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CLINICAL RESEARCH: CARDIOVASCULAR RISK

Improving Global Vascular Risk Prediction With Behavioral and Anthropometric Factors

The Multiethnic NOMAS (Northern Manhattan Cohort Study)

Ralph L. Sacco, MD, MS^_*,_*, Minesh Khatri, MD, Tatjana Rundek, MD, PhD^_*, Qiang Xu, PhD, Hannah Gardener, ScD^_*, Bernadette Boden-Albala, DrPH^,, Marco R. Di Tullio, MD^||, Shunichi Homma, MD^||, Mitchell S.V. Elkind, MD, MS and Myunghee C. Paik, PhD

^_* Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida
Department of Neurology, Columbia University, College of Physicians and Surgeons, and Mailman School of Public Health, New York, New York
Department of Biostatistics, Columbia University, College of Physicians and Surgeons, and Mailman School of Public Health, New York, New York
Department of Sociomedical Science, Columbia University, College of Physicians and Surgeons, and Mailman School of Public Health, New York, New York
^|| Department of Medicine, Columbia University, College of Physicians and Surgeons, and Mailman School of Public Health, New York, New York

Manuscript received March 17, 2009; revised manuscript received July 15, 2009, accepted July 20, 2009.

^_* Reprint requests and correspondence: Dr. Ralph L. Sacco, University of Miami, 1120 Northwest 14th Street, Miami, Florida 33136 (Email: rsacco{at}med.miami.edu).

This work was presented in part at the International Stroke Conference, New Orleans, Louisiana, February 17, 2006.

Objectives: This study sought to improve global vascular risk prediction with behavioral and anthropometric factors.

Background: Few cardiovascular risk models are designed to predict the global vascular risk of myocardial infarction, stroke, or vascular death in multiethnic individuals, and existing schemes do not fully include behavioral risk factors.

Methods: A randomly derived, population-based, prospective cohort of 2,737 community participants free of stroke and coronary artery disease was followed up annually for a median of 9.0 years in the NOMAS (Northern Manhattan Study) (mean age 69 years, 63.2% women, 52.7% Hispanic, 24.9% African American, and 19.9% white). A global vascular risk score (GVRS) predictive of stroke, myocardial infarction, or vascular death was developed by adding variables to the traditional Framingham cardiovascular variables based on the likelihood ratio criteria. Model utility was assessed through receiver-operating characteristics, calibration, and effect on reclassification of subjects.

Results: Variables that significantly added to the traditional Framingham profile included waist circumference, alcohol consumption, and physical activity. Continuous measures for blood pressure and fasting blood sugar were used instead of hypertension and diabetes. Ten-year event-free probabilities were 0.95 for the first quartile of GVRS, 0.89 for the second quartile, 0.79 for the third quartile, and 0.56 for the fourth quartile. The addition of behavioral factors in our model improved prediction of 10-year event rates compared with a model restricted to the traditional variables.

Conclusions: A GVRS that combines traditional, behavioral, and anthropometric risk factors; uses continuous variables for physiological parameters; and is applicable to nonwhite subjects could improve primary prevention strategies.

Key Words: cardiovascular disease • cerebrovascular disease • prevention • risk factors • epidemiology

Abbreviations and Acronyms   AIC = Akaike Information Criterion   AUC = area under the curve   GVRS = global vascular risk score   MI = myocardial infarction   ROC = receiver-operator characteristic

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