Source/Disclosures
Disclosures: Sedlak reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
April 17, 2020
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Risk scores inaccurately predict CVD rates in women with INOCA

Source/Disclosures
Disclosures: Sedlak reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Tara Sedlak

Six primary prevention risk assessment scores, including the Framingham risk score, Atherosclerotic Cardiovascular Disease risk score and Adult Treatment Panel III risk score, did not adequately predict the rates of CVD in women with ischemia and no obstructive CAD, according to a study published in the Journal of the American Heart Association.

Other scores assessed in this study were Reynolds risk score, Systematic Coronary Risk Evaluation (SCORE) and Cardiovascular Risk Score 2.

“Primary prevention scores such as ASCVD or Framingham risk score should not be used in these patients to make decisions about therapy,” Tara Sedlak, MD, FRCPC, MBA, cardiologist at Vancouver General Hospital and medical director at Leslie Diamond Women’s Heart Health Clinic and clinical associate professor at University of British Columbia, told Healio. “Instead, they should be followed and treated more aggressively.”

Data from Women’s Ischemia Syndrome Evaluation

Researchers analyzed data from 433 women (mean age, 57 years; 83% white) from the Women’s Ischemia Syndrome Evaluation (WISE) who did not have a history of CAD and no obstructive CAD on angiography.

“Many patients with ischemia with no obstructive coronary artery disease are being considered low risk and discharged from specialty care without any treatment or follow-up,” Sedlak said in an interview. “We predicted that INOCA patients are actually higher risk than primary prevention prediction scores would estimate and that they should be followed and treated more aggressively long term.”

These women also had available data for risk assessment according to the six scores of interest. Researchers used C-statistic to evaluate predicted vs. observed event rates during 10 years of follow-up.

Of the women in this study, 43.6% had dyslipidemia, 52.7% had hypertension and 16.9% had diabetes.

Observed score-specific CVD rates during a 10-year period varied from 5.54% for SCORE to 28.87% for the Framingham risk score. Predicted event rates during this period ranged from 1.86% for SCORE to 6.99% for the Cardiovascular Risk Score 2.

Most risk scores in this study had moderate discrimination, with a C-statistic of 0.78 for the Framingham risk score and 0.53 for the ASCVD risk score and SCORE. Most scores also underestimated risk, as shown by a statistical discordance of 58% for the Adult Treatment Panel III score and 84% for the ASCVD score.

Researchers also recalibrated the ASCVD risk score, Reynolds risk score and Framingham risk scores, which improved performance, although significant underestimation persisted.

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“This study demonstrates that these patients are not low risk and that primary prevention prediction models do not accurately predict outcomes in these patients,” Sedlak told Healio.

Additional research

She also discussed further researcher needed in this area. She said, “We would like to apply secondary prevention models (models currently used in patients who have already had an event or a diagnosis of heart disease) to INOCA patients to determine if those accurately predict outcomes. There is an ongoing research study entitled the WARRIOR trial which is examining whether more aggressive therapy such as high-potency statins and ACE [inhibitors] in patients with INOCA reduce long-term outcomes such as heart attacks and stroke.” – by Darlene Dobkowski

For more information:

Tara Sedlak, MD, FRCPC, MBA, can be reached at tara.sedlak.vch.ca.

Disclosures: Sedlak reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.