Simple cardiovascular risk stratification by replacing total serum cholesterol with anthropometric measures: The MORGAM prospective cohort project

Abstract

To assess whether anthropometric measures (body mass index [BMI], waist-hip ratio [WHR], and estimated fat mass [EFM]) are independently associated with major adverse cardiovascular events (MACE), and to assess their added prognostic value compared with serum total-cholesterol. The study population comprised 109,509 individuals (53% men) from the MORGAM-Project, aged 19-97 years, without established cardiovascular disease, and not on antihypertensive treatment. While BMI was reported in all, WHR and EFM were reported in ∼52,000 participants. Prognostic importance of anthropometric measurements and total-cholesterol was evaluated using adjusted Cox proportional-hazards regression, logistic regression, area under the receiver-operating-characteristic curve (AUC_ROC), and net reclassification improvement (NRI). The primary endpoint was MACE, a composite of stroke, myocardial infarction, or death from coronary heart disease. Age interacted significantly with anthropometric measures and total-cholesterol on MACE (P ≤ 0.003), and therefore age-stratified analyses (<50 versus ≥ 50 years) were performed. BMI, WHR, EFM, and total-cholesterol were independently associated with MACE (P ≤ 0.003) and resulted in significantly positive NRI when added to age, sex, smoking status, and systolic blood pressure. Only total-cholesterol increased discrimination ability (AUC_ROC difference; P < 0.001). In subjects < 50 years, the prediction model with total-cholesterol was superior to the model including BMI, but not superior to models containing WHR or EFM, while in those ≥ 50 years, the model with total-cholesterol was superior to all models containing anthropometric variables, whether assessed individually or combined. We found a potential role for replacing total-cholesterol with anthropometric measures for MACE-prediction among individuals < 50 years when laboratory measurements are unavailable, but not among those ≥ 50 years.

Keywords: ACM, all-cause mortality; ASCVD, atherosclerotic cardiovascular disease; AUCROC, area under the receiver-operating-characteristic curve; Adipose tissue; Assessment, risk; BMI, body mass index; BP, blood pressure; Body mass index; CEP, composite cardiovascular endpoint; CI, confidence interval; CV, cardiovascular; CVD, cardiovascular disease; CVM, cardiovascular mortality; Cardiovascular diseases; Chol, serum total cholesterol; Cholesterol; DBP, diastolic blood pressure; EFM, estimated fat mass; HDL-cholesterol, high density lipoprotein cholesterol; HR, hazard ratio; IQR, interquartile range; MACE, major adverse cardiovascular events; MBP, mean blood pressure; MONICA, Multi-national MONItoring of Trends and Determinants in CArdiovascular Disease; MORGAM, MOnica, Risk, Genetics, Archiving and Monograph; NRI, net reclassification improvement; NS, non-significant; PP, pulse pressure; SBP, systolic blood pressure; SCORE, Systematic COronary Risk Evaluation; WHR, waist-hip ratio; Waist-hip ratio; cNRI, continuous net reclassification improvement.