Dr.

Atif Sher Muhammad

Interventional Cardiologist, NICVD Karachi, Pakistan

TEN YEARS RISK ASSESSMENT OF ATHEROSCLEROTIC CARDIOVASCULAR

EVENT USING ASTRO-CHARM AND POOLED COHORT EQUATION IN PAKISTANI
POPULATION

Professor Tariq Ashraf

Background

 An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths
 South Asians have relatively high risk of cardiovascular diseases (CVD) compare to other regions.
 The estimated rates of IHD for South Asian region is 2052 prevalent cases per 100,000 as
compared to global rates of 1663/100,000 cases [1].
 According to World Health Organization - Noncommunicable Diseases (NCD) Country Profiles,
2018, in Pakistani population the proportional mortality due to Cardiovascular diseases is 29%
[2].
 According to a recent study, 12% of the cases presented with STEMI consisted of premature
(<40 years) MI [3].

1. Roth GA, Johnson C, Abajobir A, et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. Journal of the
American College of Cardiology. 2017 Jun 26;70(1):1-25.
2. https://www.who.int/nmh/countries/2018/pak_en.pdf?ua=1
3. Batra MK, Rizvi NH, Sial JA, Saghir T, Karim M. Angiographic characteristics and in hospital outcome of young patients, age up to 40 versus more than
40 years undergoing primary percutaneous coronary intervention. JPMA. 2019 Sep.
Rationale & Objective

A number of risk assessment tools are available such as Framingham risk

score (RiskFRS), prospective cardiovascular Munster (PROCAM) score,
systemic coronary risk evaluation (SCORE), QRISK, WHO risk tool (RiskWHO)
and Joint British Societies risk tool (RiskJBS).
A newly established CVD risk estimator, Astronaut Cardiovascular Health and
Risk Modification (Astro-CHARM) effectiveness in South Asian population is
yet to be explored.
Therefore,
 This study was planned to evaluate the 10-years CVD risk in non-cardiac
Pakistani population by using Astro-CHARM and Pooled Cohort Equation
(PCE).
Methods

 We recruited n=386 non-cardiac subjects of either gender between 40 to

65 years of age through screening camps organized in tertiary care hospital,
recruited from different areas across Karachi, a metropolitan city of
Pakistan.
 Demographics, history, physical examination, Lipid Profile, C-reactive
protein (CRP), ECG and Coronary Artery Calcium (CAC) score were obtained.
 CVD 10-years risk was estimated through Astro-CHARM and PCE.
 IBM SPSS version-22 was used for analysis. Numerical data presented in
mean ±standard deviation whereas categorical in frequencies and
percentages.
Astro-CHARM
Calculator
Pooled Cohort Equation (PCE)
Calculator
Risk Stratification

Participants were stratified into four groups based Coronary Artery Calcium
(CAC) score
 No risk - CAC Score = 0
 Low risk – CAC Score ≤ 99
 Medium risk – CAC Score between 100 to 399
 High risk – CAC Score ≥ 400

Participants with ≥ 7.5% of 10-years ASCVD risk based on Astro-CHARM and

PCE were stratified as high risk.
Baseline Characteristics

A total of 386 individuals with mean age of 49.0 ±7.1 years (40 to 65 years) were recruited
for this study.

Gender Distribution Distribution by Mother Tongue

Male Female Sindhi Punjabi Urdu
Pushto Balochi Others

72 54
175 10 19% 14% 50
211
45% 3% 13%
55% 71
18% 129
33%
Risk Profile

Hypertension was observed in 45.6% (176) participants and 30.6% (118) participants had
family history of heart attack
50.0%
45.6%
45.0%
40.0%
35.0%
30.6%
30.0%
25.0%
20.0%
15.8% 14.2%
15.0%
10.0%
5.0%
0.0%
Hypertension Diabetes Currently Smoke Family History of Heart Attack
Risk profile comparison

PAK Global PAK Global PAK Global

55.0% 51.0 ± 7.5 45.6%

54.7% 49.0 ± 7.11 22.0%

Male Gender Age (years) Hypertension

PAK Global PAK Global PAK Global

15.8% 138.83 ± 21.23
6.02 ± 5.75
8.0% 123 ± 18
1.6 [0.5, 4.3]

Diabetes CRP SBP

PAK = Our study

Global = Khera A, Budoff MJ, O’Donnell CJ, Ayers CA, Locke J, de Lemos JA, Massaro JM, McClelland RL, Taylor A, Levine BD. Astronaut Cardiovascular Health
and Risk Modification (Astro-CHARM) coronary calcium atherosclerotic cardiovascular disease risk calculator. Circulation. 2018 Oct 23;138(17):1819-27.
Coronary Artery Calcium

Mean Coronary Artery Calcium Score was 31.57 ± 195.63 Agatston Units

Zero 1 to 99 100 to 399 400 or high Male Female

19 6 81.7
5% 2%
79 65.9
20%

282 25.6
73% 14.3
6.6
2.9 1.9 1.1

Zero 1 to 99 100 to 399 400 or high

An estimated 10-year risk
Astro-CHARM

An average estimated 10-year risk of fatal or non-fatal myocardial infarction or stroke as

per the Astro-CHARM was 3.57 ± 4.61% ranging over 0.2 to 40.3%.

Male Female
< 7.5% ≥ 7.5% 94.3
84.4

343
89%

43
11%
15.6
5.7

< 7.5% ≥ 7.5%

An estimated 10-year risk
PCE

10-year risk of atherosclerotic cardiovascular disease based on Pooled Cohort Risk

Assessment Equations was 4.96 ± 5.79% ranging over 0.2 to 43.8%.
Male Female

< 7.5% ≥ 7.5% 92.0

68.7

306
79%
80 31.3
21%

8.0

< 7.5% ≥ 7.5%

An estimated 10-year risk
40-50 years vs. > 50 years

AS per both Astro-CHARM and PCE estimated 10-year risk of fatal or non-fatal
myocardial infarction or stroke was found to be significantly higher among the participants
of age above 50 years
Astro-CHARM PCE
40 to 50 years > 50 years 40 to 50 years > 50 years
94.2 94.6
80.0

53.8
46.2

20.0
5.8 5.4

< 7.5% ≥ 7.5% < 7.5% ≥ 7.5%

An estimated 10-year risk
Pooled Cohort Equations vs. Astro-CHARM

Correlation between the risk estimates of both the modalities was

found to be 0.721 (p<0.001)

4.96 ± 5.78%
Estimated 10-year risk of
3.57 ± 4.61%
Estimated 10-year risk of fatal or non-
atherosclerotic cardiovascular disease fatal myocardial infarction or stroke

P-value < 0.01

Bland-Altman plot
Past Knowledge

 A study by Ashraf et al. [1] reported that 10-year risk was higher in
Pakistani males (28.2%) as compared to females (10.6%) without ASCVD,
whereas lifetime risk was 49.4% in males and 31.9% in females.
 Namratha et al. [2] in their Mediators of Atherosclerosis in South Asians
Living in America (MASALA) study found 10-year predicted risk in males
and female to be 49% and 13%, respectively.

1. Ashraf T, Achakzai AS, Farooq F, Memon MA, Mengal N, Abbas KY, Ishaq H, Mueed A. Estimating risk of atherosclerotic cardiovascular diseases in non-
atherosclerotic Pakistani patients: study conducted at National Institute of Cardiovascular Diseases, Karachi, Pakistan. JPMA J Pak Med Assoc. 2017 Apr
1;67(April (4)):494-8.
2. Kandula NR, Kanaya AM, Liu K, Lee JY, Herrington D, Hulley SB, Persell SD, Lloyd‐Jones DM, Huffman MD. Association of 10‐year and lifetime predicted
cardiovascular disease risk with subclinical atherosclerosis in South Asians: findings from the Mediators of Atherosclerosis in South Asians Living in
America (MASALA) study. Journal of the American Heart Association. 2014 Oct 2;3(5):e001117.
Past Knowledge

 A study by Khera et al. [1] reported ASCVD risk of ≥ 7.5% for the 12.9% of
the subjects.
 Khera et al. [1] reported CAC scores of 0, 1 to 99, 100 to 399, and ≥400 in
63%, 27%, 7%, and 3%, of the individuals respectively. Whereas, in our
study CAC scores of 0, 1 to 99, 100 to 399, and ≥400 were observed in
73.1%, 20.5%, 4.9%, and 1.6% of the participants respectively.

1. Khera A, Budoff MJ, O’Donnell CJ, Ayers CA, Locke J, de Lemos JA, Massaro JM, McClelland RL, Taylor A, Levine BD. Astronaut Cardiovascular Health and
Risk Modification (Astro-CHARM) coronary calcium atherosclerotic cardiovascular disease risk calculator. Circulation. 2018 Oct 23;138(17):1819-27.
Conclusion

Although Pooled Cohort Equation has predicted significantly higher risk as

compared to the Astro-CHARM but a longer follow-up will ensure the
effectiveness of Astro-CHARM in our local population. Moreover PCE cannot
be neglected in situations where CAC and CRP investigations are not available.

Clinical Implications
Risk assessment is a vital step in implementing and developing preventive
strategies for CVD. This baseline data shall support the clinicians to
implement risk assessment for decision-making in primary prevention.
Limitations

 Participants below 40 years of age were excluded

 Limited sample size
 Single city coverage
Thank You