ArticlesLaboratory-based versus non-laboratory-based method for assessment of cardiovascular disease risk: the NHANES I Follow-up Study cohort
Introduction
Cardiovascular disease is one of the leading causes of death worldwide,1 with 80% of cases occurring in low-income and middle-income countries.2, 3 Some developing countries spend less than US$27 per head on health care each year, compared with $3727 in high-income countries.4 Because of the limited resources available in low-income settings, finding low-cost strategies for prevention of cardiovascular disease is a priority. A well-established primary prevention strategy is to use prediction rules or risk scores to identify those at higher risk in order to target specific behavioural or drug interventions. Most risk scores have included age, sex, hypertension, smoking status, diabetes mellitus, lipid values, or family history.5, 6, 7, 8
Unfortunately, less attention has been directed at developing risk scores that would be easier to use in clinical practice without loss of predictive discrimination. In developed countries, a prediction rule that requires a laboratory test is an inconvenience; but in low-income countries, with limited testing facilities, such analysis can be too expensive to use at all. Cardiovascular disease prediction charts with and without the need for cholesterol testing for the different world regions have been released by WHO, but have not been compared with any of the standard prediction rules or validated in any cohort.9, 10, 11 In an attempt to simplify risk prediction, we assessed in a real cohort whether a prediction rule that does not need laboratory testing could predict cardiovascular disease events as effectively as one that uses laboratory-based values. Both models were assessed in the National Health and Nutrition Examination Survey (NHANES) Follow-up Study cohort.
Section snippets
Methods
We compared two risk prediction models: the laboratory-based model, which required blood testing, and the non-laboratory-based model, which required only history and physical examination measures. We compared how well either model could predict first-time fatal and non-fatal cardiovascular events in the NHANES I Epidemiologic Follow-up Study (NHEFS) cohort. In the laboratory-based model we used similar risk factors to those used in the Framingham risk score—sex, age (years), systolic blood
Results
The baseline characteristics of the population are listed in table 1. By design, the NHANES cohort was representative of the adult population in the USA. With the exception of higher rates of smoking in men and a higher proportion of women receiving treatment for hypertension, the risk factor distributions were similar between the sexes. During the 21 year follow-up, there were 44 509 person-years of follow up. Overall, there were 3400 events related to cardiovascular disease among 1529
Discussion
Our study shows that a non-laboratory-based risk method that uses information easily obtained in one outpatient visit can predict cardiovascular disease outcomes as accurately as one that requires laboratory testing. Our values of predictive discrimination of 0·83 (women) and 0·78 (men) for the non-laboratory-based model are no different than the corresponding values in the laboratory-based model. Further, this study showed that the prediction method in the NHEFS cohort using these easily
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