Background/Purpose: Patients with lupus erythematosus (LE) are at an increased risk of clinical events from atherosclerotic cardiovascular disease (ASCVD), yet the accuracy of risk estimation tools in this population remains unclear. Here, we compared the new American Heart Association cardiovascular risk calculator, PREVENT, with the previous ACC ASCVD Risk Estimator Plus (ACC) in our longitudinal cohort of patients with cutaneous LE without (CLE-only) or with (CLE+SLE) concurrent systemic LE.

Methods: Utilizing our prospective longitudinal database of patients with LE, we conducted a retrospective chart review to estimate the risk of an ASCVD event in the next 10 years (“10-year ASCVD event risk”) using both calculators, incorporating optional variables when available.

Results: A highly significant correlation was identified between the two calculators (p< 10-15), but with considerable scatter (r2=0.47) (Figure 1). The PREVENT calculator consistently generated far lower estimates of 10-year ASCVD event risk (median 2.33%, IQR 0.79%-5.16%) compared with the ACC calculator (median 4.65%, IQR 1.30%-11.98%; p< 10-15 by the Wilcoxon signed-rank test), consistent with previous studies. Subtype analyses revealed significant differences between the two calculators for CLE-only patients and for CLE+SLE patients as well (p< 10-15), although no significant difference was observed within PREVENT-generated scores between these two subgroups (p=0.11). Clinical management of ASCVD is typically driven by risk category, and the PREVENT calculator reclassified 43.2% (120 out of 278) of the lupus patients to a lower category than was assigned by the ACC calculator (Figure 2).

Conclusion: Given an actual 10-year ASCVD event rate of 13.5% in this cohort (Zhao M et al. 2023), both calculators underestimated risk, with PREVENT underestimating more significantly. These findings highlight the need for caution when using PREVENT for LE patients. Overall, there is a need for better cardiovascular risk assessment and management for patients with lupus erythematosus.

Figure 1. Pearson’s Correlation Between Estimated 10-Year ASCVD Event Risk by PREVENT Calculator and Estimated 10-Year ASCVD Event Risk by ACC Risk Estimator Plus for the Lupus Erythematosus Cohort. The two calculators used to estimate the risk of a future atherosclerotic cardiovascular disease (ASCVD) event for individual patients within the primary prevention lupus erythematosus (LE) cohort with sufficient data in electronic medical records were the 10-year ASCVD event risk generated by the PREVENT Calculator (y-axis) versus the ACC ASCVD Risk Estimator Plus (x-axis). Two estimates of ASCVD event risk for each of the 278 eligible patients with LE. Each dot represents an individual patient.

Figure 2. Distribution of Risk Category Change Using the PREVENT Calculator Compared to the ACC ASCVD Risk Estimator Plus (ACC) Calculator

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/rethinking-heart-risk-prediction-for-lupus-patients/