Objective To assess the performance of cardiovascular disease (CVD) risk equations in Indigenous Australians.
Methods We conducted an individual participant meta-analysis using longitudinal data of 3618 Indigenous Australians (55% women) aged 30–74 years without CVD from population-based cohorts of the Cardiovascular Risk in IndigenouS People(CRISP) consortium. Predicted risk was calculated using: 1991 and 2008 Framingham Heart Study (FHS), the Pooled Cohorts (PC), GloboRisk and the Central Australian Rural Practitioners Association (CARPA) modification of the FHS equation. Calibration, discrimination and diagnostic accuracy were evaluated. Risks were calculated with and without the use of clinical criteria to identify high-risk individuals.
Results When applied without clinical criteria, all equations, except the CARPA-adjusted FHS, underestimated CVD risk (range of percentage difference between observed and predicted CVD risks: −55% to −14%), with underestimation greater in women (−63% to −13%) than men (−47% to −18%) and in younger age groups. Discrimination ranged from 0.66 to 0.72. The CARPA-adjusted FHS equation showed good calibration but overestimated risk in younger people, those without diabetes and those not at high clinical risk. When clinical criteria were used with risk equations, the CARPA-adjusted FHS algorithm scored 64% of those who had CVD events as high risk; corresponding figures for the 1991-FHS were 58% and were 87% for the PC equation for non-Hispanic whites. However, specificity fell.
Conclusion The CARPA-adjusted FHS CVD risk equation and clinical criteria performed the best, achieving higher combined sensitivity and specificity than other equations. However, future research should investigate whether modifications to this algorithm combination might lead to improved risk prediction.
- cardiac risk factors and prevention
- global health
- coronary artery disease
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Correction notice Since this article was first published online, Charles Darwin University has been added to the first affiliation.
Contributors ELMB had full access to all the data in the study and takes responsibility for its integrity and the data analysis. ELMB led all aspects of the conduct of the study and designed the study, drafted the manuscript, collected, analysed and interpreted the data; FB analysed and interpreted the data and revised the manuscript; AR collected and analysed the data and reviewed the manuscript; JC, ST, RMcD, WEH, ZW, PJB, PLT, LD, JB and KO'D collected the data, interpreted the data and revised the manuscript; CC, PB, SG, AB and AC interpreted the data and revised the manuscript; and JS and LM-B conceived and designed the study, interpreted the data and revised the manuscript. All authors approved the final version. The corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in HEART editions and any other BMJPGL products to exploit all subsidiary rights.
Funding The CRISP consortium has received funding from the National Heart Foundation of Australia (Vanguard grant #100595) and a National Health and Medical Research Council (NHMRC) programme grant (#631947). ELMB was supported by a National Heart Foundation postdoctoral fellowship (#101291). LM-B was supported by NHMRC Fellowship (#605837) and NHMRC Practitioner Fellowship (#1078477). JC was supported by an NHMRC Research Fellowship (#1058244). JS was supported by a NHMRC Senior Research Fellowship (#1079438).
Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.The views expressed in this publication are those of the authors and do not reflect the views of the NHMRC.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. Requests for data need to be sought from CRISP study investigators, communities who contributed data and relevant ethics committees. All requests are to be sent to Dr Elizabeth Barr (corresponding author) at Elizabeth.Barr@menzies.edu.au.