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IJE Advance Access published online on January 19, 2005
International Journal of Epidemiology, doi:10.1093/ije/dyh405
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IJE © International Epidemiological Association 2005; all rights reserved.
Accepted November 16, 2004

Original paper

Prediction of coronary events in a low incidence population. Assessing accuracy of the CUORE Cohort Study prediction equation

Marco Ferrario 1*, Paolo Chiodini 2, Lloyd E. Chambless 3, Giancarlo Cesana 2, Diego Vanuzzo 4, Salvatore Panico 5, Roberto Sega 2, Lorenza Pilotto 4, Luigi Palmieri 6, Simona Giampaoli 6, and for the CUORE Project Research Group

1 Dipartimento di Scienze Cliniche e Biologiche, Università degli studi dell'Insubria, Varese 21100, Italy
2 Centro Ricerche Patologia Cronico-degenerativa, Università degli studi di Milano-Bicocca, Monza 20052, Italy
3 Collaborative Studies Coordinating Centre, Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill 27514, NC, USA
4 Centro per la Prevenzione Cardiovascolare, Azienda Socio-Sanitaria 4 Medio Friuli and Agenzia Regionale della Sanità, Udine 33100, Italy
5 Dipartimento di Medicina Clinica e Sperimentale, Università degli studi Federico II, Napoli 80131, Italy
6 Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy

* To whom correspondence should be addressed.
Marco Ferrario, E-mail: marco.ferrario{at}uninsubria.it


  Abstract

Background The aims of this paper are to derive a 10-year coronary risk predictive equation for adult Italian men, and to assess its accuracy in comparison with the Framingham Heart Study (FHS) and PROCAM study equations.

Methods The CUORE study is a prospective fixed-cohort study. Eleven cohorts, from the north and the centre-south of Italy, had been investigated at baseline between 1982 and 1996, adopting MONICA methods to measure risk factors. Among this sample of 6865 men, aged 35-69 years and free of coronary heart disease (CHD) at baseline, 312 first fatal and non-fatal major coronary events occurred in 9.1 years median follow-up. Calibration, as the difference between 10-year predicted and actual risk, and discrimination, as the ability of the risk functions to separate high-risk from low-risk subjects, have been assessed to compare accuracy of the FHS, the PROCAM, and the CUORE study equations.

Results The best CUORE equation includes age, total cholesterol, systolic blood pressure, cigarette smoking, HDL-cholesterol, diabetes mellitus, hypertension drug treatment, and family history of CHD (area under the ROC curve = 0.75). The uncalibrated estimates of the 10-year risk in this CUORE follow-up data were 0.093 and 0.109 higher (P < 0.05) from the Framingham and PROCAM risk scores, respectively, than the Kaplan-Meier estimate for CUORE, indicating risk overestimates for both equations. Standard recalibration techniques improved accuracy of the FHS equation only. PROCAM overestimates were prominent in the higher risk deciles. With an alternative method for recalibration better risk estimates were obtained, but a cohort study was needed to obtain a properly calibrated risk equation.

Conclusions The CUORE Project predictive equation showed better accuracy of the FHS and PROCAM equations, overcoming frequently reported risk overestimates. The CUORE equation may be adopted to identify men with high coronary risk in Italy.

Keywords: Coronary heart disease; prevention; risk factors; cohort studies; men; Italy.
The Progetto CUORE Research Group: MM Ferrario, G Cesana, R Sega, P Chiodini, S Sarman, C Fornari, G Corrao, L Bolognesi, Centro Ricerche Patologia Cronico-degenerativa, Università degli Studi Milano-Bicocca, Monza; D Vanuzzo, L Pilotto, T Feresin, K Mauro, M Martini, F Mattiussi, G Picco, Cardiovascular Prevention Centre, Azienda Socio-Sanitaria 4 Medio Friuli and Agenzia Regionale della Sanità, Udine; S Panico, E Celentano, A Mattiello, R Galasso, M Del Pezzo, M Santucci de Magistris, Università degli Studi Federico II, Naples; S Giampaoli, L Palmieri, F Dima, C Lo Noce, A Santaquilani, P Caiola De Sanctis, F Pannozzo, F Seccareccia, Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy.
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