Identification of patients at high cardiovascular risk: a critical appraisal of applicability of statistical risk prediction models

Assessment of cardiovascular risk is widely proposed as a basis for taking management decisions about patients presenting with hypertension or hyperch olesterolemia. Our aim was to critically assess the use of risk equations d erived from epidemiological studies for the purpose of identifying high-ris k patients. Risk equations were retrieved from the MEDLINE database and then applied to a data set of 118 patients. This data set was an evaluation study of the c linical value of the World Health Organization 1993 hypertension guidelines for the decision to treat mild hypertensive patients. We calculated agreem ent: 1) between equations and 2) between equations and the decision to trea t taken by the physician. Most models were not applicable to our population, mainly because the origi nal population had a narrow age range or comprised only males. Between-mode l agreement was better for the lower and upper risk quintiles than for the three other risk quintiles (0.58, 0.33, 0.34, 0.45, 0.70, from the lower to the upper risk quintile). When using an arbitrary threshold for defining h igh-risk patients (i.e. >2% per year), we observed a huge variation of the proportion of patients classified at high risk (from 0 to 17%). There was a poor agreement between risk models and the decision to treat taken by the physician. These results suggest that risk-based guidelines should be valid ated before their diffusion.