External Validation of the PREVENT Equations in a National Sample of US Adults

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BACKGROUND: The American Heart Association Predicting Risk of Cardiovascular Disease EVENT (PREVENT) equations were developed from observational research cohorts and electronic health record data and provide sex-specific risk estimates for cardiovascular disease (CVD), atherosclerotic CVD (ASCVD), and heart failure (HF). External validation in large contemporary samples across multiple health systems in the United States is needed. METHODS: We assembled a national electronic health record-based cohort of US adults with individual-level patient data pooled from a collective of 30 health systems (Truveta) to externally validate the outcome-specific 10-year PREVENT equations (PREVENT-CVD, PREVENT-ASCVD, and PREVENT-HF). We included patients aged 30 to 79 years without a history of prior CVD and with an ambulatory encounter in the electronic health record between 2013 and 2018. The outcomes were defined as total CVD (composite of ASCVD and HF), ASCVD, and HF through December 2024 using diagnosis codes. Model performance of the outcome-specific PREVENT base equations was assessed with the Harrell C statistic and calibration slope, stratified by sex. RESULTS: Of the 680 864 adults included, the mean (SD) age was 55 (13) years, and 56% were women. Over a mean (SD) follow-up of 6.8 (2.3) years, there were 29 535 incident CVD events, 19 280 incident ASCVD events, and 16 824 incident HF events. The median (interquartile range) 10-year predicted risk of PREVENT-CVD among women was 3.6% (1.3%-8.8%), and among men was 5.8% (2.5%-11.7%). The C statistic (95% CI) was 0.788 (0.786-0.790), and the calibration slope (95% CI) was 0.98 (0.95-1.01) for PREVENT-CVD. PREVENT-ASCVD and PREVENT-HF demonstrated similar C statistics (0.774 [0.771-0.777] and 0.824 [0.820-0.828]) and calibration slopes (1.07 [1.04-1.10] and 1.01 [0.97-1.04]) for prediction of the 10-year risk of ASCVD and HF, respectively. CONCLUSIONS: The PREVENT equations accurately and precisely estimate the 10-year risk of CVD, ASCVD, and HF in a large sample of US adults. These findings support the generalizability of the PREVENT equations to inform guideline-recommended risk assessment and preventive efforts.

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