title: Identification of vascular patients at very high risk for recurrent cardiovascular events: validation of the current ACC/AHA very high risk criteria.
abstract: OBJECTIVE
  To validate and assess performance of the current ACC/AHA very high risk criteria in patients with clinically manifest arterial disease.
  
  
  RESULTS
  Data were used from the SMART study (n = 7216) and REACH Registry (n = 48 322), two prospective cohorts of patients with manifest atherosclerotic arterial disease. Prevalence and incidence rates of recurrent major adverse cardiovascular events (MACE) were calculated, according to the ACC/AHA VHR criteria (cardiovascular disease combined with diabetes, smoking, dyslipidaemia, and/or recent recurrent coronary events). Performance of the ACC/AHA criteria was compared with single very high risk factors in terms of C-statistics and Net Reclassification Index. All patients were at VHR according to the ESC guidelines (incidence of recurrent MACE in SMART was 2.4/100PY, with 95% CI 2.3-2.5/100PY and in REACH 5.1/100PY with 95% CI 5.0-5.3/100PY). In SMART 57% of the patients were at VHR according to the ACC/AHA criteria (incidence of recurrent MACE 2.7/100PY, 95% CI 2.5-2.9/100PY) and in REACH this was 64% (5.9/100PY, 95% CI 5.7-6.1/100PY). The C-statistic for the ACC/AHA VHR criteria was 0.53 in REACH and 0.54 in SMART. Very high risk factors with comparable or slightly better performance were eGFR < 45, polyvascular disease and age >70 years. Around two third of the patients meeting the ACC/AHA VHR criteria had a predicted 10-year risk of recurrent MACE <30%.
  
  
  CONCLUSIONS
  The ACC/AHA VHR criteria have limited discriminative power. Identifying patients with clinically manifest arterial disease at VHR for recurrent vascular events using eGFR <45, polyvascular disease, or age >70 years performs as well as the ACC/AHA VHR criteria.
authors.affiliation: Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
authors.forename: M Johanneke
authors.initials: MJ
authors.lastname: van den Berg
authors.affiliation: Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, USA.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: Department of Neurology, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: L Jaap
authors.initials: LJ
authors.lastname: Kappelle
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Gert J
authors.initials: GJ
authors.lastname: de Borst
authors.affiliation: Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Maarten J
authors.initials: MJ
authors.lastname: Cramer
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: van der Graaf
authors.affiliation: Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodeling), Université Paris-Diderot, Sorbonne Paris Cité, Paris, France.|FACT (French Alliance for Cardiovascular Clinical Trials), Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France.|INSERM U-1148, Paris, France.|National Heart and Lung Institute, Royal Brompton Hospital, Imperial College, London, UK.
authors.forename: Ph Gabriel
authors.initials: PG
authors.lastname: Steg
authors.affiliation: Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
authors.forename: Frank L J
authors.initials: FLJ
authors.lastname: Visseren
mesh_terms: D000328:Adult; D000368:Aged; D050197:Atherosclerosis / Q000150:complications / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology*; D003925:Diabetic Angiopathies / Q000150:complications / Q000453:epidemiology; D050171:Dyslipidemias / Q000150:complications / Q000453:epidemiology; D042241:Early Diagnosis; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D015995:Prevalence; D011446:Prospective Studies; D012008:Recurrence; D012042:Registries; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology
keywords: Cardiovascular events; Risk prediction; Secondary prevention; Very high risk