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. 2009 Dec 8;54(24):2303-11.
doi: 10.1016/j.jacc.2009.07.047.

Improving Global Vascular Risk Prediction With Behavioral and Anthropometric Factors. The Multiethnic NOMAS (Northern Manhattan Cohort Study)

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Free PMC article

Improving Global Vascular Risk Prediction With Behavioral and Anthropometric Factors. The Multiethnic NOMAS (Northern Manhattan Cohort Study)

Ralph L Sacco et al. J Am Coll Cardiol. .
Free PMC article

Abstract

Objectives: This study sought to improve global vascular risk prediction with behavioral and anthropometric factors.

Background: Few cardiovascular risk models are designed to predict the global vascular risk of myocardial infarction, stroke, or vascular death in multiethnic individuals, and existing schemes do not fully include behavioral risk factors.

Methods: A randomly derived, population-based, prospective cohort of 2,737 community participants free of stroke and coronary artery disease was followed up annually for a median of 9.0 years in the NOMAS (Northern Manhattan Study) (mean age 69 years, 63.2% women, 52.7% Hispanic, 24.9% African American, and 19.9% white). A global vascular risk score (GVRS) predictive of stroke, myocardial infarction, or vascular death was developed by adding variables to the traditional Framingham cardiovascular variables based on the likelihood ratio criteria. Model utility was assessed through receiver-operating characteristics, calibration, and effect on reclassification of subjects.

Results: Variables that significantly added to the traditional Framingham profile included waist circumference, alcohol consumption, and physical activity. Continuous measures for blood pressure and fasting blood sugar were used instead of hypertension and diabetes. Ten-year event-free probabilities were 0.95 for the first quartile of GVRS, 0.89 for the second quartile, 0.79 for the third quartile, and 0.56 for the fourth quartile. The addition of behavioral factors in our model improved prediction of 10-year event rates compared with a model restricted to the traditional variables.

Conclusions: A GVRS that combines traditional, behavioral, and anthropometric risk factors; uses continuous variables for physiological parameters; and is applicable to nonwhite subjects could improve primary prevention strategies.

Figures

Figure 1
Figure 1. Survival Free of Stroke, MI or Vascular Death stratified by NOMAS quartiles of Global Vascular Risk Scores
GVRS 1st quartile: 4.4-8.0, 2nd quartile: 8.0-8.7, 3rd quartile: 8.7-9.3, 4th quartile: 9.3-11.6
Figure 2
Figure 2. Comparative Receiver Operating Characteristics
Receiver Operating Characteristics (ROC) for a model consisting of Framingham traditional variables, model chosen by AIC method (Framingham traditional variables and waist circumference and an interaction between alcohol use and physical activity) and the NOMAS global vascular risk score. Areas under the curve (AUC) for traditional variable model are 0.736, for the traditional variables and waist circumference and an interaction between alcohol use and physical activity 0.739, and for NOMAS GVRS 0.747.
Figure 3
Figure 3. Comparison of 10-year Predicted Probabilities of Global Vascular Risk
Comparison of 10-year predicted probabilities between the NOMAS GVRS and the model with traditional variables. Points above (below) the dashed line are the subjects whose 10-year risk is predicted higher (lower) with the NOMAS GVRS compared to the model with traditional variables. Black crosses show subjects who failed within 10 years and red dots show those who are free of the outcome for 10 years of follow-up. Note that black points above and red points below the dashed line represent correct reclassification. The crude summary proportion of correctly reclassified points by the NOMAS GVRS compared to Framingham was 54.8%. The summary statistic (weighted versions of the integrated discrimination improvement measures proposed by Pencina) between NOMAS model and traditional variables model is 8.66 and p-value computed from the bootstrap procedure of 0.055.
Figure 4
Figure 4. Calibration by decile for NOMAS GVR Score
Comparison of 10-year Kaplan-Meier (gray bar) and NOMAS model-based predicted (decile specific means; black bar) probabilities of stroke, MI or vascular death events by deciles of the NOMAS global vascular risk score.
Figure 5
Figure 5. Web-based screen for entry of Global Vascular Risk Score

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