults older than 79 years.

Conclusion: A CHD risk prediction model that accounts for deaths from noncoronary causes among older adults provided well-calibrated risk estimates but was not substantially more accurate than Framingham point scores. Moreover, adding newer risk markers did not improve accuracy. These findings emphasize the difficulties of predicting CHD risk in elderly persons and the need to improve these predictions.

Primary Funding Source: National Heart, Lung, and Blood Institute; National Institute of Neurological Disorders and Stroke; The Netherlands Organisation for Scientific Research; and the Netherlands Organisation for Health Research and Development.

Figures

Grahic Jump Location
Appendix Figure.

Calibration of predictions computed from the CORE model for men and women in the CHS and the RS.

CORE = coronary risk in the elderly; CHD = coronary heart disease; CHS = Cardiovascular Health Study; RS = Rotterdam Study.

Grahic Jump Location
Grahic Jump Location
Figure.

Association of age with 10-y actual risk for CHD and the 10-y risk for competing noncoronary death in elderly men and women in the CHS and the RS.

CHD = coronary heart disease.

Grahic Jump Location

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Health Guidelines Need to be Adjusted for Age
Posted on September 21, 2012
Albert J. Finestone M.D. M.Sc., Adjunct Prof.Med.,Assoc.Dean C.M.E.,Emeritus,
Temple University, School of Medicine , The Albert J. Finestone, M.D. Office for Cont. Med. Ed. Kresge Science Hall Ste. 100B 3440 N. Broad St. Philadelphhia, PA
Conflict of Interest: None Declared

The article recently published in the Annals of Internal Medicine (1) concerning the validation of coronary risk factors in elderly persons suggests the need to improve these predictions. The traditional risk factors are hypertension, adiposity, hypercholesterolemia and hyperglycemia. Another report evaluated the development of vascular risk factors over 15 years in relation to cognition. At midlife these are associated with cognitive dysfunction; with increasing age this relationship was attenuated (2). Diabetes is another risk factor. There is still belief in tight control of type 2 diabetes despite lack of evidence and some harm (3). Print media including medical journals, TV tout the benefits of products to help lower risk factors without considerations of age .It appears that health guidelines both to the public and the medical profession need to be adjusted for age.

References.

1. Koller MT, Leening MJT,Wolbers M et.al. Development and Validation of a Coronary Risk Prediction Model for Older U.S. and European Persons in the Cardiovascular Health Study and the Rotterdam Study. Ann Intern Med. 2012;157:389-397

2. Reijimer YD, van den Berg E, Dekker JM, Nijpels G ,et.al. Development of Vascular Risk Factors over 15 Years in Relation to Cognition : The Hoorn Study. JAGS. 2012; 60: 1426-1433

3. Finucanane TE .” Tight Control “ in Geriatrics : The Emperor Wears a Thong. JAGS. 2012 ;60 : 1571-1575

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