title: Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort.
abstract: OBJECTIVE
  To evaluate the 2013 American Heart Association (AHA)-American College of Cardiology (ACC)-Atherosclerotic Cardiovascular Disease (ASCVD) risk score among four different race/ethnic groups and to ascertain which factors are most associated with risk overestimation by the AHA-ACC-ASCVD score.
  
  
  RESULTS
  The Multi-Ethnic Study of Atherosclerosis (MESA), a prospective community-based cohort, was used to examine calibration and discrimination of the AHA-ACC-ASCVD risk score in 6441 White, Black, Chinese, and Hispanic Americans (aged 45-79 years and free of known ASCVD at baseline). Using univariable and multivariable absolute risk regression, we modelled the impact of individual risk factors on the discordance between observed and predicted 10-year ASCVD risk. Overestimation was observed in all race/ethnic groups in MESA and was highest among Chinese (252% for women and 314% for men) and lowest in White women (72%) and Hispanic men (67%). Higher age, Chinese race/ethnicity (when compared with White), systolic blood pressure (treated and untreated), diabetes, alcohol use, exercise, lipid-lowering medication, and aspirin use were all associated with more risk overestimation, whereas family history was associated with less risk overestimation in a multivariable model (all P < 0.05).
  
  
  CONCLUSIONS
  The AHA-ACC-ASCVD risk score overestimates ASCVD risk among men, women, and all four race/ethnic groups evaluated in a modern American primary prevention cohort. Clinicians treating patients similar to those in MESA, particularly older individuals and those with factors associated with more risk overestimation, may consider interpreting absolute ASCVD risk estimates with caution.
authors.affiliation: Jewish Hospital, Louisville, KY, USA.|Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.|Division of Cardiovascular Medicine, University of Louisville, 550 South Jackson Street, Louisville, KY 40202, USA.
authors.forename: Andrew Paul
authors.initials: AP
authors.lastname: DeFilippis
authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Rebekah
authors.initials: R
authors.lastname: Young
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: John W
authors.initials: JW
authors.lastname: McEvoy
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Erin D
authors.initials: ED
authors.lastname: Michos
authors.affiliation: National Institutes of Health, Bethesda, MD, USA.
authors.forename: Veit
authors.initials: V
authors.lastname: Sandfort
authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Kronmal
authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Robyn L
authors.initials: RL
authors.lastname: McClelland
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000572:American Heart Association; D001213:Asian / Q000706:statistics & numerical data; D002309:Cardiology; D003324:Coronary Artery Disease / Q000453:epidemiology / Q000208:ethnology / Q000517:prevention & control*; D005260:Female; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D017678:Sex Distribution; D014481:United States / Q000453:epidemiology; D044465:White People / Q000208:ethnology
keywords: Cardiovascular risk prediction; Prevention; Risk factors