Performance of Framingham cardiovascular disease (CVD) predictions in the Rotterdam Study taking into account competing risks and disentangling CVD into coronary heart disease (CHD) and stroke.
BACKGROUND
To evaluate the performance of Framingham predictions of cardiovascular disease (CVD) risk corrected for the competing risk of non-CVD death, in an independent European cohort of older individuals and subsequently extend the predictions by disentangling CVD into coronary heart disease (CHD) and stroke separately.


METHODS
We used the Rotterdam Study data, a prospective cohort study of individuals aged 55 years and older (N=6004), to validate the Framingham predictions of CVD, defined as first occurrence of myocardial infarction, coronary death or stroke during 15 years of follow-up, corrected for the competing risk of non-CVD death. We subsequently estimated the risks of CHD and stroke separately, and used the sum as a predictor for the total CVD risk. Calibration plots and c-statistics were used to evaluate the performance of the models.


RESULTS
Performance of the Framingham predictions was good in the low- to intermediate risk (≤30%, 15-year CVD risk) (17.5% observed vs. 16.6% expected) but poorer in the higher risk (>30%) categories (36.3% observed vs. 44.1% expected). The c-statistic increased from 0.66 to 0.69 after refitting. Separately estimating CHD and stroke revealed considerable heterogeneity with regard to the contribution of CHD and stroke to total CVD risk.


CONCLUSIONS
Framingham CVD risk predictions perform well in the low- to intermediate risk categories in the Rotterdam Study. Disentangling CVD into CHD and stroke separately provides additional information about the individual contribution of CHD and stroke to total individual CVD risk.
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.
Bob J H
BJ
van Kempen
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.
Bart S
BS
Ferket
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
Maryam
M
Kavousi
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.
Maarten J G
MJ
Leening
Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
Ewout W
EW
Steyerberg
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.
M Arfan
MA
Ikram
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
Jacqueline C M
JC
Witteman
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
Albert
A
Hofman
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
Oscar H
OH
Franco
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands; Department of Health Policy and Management, Harvard School of Public Health, Boston, USA. Electronic address: m.hunink@erasmusmc.nl.
M G Myriam
MG
Hunink
D000368:Aged; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000453:epidemiology; D015331:Cohort Studies; D003327:Coronary Disease / Q000175:diagnosis* / Q000453:epidemiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology*
Cardiovascular disease; Framingham risk score; Risk prediction; Rotterdam Study