Distribution of Estimated 10-Year Risk of Recurrent Vascular Events and Residual Risk in a Secondary Prevention Population.
BACKGROUND
Among patients with clinically manifest vascular disease, the risk of recurrent vascular events is likely to vary. We assessed the distribution of estimated 10-year risk of recurrent vascular events in a secondary prevention population. We also estimated the potential risk reduction and residual risk that can be achieved if patients reach guideline-recommended risk factor targets.


METHODS
The SMART score (Second Manifestations of Arterial Disease) for 10-year risk of myocardial infarction, stroke, or vascular death was applied to 6904 patients with vascular disease. The risk score was externally validated in 18 436 patients with various manifestations of vascular disease from the TNT (Treating to New Targets), IDEAL (Incremental Decrease in End Points Through Aggressive Lipid Lowering), SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels), and CAPRIE (Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events) trials. The residual risk at guideline-recommended targets was estimated by applying relative risk reductions from meta-analyses to the estimated risk for targets for systolic blood pressure, low-density lipoprotein cholesterol, smoking, physical activity, and use of antithrombotic agents.


RESULTS
The external performance of the SMART risk score was reasonable, apart from overestimation of risk in patients with 10-year risk >40%. In patients with various manifestations of vascular disease, median 10-year risk of a recurrent major vascular event was 17% (interquartile range, 11%-28%), varying from <10% in 18% to >30% in 22% of the patients. If risk factors were at guideline-recommended targets, the residual 10-year risk would be <10% in 47% and >30% in 9% of the patients (median, 11%; interquartile range, 7%-17%).


CONCLUSIONS
Among patients with vascular disease, there is very substantial variation in estimated 10-year risk of recurrent vascular events. If all modifiable risk factors were at guideline-recommended targets, half of the patients would have a 10-year risk <10%. These data suggest that even with optimal treatment, many patients with vascular disease will remain at >20% and even >30% 10-year risk, clearly delineating an area of substantial unmet medical need.
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Lotte
L
Kaasenbrood
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
S Matthijs
SM
Boekholdt
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Yolanda
Y
van der Graaf
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Kausik K
KK
Ray
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Ron J G
RJ
Peters
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
John J P
JJ
Kastelein
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Pierre
P
Amarenco
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
John C
JC
LaRosa
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Maarten J M
MJ
Cramer
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Jan
J
Westerink
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
L Jaap
LJ
Kappelle
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.).
Gert J
GJ
de Borst
From Department of Vascular Medicine (L.K., J.W., F.L.J.V.), Julius Centre for Health Sciences and Primary Care (Y.v.d.G.), Department of Cardiology (M.J.M.C.), Department of Neurology (L.J.K.), and Department of Vascular Surgery (G.J.d.B.), University Medical Centre Utrecht, the Netherlands; Departments of Cardiology (S.M.B., R.J.G.P.) and Vascular Medicine (J.J.P.K.), Academic Medical Centre, Amsterdam, the Netherlands; School of Public Health, Imperial College London, United Kingdom (K.K.R.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); and SUNY Health Science Center at Brooklyn, New York, NY (J.C.L.). f.l.j.visseren@umcutrecht.nl.
Frank L J
FL
Visseren
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D008078:Cholesterol, LDL / Q000097:blood; D015444:Exercise; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology; D011446:Prospective Studies; D012907:Smoking / Q000097:blood / Q000401:mortality / Q000503:physiopathology; D014652:Vascular Diseases / Q000097:blood / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology
D008078:Cholesterol, LDL; D005343:Fibrinolytic Agents
cardiovascular disease; guideline adherence; risk assessment; risk factors; secondary prevention