Performance of the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis Is Not Superior to the ACC/AHA Risk Calculator

Bengt Wahlin; Lena Innala; Staffan Magnusson; Bozena Möller; Torgny Smedby; Solbritt Rantapää-Dahlqvist; Solveig Wållberg-Jonsson

doi:10.3899/jrheum.171008

Article Figures & Data

Figures

Tables
Supplementary Materials
Additional Files

Download figure
Open in new tab
Download powerpoint
Figure 1.
Observed and predicted proportion of events in deciles of estimated risk from ERS-RA (reported; upper left), ERS-RA (measured; upper right), ACC/AHA (lower left), and ACC/AHA × 1.5 (lower right). Black bars are observed proportion of events, grey bars estimated proportion of events. Numbers on x-axis denote the range of estimated risk for every decile. ERS-RA: Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis; ACC/AHA: American College of Cardiology/American Heart Association.
Download figure
Open in new tab
Download powerpoint
Figure 2.
Observed and predicted proportion of events in deciles of estimated risk in patients with ESR ≥ 40 mm/h. ERS-RA (reported) is upper left, ERS-RA (measured) upper right, ACC/AHA lower left, and ACC/AHA × 1.5 lower right. Black bars are observed proportion of events, grey bars estimated proportion of events. Numbers on x-axis denote the range of estimated risk for every decile. ERS-RA: Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis; ACC/AHA: American College of Cardiology/American Heart Association.

View popup

Table 1.

Characteristics of the 665 patients with RA (aged 40–80 years) included in the study.

Characteristics	Values
Demographic
Age at inclusion, yrs, mean (SD)	58.3 (10.0)
Female, n (%)	467 (69)
Cardiovascular risk factors
Diabetes, n (%)	43 (6.4)
Current smoking, n (%)	188 (28)
Systolic BP, mmHg, mean (SD)	144 (20)
Diastolic BP, mmHg, mean (SD)	83 (10)
Antihypertensive treatment, n (%)	163 (20)
Antihypertensive treatment and/or BP > 140/90, n (%)	356 (53)
Cholesterol, mmol/l, mean (SD)	5.69 (1.11)
HDL cholesterol, mmol/l, mean (SD)	1.52 (0.49)
Triglycerides, mmol/l, mean (SD)	1.48 (0.71)
Statin treatment, n (%)	45 (6.7)
Statin treatment and/or hyperlipidemia, n (%)	495 (73)
BMI, kg/m², mean (SD)	26.8 (4.3)
RA variables
ESR, mm/h, median (IQR)	24 (12–40)
CRP, mg/l, median (IQR)	10 (7–26)
CDAI, median (IQR)	21 (13–30)
CDAI > 10, n (%)	569 (85.6)
Tender joint count, n, median (IQR)	5 (2–9)
Swollen joint count, n, median (IQR)	6 (3–10)
DAS28, median (IQR)	4.7 (3.7–5.6)
HAQ median (IQR)	0.75 (0.38–1.25)
HAQ > 0.5, n (%)	456 (68.6)
Patient global VAS, mm, median (IQR)	45 (23–64)
Positive anti-CCP, n (%)	423/611 (69)
Corticosteroids, n (%)	342 (51.4)

RA: rheumatoid arthritis; BP: blood pressure; HDL: high-density lipoproteins; BMI: body mass index; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; CDAI: Clinical Disease Activity Index; DAS28: 28-joint count Disease Activity Score; HAQ: Health Assessment Questionnaire; VAS: visual analog scale; anti-CCP: anticyclic citrullinated peptide antibodies; IQR: interquartile range.

View popup

Table 2.

Cardiovascular risk estimations from the risk scores, calculated for the patients with RA included in the study.

ERS-RA (reported)
Male and female patients	6.3 (3.0–11.5)
Female patients	4.7 (2.4–8.3)
Male patients	10.6 (5.4–16.8)
ESR ≥ 40 mm/h, female and male	7.2 (4.1–12.9)
ERS-RA (measured)
Male and female patients	8.3 (3.9–14.8)
Female patients	6.4 (3.2–11.9)
Male patients	12.8 (7.7–20.7)
ESR ≥ 40 mm/h, female and male	9.8 (5.3–16.6)
ACC/AHA
Male and female patients	6.3 (2.4–13.2)
Female patients	4.4 (1.7–9.2)
Male patients	11.8 (6.4–19.8)
ESR ≥ 40 mm/h, female and male	7.6 (3.2–14.9)
ACC/AHA × 1.5
Male and female patients	9.4 (3.6–19.9)
Female patients	6.6 (2.6–13.7)
Male patients	17.7 (9.7–29.7)
ESR ≥ 40 mm/h, female and male	11.4 (4.8–22.3)

Risk is presented as median 10-year risk of cardiovascular event in % (IQR). RA: rheumatoid arthritis; ERS-RA: Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis; ESR: erythrocyte sedimentation rate; ACC/AHA: American College of Cardiology/American Heart Association; IQR: interquartile range.

View popup

Table 3.

Estimated risk, proportion of patients with observed events, and area under the curve (AUC) of the ROC curves in RA patients with estimated cardiovascular risk of 5–15 %.

ERS-RA (reported)
Median estimated risk	8.3
Observed event	14.0
AUC (95% CI)	0.52 (0.43–0.61)
ERS-RA (measured)
Median estimated risk	9.2
Observed event	11.6
AUC (95% CI)	0.60 (0.51–0.69)
ACC/AHA
Median estimated risk	8.6
Observed event	12.3
AUC (95% CI)	0.59 (0.48–0.70)
ACC/AHA × 1.5
Median estimated risk	9.4
Observed event	9.1
AUC (95% CI)	0.59 (0.46–0.71)

Data are % unless otherwise indicated. ROC: receiver-operating characteristics; RA: rheumatoid arthritis; ERS-RA: Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis; ACC/AHA: American College of Cardiology/American Heart Association.

View popup

Table 4.

Predictive values and distribution of events.

Risk Calculator	High Risk (≥ 7.5%), n	Low Risk (< 7.5%), n	Events in Patients with Low risk/total, n (% of total events)	PPV	NPV
ERS-RA (reported)	276	389	18/73 (24.7)	0.199	0.954
ERS-RA (measured)	305	360	9/73 (12.3)	0.210	0.975
ACC/AHA	292	370	14/72 (19.4)	0.199	0.962
ACC/AHA × 1.5	373	289	10/72 (13.9)	0.166	0.965

PPV: positive predictive value; NPV: negative predictive value; ERS-RA: Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis; ACC/AHA: American College of Cardiology/American Heart Association.