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Original research article
Cardiovascular risk model performance in women with and without hypertensive disorders of pregnancy
  1. Veerle Dam1,2,
  2. N Charlotte Onland-Moret1,
  3. W M Monique Verschuren1,3,
  4. Jolanda M A Boer3,
  5. Laura Benschop2,4,
  6. Arie Franx5,
  7. Karel G M Moons1,
  8. Eric Boersma6,
  9. Yvonne T van der Schouw1
  10. on behalf of the CREW-consortium
    1. 1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
    2. 2 Netherlands Heart Institute, Utrecht, The Netherlands
    3. 3 National Institute of Public Health and the Environment, Bilthoven, The Netherlands
    4. 4 Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
    5. 5 Division of Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands
    6. 6 Department of Cardiology, Erasmus University Medical Center, Rotterdam
    1. Correspondence to Professor Yvonne T van der Schouw; Y.T.vanderSchouw{at}umcutrecht.nl

    Abstract

    Objectives Compare the predictive performance of Framingham Risk Score (FRS), Pooled Cohort Equations (PCEs) and Systematic COronary Risk Evaluation (SCORE) model between women with and without a history of hypertensive disorders of pregnancy (hHDP) and determine the effects of recalibration and refitting on predictive performance.

    Methods We included 29 751 women, 6302 with hHDP and 17 369 without. We assessed whether models accurately predicted observed 10-year cardiovascular disease (CVD) risk (calibration) and whether they accurately distinguished between women developing CVD during follow-up and not (discrimination), separately for women with and without hHDP. We also recalibrated (updating intercept and slope) and refitted (recalculating coefficients) the models.

    Results Original FRS and PCEs overpredicted 10-year CVD risks, with expected:observed (E:O) ratios ranging from 1.51 (for FRS in women with hHDP) to 2.29 (for PCEs in women without hHDP), while E:O ratios were close to 1 for SCORE. Overprediction attenuated slightly after recalibration for FRS and PCEs in both hHDP groups. Discrimination was reasonable for all models, with C-statistics ranging from 0.70-0.81 (women with hHDP) and 0.72–0.74 (women without hHDP). C-statistics improved slightly after refitting 0.71–0.83 (with hHDP) and 0.73–0.80 (without hHDP). The E:O ratio of the original PCE model was statistically significantly better in women with hHDP compared with women without hHDP.

    Conclusions SCORE performed best in terms of both calibration and discrimination, while FRS and PCEs overpredicted risk in women with and without hHDP, but improved after recalibrating and refitting the models. No separate model for women with hHDP seems necessary, despite their higher baseline risk.

    • epidemiology
    • pregnancy
    • coronary artery disease
    • cardiac risk factors and prevention

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    Footnotes

    • Contributors VD, NCOM and YTvdS designed the study. VD did the statistical analyses. VD drafted the first version of the manuscript. VD, YTvdS, NCOM, WMMV, JMAB, LB, AF, KGMM and EB provided critical input to the manuscript and approved the final version for publication.

    • Funding This work was supported by the Dutch Heart Foundation (2013T083 to VD and LB) and is part of the Dutch national consortium to promote CardiovasculaR hEalthy aging in Women (CREW) project.

    • Competing interests None declared.

    • Patient consent All participants provided written informed consent before study inclusion.

    • Ethics approval The study was approved by the institutional review board of the University Medical Center Utrecht and the medical ethical committee of TNO Nutrition and Food Research (MORGEN-EPIC).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators Collaborators CREW-consortium sorted the last author in alphabetical order: Yolande Appelman (VU University Medical Center, Amsterdam, The Netherlands); Sara Baart (Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands); Laura Benschop (Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands); Eric Boersma (Erasmus University Medical Center, Rotterdam, The Netherlands); Laura Brouwers (Netherlands Heart Institute, Utrecht, The Netherlands; University Medical Center Utrecht, Utrecht, The Netherlands); Ricardo P J Budde (Erasmus University Medical Center, Rotterdam, The Netherlands); Suzanne C Cannegieter (Leiden University Medical Center, Leiden, The Netherlands); Veerle Dam (Netherlands Heart Institute, Utrecht, The Netherlands; Julius Center, Utrecht, University Medical Center, Utrecht, the Netherlands); Rene M J C Eijkemans (Julius Center, Utrecht, University Medical Center, Utrecht, The Netherlands); Bart C J M Fauser (University Medical Center Utrecht, Utrecht, The Netherlands); Michel D Ferrari (Leiden University Medical Center, Leiden, The Netherlands); Arie Franx (University Medical Center Utrecht, Utrecht, The Netherlands); Christianne J M de Groot (VU University Medical Center, Amsterdam, The Netherlands); Marlise N Gunning (Netherlands Heart Institute, Utrecht, The Netherlands; University Medical Center Utrecht, Utrecht, The Netherlands); Annemiek Hoek (University Medical Center Groningen, Groningen, The Netherlands); Hendrik Koffijberg (Julius Center, Utrecht, University Medical Center, Utrecht, The Netherlands; University of Twente, Enschede, The Netherlands); Maria P H Koster (Erasmus University Medical Center, Rotterdam, The Netherlands); Mark C Kruit (Leiden University Medical Center, Leiden, The Netherlands); Ghizelda R Lagerweij (Netherlands Heart Institute, Utrecht, The Netherlands; Julius Center, Utrecht, University Medical Center, Utrecht, The Netherlands); Cornelis B Lambalk (VU University Medical Center, Amsterdam, The Netherlands); Joop S E Laven (Erasmus University Medical Center, Rotterdam, The Netherlands); Katie M Linstra (Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands; Leiden University Medical Center, Leiden, The Netherlands); Aad van der Lugt (Erasmus University Medical Center, Rotterdam, The Netherlands); Angela H E M Maas (Radboud University Medical Center, Nijmegen, The Netherlands); Antoinette Maassen van den Brink (Erasmus University Medical Center, Rotterdam, The Netherlands); Cindy Meun (Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands); Saskia Middeldorp (Academic Medical Center, Amsterdam, The Netherlands); Karel G M Moons (Julius Center, Utrecht, University Medical Center, Utrecht, The Netherlands); Bas B van Rijn (University Medical Center Utrecht, Utrecht, The Netherlands); Jeanine E Roeters van Lennep (Erasmus University Medical Center, Rotterdam, The Netherlands); Jolien W Roos-Hesselink (Erasmus University Medical Center, Rotterdam, The Netherlands); Luuk J J Scheres (Netherlands Heart Institute, Utrecht, The Netherlands; Leiden University Medical Center, Leiden, The Netherlands; Academic Medical Center, Amsterdam, The Netherlands); Yvonne T van der Schouw (Julius Center, Utrecht, University Medical Center, Utrecht, The Netherlands); Eric A P Steegers (Erasmus University Medical Center, Rotterdam, The Netherlands); Regine P M Steegers-Theunissen (Erasmus University Medical Center, Rotterdam, The Netherlands); Gisela M Terwindt (Leiden University Medical Center, Leiden, The Netherlands); Birgitta K Velthuis (University Medical Center Utrecht, Utrecht, The Netherlands); Marieke J H Wermer (Leiden University Medical Center, Leiden, the Netherlands); Gerbrand A Zoet (Netherlands Heart Institute, Utrecht, The Netherlands; University Medical Center Utrecht, Utrecht, The Netherlands).

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