Using clinical prediction models to personalise lifestyle interventions for cardiovascular disease prevention: A systematic literature review

Cardiovascular disease (CVD) is one of the leading causes of death across the world. CVD can lead to angina, heart attacks, heart failure, strokes, and eventually, death; among many other serious conditions. The early intervention with those at a higher risk of developing CVD, typically with statin treatment, leads to better health outcomes. For this reason, clinical prediction models (CPMs) have been developed to identify those at a high risk of developing CVD so that treatment can begin at an earlier stage. Currently, CPMs are built around statistical analysis of factors linked to developing CVD, such as body mass index and family history. The emerging field of machine learning (ML) in healthcare, using computer algorithms that learn from a dataset without explicit programming, has the potential to outperform the CPMs available today. ML has already shown exciting progress in the detection of skin malignancies, bone fractures and many other medical conditions. In this review, we will analyse and explain the CPMs currently in use with comparisons to their developing ML counterparts. We have found that although the newest non-ML CPMs are effective, ML-based approaches consistently outperform them. However, improvements to the literature need to be made before ML should be implemented over current CPMs.

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Clinical Prediction Models for Primary Prevention of Cardiovascular Disease: Validity in Independent Cohorts

10.1101/2021.01.31.21250871 ◽

2021 ◽

Author(s):

Gaurav Gulati ◽

Riley J Brazil ◽

Jason Nelson ◽

David van Klaveren ◽

Christine M. Lundquist ◽

...

Keyword(s):

Cardiovascular Disease ◽

Decision Making ◽

Primary Prevention ◽

Prediction Models ◽

Model Updating ◽

Clinical Prediction ◽

Net Benefit ◽

Clinical Prediction Models ◽

C Statistic ◽

Prevention Of Cardiovascular Disease

AbstractBackgroundClinical prediction models (CPMs) are used to inform treatment decisions for the primary prevention of cardiovascular disease. We aimed to assess the performance of such CPMs in fully independent cohorts.Methods and Results63 models predicting outcomes for patients at risk of cardiovascular disease from the Tufts PACE CPM Registry were selected for external validation on publicly available data from up to 4 broadly inclusive primary prevention clinical trials. For each CPM-trial pair, we assessed model discrimination, calibration, and net benefit. Results were stratified based on the relatedness of derivation and validation cohorts, and net benefit was reassessed after updating model intercept, slope, or complete re-estimation. The median c statistic of the CPMs decreased from 0.77 (IQR 0.72-0.78) in the derivation cohorts to 0.63 (IQR 0.58-0.66) when externally validated. The validation c-statistic was higher when derivation and validation cohorts were considered related than when they were distantly related (0.67 vs 0.60, p < 0.001). The calibration slope was also higher in related cohorts than distantly related cohorts (0.69 vs 0.58, p < 0.001). Net benefit analysis suggested substantial likelihood of harm when models were externally applied, but this likelihood decreased after model updating.ConclusionsDiscrimination and calibration decrease significantly when CPMs for primary prevention of cardiovascular disease are tested in external populations, particularly when the population is only distantly related to the derivation population. Poorly calibrated predictions lead to poor decision making. Model updating can reduce the likelihood of harmful decision making, and is needed to realize the full potential of risk-based decision making in new settings.

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Field Synopsis of Sex in Clinical Prediction Models for Cardiovascular Disease

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.115.002473 ◽

2016 ◽

Vol 9 (2 suppl 1) ◽

pp. S8-S15 ◽

Cited By ~ 4

Author(s):

Jessica K. Paulus ◽

Benjamin S. Wessler ◽

Christine Lundquist ◽

Lana L.Y. Lai ◽

Gowri Raman ◽

...

Keyword(s):

Cardiovascular Disease ◽

Prediction Models ◽

Clinical Prediction ◽

Clinical Prediction Models

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Abstract 174: Clinical Prediction Models for Cardiovascular Disease: The Tufts PACE CPM Database

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.8.suppl_2.174 ◽

2015 ◽

Vol 8 (suppl_2) ◽

Author(s):

Benjamin S Wessler ◽

Lana Lai YH ◽

Whitney Kramer ◽

Michael Cangelosi ◽

Gowri Raman ◽

...

Keyword(s):

Cardiovascular Disease ◽

Prediction Models ◽

De Novo ◽

Prognostic Models ◽

Calibration Plot ◽

Clinical Prediction ◽

Clinical Prediction Models ◽

Coronary Syndrome ◽

Stage Of Development ◽

Distinct Index

Background: Clinical prediction models (CPMs) estimate the probability of clinical outcomes and hold the potential to improve decision making and individualize care. For patients with cardiovascular disease (CVD) there are numerous CPMs available though the extent of this literature is not well described. Methods and Results: We conducted a systematic review for articles containing CPMs for CVD published between January 1990 through May 2012. CVD includes coronary artery disease (CAD), congestive heart failure (CHF), arrhythmias, stroke, venous thromboembolism (VTE) and peripheral vascular disease (PVD). We created a novel database and characterized CPMs based on the stage of development, population under study, performance, covariates, and predicted outcomes. We included articles that describe newly developed CPMs that predict the risk of developing an outcome (prognostic models) or the probability of a specific diagnosis (diagnostic models). There are 796 models included in this database representing 31 distinct index conditions. 717 (90%) are de novo CPMs, 21 (3%) are CPM recalibrations, and 58 (7%) are CPM adaptations. There are 215 CPMs for patients with CAD, 168 CPMs for population samples at risk for incident CVD, and 79 models for patients with CHF (Figure). De novo CPMs predicting mortality were most commonly published for patients with known CAD (98 models) followed by HF (63 models) and stroke (24 models). There are 77 distinct index/ outcome (I/O) pairings and models are roughly evenly split between those predicting short term outcomes (< 3 months) and those predicting long term outcomes (< 6 months). There are 41 diagnostic CPMs included in this database, most commonly predicting diagnoses of CAD (11 models), VTE (10 models), and acute coronary syndrome (5 models). Of the de novo models in this database 450 (63%) report a c-statistic and 259 (36%) report either the Hosmer-Lemeshow statistic or show a calibration plot. Conclusions: There is an abundance of CPMs available for many CVD conditions, with substantial redundancy in the literature. The comparative performance of these models, the consistency of effects and risk estimates across models and the actual and potential clinical impact of this body of literature is poorly understood.

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