Abstract
The authors assessed the increase in the predictivity of ischemic stroke (IS) resulting from the addition of nontraditional risk factors and markers of subclinical disease to a basic model containing only traditional risk factors (current smoking, diabetes mellitus, systolic blood pressure, antihypertensive therapy, prior coronary disease, and left ventricular hypertrophy) among 14,685 middle-aged persons in the Atherosclerosis Risk in Communities Study. Participants were recruited from four US communities in 1987-1989. Risk prediction scores for IS through 2000 were estimated from Cox models. The ability to predict which persons would develop IS was assessed by means of the area under the receiver operating characteristic curve-the probability that persons with IS had a higher risk score than those without IS. Among 22 nontraditional factors considered, the joint addition of body mass index, waist:hip ratio, high density lipoprotein cholesterol, albumin, von Willebrand factor, alcohol consumption, peripheral arterial disease, and carotid artery wall thickness modestly and statistically significantly improved prediction of future IS over a risk score that included traditional factors. Further improvement was obtained by adding age and race. For women, the area under the receiver operating characteristic curve went from 0.79 to 0.83 to 0.84; for men, it went from 0.76 to 0.78 to 0.80. These modest improvements are not enough to influence clinical and public health efforts to reduce the community burden of IS.
Highlights
We explored how well additional ischemic stroke risk factors already found in the Atherosclerosis Risk in Communities (ARIC) Study or markers of subclinical disease improved prediction of individual risk beyond the basic factors, in terms of statistically significant increases in the area under the receiver operating characteristic (ROC) curve
The hazard rate ratios for diabetes were much larger for ARIC than for Framingham, and for men the hazard rate ratio for systolic blood pressure was smaller in ARIC than in Framingham
Coefficients in the basic ischemic stroke risk factor model were not significantly different between men and women, but ARIC coefficients sometimes differed from those of the Framingham Study; this suggests a need for caution when applying model coefficients to external populations
Summary
We sought to develop a risk score for ischemic stroke, similar to a Framingham risk score for stroke [2], using data from the Atherosclerosis Risk in Communities (ARIC) Study and including the “established” basic risk factors age, current smoking, diabetes mellitus, systolic blood pressure, antihypertensive therapy, prior coronary heart disease, and left ventricular hypertrophy, as well as race. Investigators in the Cardiovascular Health Study produced a stroke risk score [3] for persons aged 65 years or older, considering additional risk factors beyond the traditional factors. We explored how well additional ischemic stroke risk factors already found in the ARIC Study or markers of subclinical disease improved prediction of individual risk beyond the basic factors, in terms of statistically significant increases in the area under the receiver operating characteristic (ROC) curve.
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