Cardiovascular disease risk prediction in multi-ethnic Asian populations: evidence from two population-based cohorts in Singapore

Background: The rising burden of cardiovascular diseases (CVD) in Asia requires risk assessment tools tailored to Asian populations. Therefore, we recalibrated the ACC/AHA Pooled Cohort Equations for non-Hispanic Whites (PCE-W) and compared its performance in predicting 10-year CVD risk with two other established CVD prediction models that have been recently recalibrated for Asian populations. Methods: We used data from the Singapore Multi-Ethnic Cohort (MEC1) and the Singapore Epidemiology of Eye Diseases (SEED) cohort comprising ethnic Chinese, Indian, and Malay participants. The PCE-W was recalibrated using data from MEC1, externally validated in the SEED cohort, and compared against the Singapore-modified Framingham Risk Score (SG-FRS-2023) and the SCORE2 Asia-Pacific model using the concordance index (C-index). Calibration was assessed using the calibration-in-the-large method, the calibration slope, and a goodness-of-fit test. Findings: All three models demonstrated possibly helpful to clearly useful discrimination in MEC1 and SEED, with overall C-indices ranging from 0.728 to 0.811. The recalibrated PCE-W outperformed the original PCE-W in MEC1 and SEED, although some misestimations remained among Chinese men and women and Malay women (calibration-in-the-large ranged from -0.479 to 0.260). The SG-FRS-2023 displayed generally satisfactory calibration across both MEC1 and SEED but tended to overestimate risk in Chinese (calibration-in-the-large -0.671) and Indian men (calibration-in-the-large -0.214) in the SEED cohort. The SCORE2 Asia-Pacific model performed satisfactorily among Indians but overestimated risk in Chinese (calibration-in-the-large ranged from -0.570 to -1.185) and showed poor model fit in Malays. Interpretation: The recalibrated PCE-W, SG-FRS-2023, and SCORE2 Asia-Pacific model demonstrated possibly helpful to clearly useful discrimination across two multi-ethnic cohorts in Singapore. In terms of calibration, the recalibrated PCE-W and SG-FRS-2023, both recalibrated using local data, performed better than the SCORE2 Asia-Pacific model. Our study supports the use of the established CVD prediction models in Asian populations following appropriate local recalibration. Funding: This work was supported by the Singapore Ministry of Health's National Medical Research Council and the Singapore Biomedical Research Council.