Development and validation of a prediction rule for recurrent vascular events based on a cohort study of patients with arterial disease: the SMART risk score

Johannes A N Dorresteijn; Frank L J Visseren; Annemarie M J Wassink; Martijn J A Gondrie; Ewout W Steyerberg; Paul M Ridker; Nancy R Cook; Yolanda van der Graaf; on behalf of the SMART Study Group

doi:10.1136/heartjnl-2013-303640

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Prognosis research

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Development and validation of a prediction rule for recurrent vascular events based on a cohort study of patients with arterial disease: the SMART risk score

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Re:Re:Use SMART risk score to correct under- and overtreatment.
Johannes A. Dorresteijn
Published on: 23 November 2015
Re:Use SMART risk score to correct under- and overtreatment.
Johannes A.N. Dorresteijn
Published on: 23 November 2015
Use SMART risk score to correct under- and overtreatment.
Siep Thomas
Published on: 23 November 2015

Published on: 23 November 2015
Re:Re:Use SMART risk score to correct under- and overtreatment.
- Johannes A. Dorresteijn, Physician
- Other Contributors:
  Frank L.J. Visseren, Yolanda van der Graaf
As was pointed out by dr. Thomas and dr. Pleumeekers in personal communication, we have to admit that the case of a 70-year old patient with a 15% 10-year risk is not unthinkable. For example, a patient with the following characteristics has a predicted 15% 10-year risk for recurrent cardiovascular events: male 70 years, no smoker, systolic blood pressure 130 mmHg, diabetes mellitus no, CAD yes, CVD no, AAA no, PAD no,...
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As was pointed out by dr. Thomas and dr. Pleumeekers in personal communication, we have to admit that the case of a 70-year old patient with a 15% 10-year risk is not unthinkable. For example, a patient with the following characteristics has a predicted 15% 10-year risk for recurrent cardiovascular events: male 70 years, no smoker, systolic blood pressure 130 mmHg, diabetes mellitus no, CAD yes, CVD no, AAA no, PAD no, 11 years since first diagnosis, HDL cholesterol 1,33 mmol/L, total cholesterol 4,7 mmol/L, eGFR 91 mL/min and hs-CRP 0,2 mg/dL. We do appreciate the effort of these commentators to highlight potential therapeutic implications that such a low predicted risk might have, but remain unsure about discontinuing statins and other preventive medication on the basis of SMART risk score predictions given the other two reasons described.
Conflict of Interest:
None
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Conflict of Interest:
None declared.
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Published on: 23 November 2015
Re:Use SMART risk score to correct under- and overtreatment.
- Johannes A.N. Dorresteijn, Physician
- Other Contributors:
  Frank L.J. Visseren, Yolanda van der Graaf
Complex drug regimens and overtreatment in elderly persons are important medical issues. Less stringent treatment for example of blood pressure, may be allowed or is even advisable in the elderly, especially in the presence of coexisting morbidities, adverse side effects of medication or impaired mobility. Still, the SMART risk score will not help determine which patients can safely withdraw treatment for several reasons...
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Complex drug regimens and overtreatment in elderly persons are important medical issues. Less stringent treatment for example of blood pressure, may be allowed or is even advisable in the elderly, especially in the presence of coexisting morbidities, adverse side effects of medication or impaired mobility. Still, the SMART risk score will not help determine which patients can safely withdraw treatment for several reasons. First, SMART risk score predictions are based on current practice. This means: assuming optimal medical treatment according to current standards, including antiplatelet therapy, lipid-lowering and blood pressure-lowering medication when indicated. Second, the SMART study was not a trial. This means that the counterfactual situation, withdrawal of treatment, is not observed. The magnitude of the risk increase and potential rebound effects after withdrawal of treatment are, therefore, unknown. Third, the patient described above is non-existent. According to the SMART risk score, a 70-year old male with a history of a PCI 11 years earlier has a minimum risk of 20%, assuming no other risk factors are present. Thus, at this age, all patients will be at high risk, some only more than others. In conclusion, we advise using the SMART risk score only for identifying those patients at highest risk for recurrent vascular events and to consider intensifying treatment, but not for making decisions about treatment withdrawal. We agree with our colleagues that stopping preventive treatment is an underexposed activity in clinical practice and need proper scientific evaluation. Assessing the effects of stopping medication in prospective randomized clinical trials would deliver answers to these burning questions.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 23 November 2015
Use SMART risk score to correct under- and overtreatment.
- Siep Thomas, Prof. Em of General Practice
- Other Contributors:
  Ber Pleumeekers
Dorresteijn et al, (Heart 2013;99:866-872), presented a new tool, the SMART risk score, for predicting 10 year risk of recurrence in patients with established cardiovascular disease. This enables clinicians for the first time to differentiate treatment within the hitherto broadly assumed recurrence rate of at least 20% leading to guidelines that, so far, advise maximal drug treatment for elevated risk factors for all patie...
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Dorresteijn et al, (Heart 2013;99:866-872), presented a new tool, the SMART risk score, for predicting 10 year risk of recurrence in patients with established cardiovascular disease. This enables clinicians for the first time to differentiate treatment within the hitherto broadly assumed recurrence rate of at least 20% leading to guidelines that, so far, advise maximal drug treatment for elevated risk factors for all patients alike. Surprisingly, the authors seem to restrict its clinical use to those with the highest risks (presumably the 23% of their cohort with remaining risks of over 26%, fig. 2) thus aiming at correcting 'undertreatment'. With this choice they miss the opportunity to use it also to revise possible 'overtreatment', which may have occurred in 21% of their cohort with risk levels of 15% or lower. We like to illustrate the relevance of an extended strategy with a hypothetical example wherein a GP is consulted by a healthy 70 year old male asking her support to stop his daily aspirin and statin medication. He has been using this for 11 years, after a percutaneous coronary intervention. He has never had an elevated blood pressure or any cardiovascular complaints since and his Smart risk score is 15%. The GP tells him that his age, being irreversible, has now lowered the attributable risk of his reversible risk factors to such an extent (to approx. 5%) that the harm of stopping his medication (leading to a relative increase in attributable risk of approx. 35% ,or 2-3% absolute) will not lead to an sizeable extra risk. Moreover continuing the medication won't prevent the increasing risk of concurrent events from other diseases. The patient, content to have overgrown most of his corrigible risk, decides to stop. Our problem with this example is that the argumentation around attributable risk and remaining risk after minimising or maximizing treatment has to come from educated guesses. We would therefore urge the authors of the SMART risk score to support potential users by providing more easily accessible data on these items in order to enable them to further clarify the abstract thinking of prevention statistics for their patients
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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