Research Program Manager Johns Hopkins Bloomberg School of Public Health Baltimore, United States
Background: The use of race in clinical risk prediction tools may exacerbate racial disparities in health care access and outcomes.
Objectives: To quantify the number of individuals reclassified for primary prevention of cardiovascular disease based on 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% due to a change in their race alone.
Methods: Cross-sectional analysis of individuals aged 40 to 75 without a history of a cardiovascular events, diabetes, or other high-risk features using 2005-2018 National Health and Nutritional Examination Survey (NHANES). We compared Atherosclerotic Cardiovascular Disease (ASCVD) risk scores using the AHA/ACC equation recommended for white or other-raced individuals with that recommended for black individuals. We also calculated ASCVD risk using the race agnostic Framingham Risk Equation. The main outcome was the number of individuals reclassified for primary prevention of cardiovascular disease based on 10-year ASCVD risk of 10%.
Results: A total of 2,946 white, 1,361 black, and 2,495 other-race individuals were included in the analysis. Using the AHA/ACC equation, the mean 10-year ASCVD risk for white individuals was 5.80% (95% confidence interval [CI] 5.54, 6.06), for blacks the mean risk was 7.04% (CI 6.69, 7.39), and for other races it was 4.93% (CI 4.61, 5.24). When using the AHA/ACC equation designated for the opposite race (white/other race vs black), the mean ASCVD risk score increased for white individuals by an average of 1.02% (CI 0.90, 1.13), for black individuals it decreased by an average of -1.82% (CI -1.67, -1.96), and for other races it increased by 0.98% (CI 0.85, 1.10). When using clinical ASCVD categories of < 7.5%, 7.5-10%, and >10%, 16.93% percent of all individuals were reclassified when using the AHA/ACC’s equation designated for the opposite race. A total of 8.99% of white, 10.73% black, and 8.58% other race individuals were reclassified above or below the 10% clinical threshold when their race alone was switched. Modestly greater whites (10.92%), blacks (13.10%), and others (8.58%) were reclassified using a more stringent clinical risk threshold of 7.5%. When using the race agnostic Framingham risk equation, the mean ASCVD risk score increased for all groups examined - whites (absolute increase 3.70%), blacks (2.64%), other (3.98%) compared to the AHA/ACC risk score of their designated race.
Conclusions: Changing race within a commonly used cardiovascular risk prediction tool results in significant changes in risk classification among eligible white and black individuals in the United States.
