Prediction of Cardiovascular Disease Mortality in a Middle Eastern Country: Performance of the Globorisk and Score Functions in Four Population-Based Cohort Studies of Iran

BackgroundConsidering the importance of cardiovascular disease (CVD) risk prediction for healthcare systems and the limited information available in the Middle East, we evaluated the SCORE and Globorisk models to predict CVD death in a country of this region.MethodsWe included ۲۴ ۴۲۷ participants (۱۱ ۱۸۷ men) aged ۴۰-۸۰ years from four population-based cohorts in Iran. Updating approaches were used to recalibrate the baseline survival and the overall effect of the predictors of the models. We assessed the models’ discrimination using C-index and then compared the observed with the predicted risk of death using calibration plots. The sensitivity and specificity of the models were estimated at the risk thresholds of ۳%, ۵%, ۷%, and ۱۰%. An agreement between models was assessed using the intra-class correlation coefficient (ICC). We applied decision analysis to provide perception into the consequences of using the models in general practice; for this reason, the clinical usefulness of the models was assessed using the net benefit (NB) and decision curve analysis. The NB is a sensitivity penalized by a weighted false positive (FP) rate in population level.ResultsAfter ۱۵۴ ۵۲۲ person-years of follow-up, ۴۳۷ cardiovascular deaths (۲۸۰ men) occurred. The ۱۰-year observed risks were ۴.۲% (۹۵% CI: ۳.۷%-۴.۸%) in men and ۲.۱% (۱.۸-۲%.۵%) in women. The c-index for SCORE function was ۰.۷۸۴ (۰.۷۵۶-۰.۸۱۲) in men and ۰.۷۸۰ (۰.۷۴۴-۰.۸۱۵) in women. Corresponding values for Globorisk were ۰.۷۹۳ (۰.۷۶۶-۰.۸۲۰) and ۰.۷۹۳ (۰.۷۵۷-۰.۸۲۹). The deviation of the calibration slopes from one reflected a need for recalibration; after which, the predicted-to-observed ratio for both models was ۱.۰۲ in men and ۰.۹۵ in women. Models showed good agreement (ICC ۰.۹۳ in men, and ۰.۸۹ in women). Decision curve showed that using both models results in the same clinical usefulness at the risk threshold of ۵%, in both men and women; however, at the risk threshold of ۱۰%, Globorisk had better clinical usefulness in women (Difference: ۸%, ۹۵% CI: ۴%-۱۳%).ConclusionOriginal Globorisk and SCORE models overestimate the CVD risk in Iranian populations resulting in a high number of people who need intervention. Recalibration could adopt these models to precisely predict CVD mortality. Globorisk showed better performance clinically, only among high-risk women.

Keywords:

Cardiovascular Diseases , Mortality , Prediction Model , Statistical , Decision-Making