title: Comparison of application of the ACC/AHA guidelines, Adult Treatment Panel III guidelines, and European Society of Cardiology guidelines for cardiovascular disease prevention in a European cohort.
abstract: OBJECTIVE
  The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines introduced a prediction model and lowered the threshold for treatment with statins to a 7.5% 10-year hard atherosclerotic cardiovascular disease (ASCVD) risk. Implications of the new guideline's threshold and model have not been addressed in non-US populations or compared with previous guidelines.
  
  
  OBJECTIVE
  To determine population-wide implications of the ACC/AHA, the Adult Treatment Panel III (ATP-III), and the European Society of Cardiology (ESC) guidelines using a cohort of Dutch individuals aged 55 years or older.
  
  
  METHODS
  We included 4854 Rotterdam Study participants recruited in 1997-2001. We calculated 10-year risks for "hard" ASCVD events (including fatal and nonfatal coronary heart disease [CHD] and stroke) (ACC/AHA), hard CHD events (fatal and nonfatal myocardial infarction, CHD mortality) (ATP-III), and atherosclerotic CVD mortality (ESC).
  
  
  METHODS
  Events were assessed until January 1, 2012. Per guideline, we calculated proportions of individuals for whom statins would be recommended and determined calibration and discrimination of risk models.
  
  
  RESULTS
  The mean age was 65.5 (SD, 5.2) years. Statins would be recommended for 96.4% (95% CI, 95.4%-97.1%; n = 1825) of men and 65.8% (95% CI, 63.8%-67.7%; n = 1523) of women by the ACC/AHA, 52.0% (95% CI, 49.8%-54.3%; n = 985) of men and 35.5% (95% CI, 33.5%-37.5%; n = 821) of women by the ATP-III, and 66.1% (95% CI, 64.0%-68.3%; n = 1253) of men and 39.1% (95% CI, 37.1%-41.2%; n = 906) of women by ESC guidelines. With the ACC/AHA model, average predicted risk vs observed cumulative incidence of hard ASCVD events was 21.5% (95% CI, 20.9%-22.1%) vs 12.7% (95% CI, 11.1%-14.5%) for men (192 events) and 11.6% (95% CI, 11.2%-12.0%) vs 7.9% (95% CI, 6.7%-9.2%) for women (151 events). Similar overestimation occurred with the ATP-III model (98 events in men and 62 events in women) and ESC model (50 events in men and 37 events in women). The C statistic was 0.67 (95% CI, 0.63-0.71) in men and 0.68 (95% CI, 0.64-0.73) in women for hard ASCVD (ACC/AHA), 0.67 (95% CI, 0.62-0.72) in men and 0.69 (95% CI, 0.63-0.75) in women for hard CHD (ATP-III), and 0.76 (95% CI, 0.70-0.82) in men and 0.77 (95% CI, 0.71-0.83) in women for CVD mortality (ESC).
  
  
  CONCLUSIONS
  In this European population aged 55 years or older, proportions of individuals eligible for statins differed substantially among the guidelines. The ACC/AHA guideline would recommend statins for nearly all men and two-thirds of women, proportions exceeding those with the ATP-III or ESC guidelines. All 3 risk models provided poor calibration and moderate to good discrimination. Improving risk predictions and setting appropriate population-wide thresholds are necessary to facilitate better clinical decision making.
authors.affiliation: Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Maryam
authors.initials: M
authors.lastname: Kavousi
authors.affiliation: Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands2Department of Cardiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Maarten J G
authors.initials: MJ
authors.lastname: Leening
authors.affiliation: Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Nanchen
authors.affiliation: Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois5Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Philip
authors.initials: P
authors.lastname: Greenland
authors.affiliation: Trinity College, Dublin, Ireland.
authors.forename: Ian M
authors.initials: IM
authors.lastname: Graham
authors.affiliation: Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands8Department of Radiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands9Department of Neurology, Erasmus MC-University Medic.
authors.forename: M Arfan
authors.initials: MA
authors.lastname: Ikram
authors.affiliation: Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands10Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands11Inspectorate for Health Care, the Hague, t.
authors.forename: Bruno H
authors.initials: BH
authors.lastname: Stricker
authors.affiliation: Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Albert
authors.initials: A
authors.lastname: Hofman
authors.affiliation: Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Oscar H
authors.initials: OH
authors.lastname: Franco
mesh_terms: D000368:Aged; D000572:American Heart Association; D002309:Cardiology; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000517:prevention & control*; D015331:Cohort Studies; D005060:Europe; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009426:Netherlands; D017410:Practice Guidelines as Topic; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012955:Societies, Medical; D020521:Stroke / Q000453:epidemiology; D014481:United States
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors