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What a Difference a Decade Makes

Andrew L. Avins, MD, MPH; Warren S. Browner, MD, MPH

JAMA. 1998;279:445-449.

Context.— A patient's coronary heart disease (CHD) risk must be correctly classified to successfully apply risk-based guidelines for treatment of hypercholesterolemia.

Objective.— To determine the classification accuracy of the National Cholesterol Education Program (NCEP) CHD risk-stratification system and compare it with a simple revised system that gives greater weight to age as a CHD risk factor.

Design.— Modeling of 10-year CHD risk, using equations from the Framingham Heart Study applied to a cross-sectional survey of the US population.

Subjects.— The 3284 subjects aged 20 to 74 years surveyed in the Second National Health and Nutrition Examination Survey (1978-1982) who had fasting lipid levels measured.

Main Outcome Measures.— The area under the receiver operating characteristic curve (AUC) for 10-year CHD risk for the NCEP and revised scales.

Results.— Among all adults with a low-density lipoprotein cholesterol value of at least 4.1 mmol/L (160 mg/dL), the NCEP system showed fairly good discrimination (AUC=0.90), though there was a substantial decline among men 35 to 74 years old and women 55 to 74 years old (AUC=0.81). By contrast, the revised system showed superior performance in all hypercholesterolemic adults (AUC=0.94-0.97) as well as in the subgroup of men 35 to 74 years old and women 55 to 74 years old (AUC=0.94-0.96).

Conclusions.— Simple modifications of the NCEP treatment criteria result in a substantially improved ability to discriminate between higher and lower CHD risk groups. Unlike the NCEP system, this revised system retains its classification ability in all age groups studied.

From the General Internal Medicine Section, Veterans Affairs Medical Center, San Francisco, Calif, and the Department of Epidemiology and Biostatistics, University of California, San Francisco.

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