EvidenceAlerts

Dalton JE, Rothberg MB, Dawson NV, et al. Failure of Traditional Risk Factors to Adequately Predict Cardiovascular Events in Older Populations. J Am Geriatr Soc. 2020 Jan 20. doi: 10.1111/jgs.16329. (Original study)
Abstract

BACKGROUND: Accurate assessment of atherosclerotic cardiovascular disease (ASCVD) risk across heterogeneous populations is needed for effective primary prevention. Little is known about the performance of standard cardiovascular risk factors in older adults.

OBJECTIVE: To evaluate the performance of the American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) risk model, as well as the underlying cardiovascular risk factors, among adults older than 65 years.

DESIGN AND SETTING: Retrospective cohort derived from a regional referral system's electronic medical records.

PARTICIPANTS: A total of 25 349 patients who were 65 years or older at study baseline (date of the first outpatient lipid panel taken between 2007 and 2010).

MEASUREMENTS: Exposures of interest were traditional cardiovascular risk factors, as defined by inclusion in the PCE model. The primary outcome was major ASCVD events, defined as a composite of myocardial infarctions, stroke, and cardiovascular death.

RESULTS: The PCE and internally estimated models produced similar risk distributions for white men aged 65 to 74 years. For all other groups, PCE predictions were generally lower than those of the internal models, particularly for African Americans. Discrimination of the PCE was poor for all age groups, with concordance index (95% confidence interval) estimates of 0.62 (0.60-0.64), 0.56 (0.54-0.57), and 0.52 (0.49-0.54) among patients aged 65 to 74, 75 to 84, and 85 years and older, respectively. Reestimating relationships within these age groups resulted in better calibration but negligible improvements in discrimination. Blood pressure, total cholesterol, and diabetes either were not associated at all or had inverse associations in the older age groups.

CONCLUSION: Traditional clinical risk factors for cardiovascular disease failed to accurately characterize risk in a contemporary population of Medicare-aged patients. Among those aged 85 years and older, some traditional risk factors were not associated with ASCVD events. Better risk models are needed to appropriately inform treatment decision making for the growing population of older adults.

Ratings
Discipline Area Score
Family Medicine (FM)/General Practice (GP) 7 / 7
General Internal Medicine-Primary Care(US) 7 / 7
Geriatrics 6 / 7
Internal Medicine 6 / 7
Comments from MORE raters

Family Medicine (FM)/General Practice (GP) rater

This paper helps us question what we should be doing for primary prevention in the elderly. Less might be better.

General Internal Medicine-Primary Care(US) rater

Provides additional data that primary care providers can use to guide their decision on cholesterol management, particularly among geriatric patients.

Geriatrics rater

20th Century personality Will Rogers once declared, "It ain't so much what you don't know that gets you into trouble, as what you KNOW that ain't so!" Generations of primary care physicians have been trained to apply a 1-size-fits-all approach to cardiovascular risk assessment and modification. This study calls into question the wisdom of that logic for aging adults. Although I wonder why established risk factors would not be associated with cardiovascular events, a more compelling question is: Can any factors accurately predict older adult cardiovascular events if these factors do not?

Internal Medicine rater

Interesting paper that points out (as other papers have) that the risk equations used for predicting CAD are imperfect. I think the emphasis on the elderly in this paper is useful since the equations would predict that all men aged >=65 have a greater than 7.5% 10-year CVD risk. The clinical implication of the paper`s findings are that by using the current equations we may be making errors in our judgements of starting things like statins.

Internal Medicine rater

I don't think this is completely new, but the lack of predictive value in patients >85 years old is pretty striking. Interesting that smoking and low HDL still seem to confer risk late in life.
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