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Original Investigation
April 28, 2021

Performance of the American Heart Association/American College of Cardiology Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Self-reported Physical Activity Levels

Author Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
  • 2Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
  • 3Department of Kinesiology and Institute for Applied Life Sciences, University of Massachusetts, Amherst
  • 4Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 5Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
  • 6Department of Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago, Illinois
JAMA Cardiol. 2021;6(6):690-696. doi:10.1001/jamacardio.2021.0948
Key Points

Question  What is the risk prediction performance of American Heart Association/American College of Cardiology pooled cohort equations across strata of self-reported leisure-time physical activity levels?

Findings  In this cohort study of 18 824 participants, pooled cohort equations showed good risk discrimination and calibration performance across the spectrum of estimated leisure-time physical activity levels. Higher leisure-time physical activity level is associated with lower cardiovascular risk; adding reported leisure-time physical activity to pooled cohort equations did not change risk discrimination and reclassification capabilities of the risk prediction model.

Meaning  In this study, pooled cohort equations appear to be accurate at predicting 10-year atherosclerotic cardiovascular disease risk across all strata of physical activity; the addition of self-reported leisure-time and addition of physical activity to the pooled cohort equation do not meaningfully change the risk prediction model performance.


Importance  The American Heart Association/American College of Cardiology pooled cohort equations (PCEs) are used for predicting 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Pooled cohort equation risk prediction capabilities across self-reported leisure-time physical activity (LTPA) levels and the change in model performance with addition of LTPA to the PCE are unclear.

Objective  To evaluate PCE risk prediction performance across self-reported LTPA levels and the change in model performance by adding LTPA to the existing PCE model.

Design, Setting, and Participants  Individual-level pooling of data from 3 longitudinal cohort studies—Atherosclerosis Risk in Communities, Multi-Ethnic Study of Atherosclerosis, and Cardiovascular Health Study—was performed. A total of 18 824 participants were stratified into 4 groups based on self-reported LTPA levels: inactive (0 metabolic equivalent of task [MET]-min/wk), less than guideline-recommended (<500 MET-min/wk), guideline-recommended (500-1000 MET-min/week), and greater than guideline-recommended (>1000 MET-min/wk). Pooled cohort equation risk discrimination was studied using the C statistic and reclassification capabilities were studied using the Greenwood Nam-D’Agostino χ2 goodness-of-fit test. Change in risk discrimination and reclassification on adding LTPA to PCEs was evaluated using change in C statistic, integrated discrimination index, and categorical net reclassification index.

Main Outcomes and Measures  Adjudicated ASCVD events during 10-year follow-up.

Results  Among 18 824 participants studied, 10 302 were women (54.7%); mean (SD) age was 57.6 (8.2) years. A total of 5868 participants (31.2%) were inactive, 3849 (20.4%) had less than guideline-recommended LTPA, 3372 (17.9%) had guideline-recommended LTPA, and 5735 (30.5%) had greater than guideline-recommended LTPA level. Higher LTPA levels were associated with a lower risk of ASCVD after adjustment for risk factors (hazard ratio [HR] per 1-SD higher LTPA, 0.91; 95% CI, 0.86-0.96). Across LTPA groups, PCE risk discrimination (C statistic, 0.76-0.78) and risk calibration (all χ2 P > .10) was similar. Addition of LTPA to the PCE model resulted in no significant change in the C statistic (0.0005; 95% CI, −0.0004 to 0.0015; P = .28) and categorical net reclassification index (−0.003; 95% CI, −0.010 to 0.010; P = .95), but a minimal improvement in the integrated discrimination index (0.0008; 95% CI, 0.0002-0.0013; P = .005) was observed. Similar results were noted when cohort-specific coefficients were used for creating the baseline model.

Conclusions and Relevance  Higher self-reported LTPA levels appear to be associated with lower ASCVD risk and increasing LTPA promotes cardiovascular wellness. These findings suggest the American Heart Association/American College of Cardiology PCEs are accurate at estimating the probability of 10-year ASCVD risk regardless of LTPA level. The addition of self-reported LTPA to PCEs does not appear to be associated with improvement in risk prediction model performance.

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