Studies consider cardiovascular risk prediction in women, all U.S. adults
Female-specific factors should not be used to reclassify women's cardiovascular risk when making prescribing decisions, one study noted, while a second study found that 4.3 million Americans have elevated risk for heart failure but low risk for atherosclerotic cardiovascular disease.
Two studies reviewed how cardiovascular factors in women and the general population should be weighed when considering risk prediction.
Female-specific early indicators of cardiovascular disease (CVD) risk should not be used to reclassify women ages 45 to 69 years when considering whether to prescribe blood pressure- or lipid-lowering medication, the first study found.
To assess whether adding female-specific risk factors to traditional risk factors could improve CVD risk prediction, researchers used the UK Biobank Study to derive a cohort of women who were ages 45 to 69 and free of CVD at baseline (2006-2010) and followed them until the end of 2019. Risk factors from three CVD risk calculators were considered: the Pooled Cohort Equation–Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT.
Female-specific risk factors included early menarche (<11 years); endometriosis; excessive, frequent, or irregular menstruation; miscarriage and number of miscarriages; number of stillbirths; infertility; preeclampsia or eclampsia; gestational diabetes (without subsequent type 2 diabetes); and premature menopause (<40 years), early menopause (<45 years), or natural or surgical early menopause (menopause <45 years or unknown and oophorectomy reported at age <45 years). Results were published Dec. 6 by Circulation: Cardiovascular Quality and Outcomes.
Among 135,142 women (mean age, 57.5 years), CVD incidence was 5.3 per 1,000 person-years using risk factors from the Pooled Cohort Equation–Atherosclerotic Cardiovascular Disease. The c-indices for the Pooled Cohort Equation–Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models were 0.710, 0.713, and 0.718, respectively. Adding each of the female-specific risk factors did not improve the c-index, the net reclassification index, the integrated discrimination index, the slope of the regression line for predicted versus observed events, or the Brier score or plots of calibration. Adding all female-specific risk factors simultaneously increased the c-index for the three models to 0.712, 0.715, and 0.720, respectively.
An accompanying editorial stated that while female-specific risk factors may not improve CVD risk calculators, these risk factors still play an important role in comprehensive cardiovascular care in women because they occur earlier in life, which is a valuable opportunity for earlier intervention.
“Clinicians should continue to obtain a comprehensive obstetric and gynecological history when assessing CVD risk in women. In women with female-specific risk factors, early prevention and closer monitoring for the development of traditional risk factors could help prevent CVD downstream. … By focusing on catching and treating traditional risk factors early in their course, we may ultimately lower the high morbidity of CVD in women,” the editorialists wrote.
The second study, a brief research report published in Annals of Internal Medicine on Dec. 17, described U.S. adults at elevated risk for heart failure (HF) based on the PREVENT equations, compared HF and atherosclerotic cardiovascular disease (ASCVD) risk groups, and assessed current risk factor management using data from the combined 2017 to March 2020 cycle of the National Health and Nutrition Examination Survey to study nonpregnant adults aged 30 to 79 years without known CVD.
The study included 4,872 participants with a mean age of 51 years; 51.6% were women. Overall, based on this sample, the researchers determined that the PREVENT equations would classify 15 million U.S. adults as having a 10-year risk for HF greater than 10%. In addition, while HF risk was strongly correlated with ASCVD risk, it is estimated that 4.3 million Americans have elevated HF risk but low ASCVD risk (<10%), the study noted. Uncontrolled risk factors were common in most participants with elevated HF risk, particularly hypertension and obesity.
“Our findings are novel in their use of the PREVENT equations to understand population-wide HF risk,” the researchers wrote. “The most important interventions to reduce HF risk, hypertension control and obesity reduction, are clinically important regardless of HF risk, although HF risk increases the potential importance. People with both elevated HF risk and obesity might receive extra benefit from weight lowering medications.”