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Discordance between 10-year cardiovascular risk estimates using the ACC/AHA 2013 estimator and coronary artery calcium in individuals from 5 racial/ethnic groups: Comparing MASALA and MESA

  • Author Footnotes
    1 These authors contributed equally to this work as co-first authors.
    Mahmoud Al Rifai
    Footnotes
    1 These authors contributed equally to this work as co-first authors.
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Department of Internal Medicine, University of Kansas School of Medicine, Wichita, KS, USA
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  • Author Footnotes
    1 These authors contributed equally to this work as co-first authors.
    Miguel Cainzos-Achirica
    Footnotes
    1 These authors contributed equally to this work as co-first authors.
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Bellvitge University Hospital and Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    RTI Health Solutions, Pharmacoepidemiology and Risk Management, Barcelona, Spain
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  • Alka M. Kanaya
    Affiliations
    Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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  • Namratha R. Kandula
    Affiliations
    Feinberg School of Medicine, Division of General Internal Medicine, Northwestern University, Chicago, IL, USA

    Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
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  • Zeina Dardardi
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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  • Parag H. Joshi
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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  • Jaideep Patel
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Department of Cardiology, VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
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  • Matthew Budoff
    Affiliations
    Division of Cardiology, Los Angeles Biomedical Research Institute, Torrance, CA, USA
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  • Joseph Yeboah
    Affiliations
    Department of Cardiology, Wake Forest Baptist Health, Winston-Salem, NC, USA
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  • Eliseo Guallar
    Affiliations
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA

    Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
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  • Roger S. Blumenthal
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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  • Michael J. Blaha
    Correspondence
    Corresponding author. Ciccarone Center for the Prevention of Heart Disease, The Johns Hopkins Hospital, Blalock 524D1, 600 N Wolfe St, Baltimore, MD, 21287, USA.
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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  • Author Footnotes
    1 These authors contributed equally to this work as co-first authors.

      Highlights

      • The performance of the pooled cohort equations (PCE) among South Asians (SAs) is uncertain.
      • In the absence of 10-year follow-up for ASCVD events, coronary artery calcium may be used as a surrogate outcome.
      • We studied the prevalence of CAC across strata of ASCVD risk in SAs as well as in other 4 races/ethnicities.
      • There was a higher odds of CAC = 0 among low and intermediate risk SAs as compared to NHWs.
      • The PCE may overestimate risk in low and intermediate risk in SAs living in the US even to a greater extent than in NHWs.

      Abstract

      Background and aims

      South Asian (SA) individuals are thought to represent a group that is at high-risk for atherosclerotic cardiovascular disease (ASCVD). However, the performance of the Pooled Cohort Equations (PCE) remains uncertain in SAs living in the US. We aimed to study the interplay between predicted 10-year ASCVD risk and coronary artery calcium (CAC) in SAs compared to other racial/ethnic groups.

      Methods

      We studied 536 SAs from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, and 2073 Non-Hispanic Whites (NHWs), 1514 African Americans (AAs), 1254 Hispanics, and 671 Chinese Americans (CAs) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were not currently on statins. We used logistic regression models to assess the association between race/ethnicity and CAC within each ASCVD risk stratum.

      Results

      SAs at low and at intermediate estimated ASCVD risk were more likely to have CAC = 0 compared to NHWs, while SAs at high risk had a similar CAC burden to NHWs. For example, intermediate-risk SAs had a 73% higher odds of CAC = 0 compared to NHWs (95% 1.00–2.99), while high-risk SAs were equally likely to have CAC = 0 (OR 0.95, 95% CI 0.65–1.38) and CAC >100 (OR 0.86, 95% CI 0.61–1.22).

      Conclusions

      Our results suggest that the extent of ASCVD risk overestimation using the PCEs may be even greater among SAs considered at low and intermediate risk than among NHWs. Studies with incident ASCVD events are required to validate and/or recalibrate current ASCVD risk prediction tools in this group.

      Keywords

      Abbreviations:

      AA (African American), ACC (American College of Cardiology), AHA (American Heart Association), ASCVD (Atherosclerotic Cardiovascular Disease), CA (Chinese American), CAC (coronary artery calcium), CT (computed tomography), MASALA (Mediators of Atherosclerosis in South Asians Living in America), MESA (Multi-Ethnic Study of Atherosclerosis), NHW (non-Hispanic White), PCE (Pooled Cohort Equations), SA (South Asian)
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