Use of mediterranean diet adherence and physical activity for refining cardiovascular risk prediction in the general population
Abstract
The SCORE2/SCORE2-OP, recommended for estimating 10-year risk of first atherosclerotic cardiovascular disease (ASCVD), does not include lifestyle factors. We investigated whether adding self-reported physical activity and Mediterranean diet adherence improves prediction beyond SCORE2/SCORE2-OP. We analyzed participants from the population-based cohort with data for the Physical Activity Frequency Questionnaire (PAFQ) and Mediterranean Diet Score (MedDietScore). Participants with history of cardiovascular disease, lipid-lowering therapy, diabetes, severe chronic kidney disease or LDL-cholesterol > 4.9 mmol/L were excluded from this analysis. Different Cox-based prediction models were tested: SCORE2 or SCORE2-OP depending on the participant age, alone or in addition to PAFQ, MedDietScore or both. Discrimination (Harrell’s C), calibration slope and net reclassification improvement (NRI) were calculated. The primary outcome was first incident ASCVD (myocardial infarction, ischemic stroke and cardiovascular death). A total of 2,587 participants (59% women; median age 55 years) were followed for a median duration of 9.0 years (IQR: 8.13-11.6), during which 145 ASCVD events occurred. Of these, 2,348 were younger than 70 years and evaluated using SCORE2, with 106 ASCVD events. The remaining 239 were aged 70 years or older and assessed with SCORE2-OP, with 39 ASCVD events. Adding physical activity or diet or both to SCORE2 did not improve discrimination (Harrell’s C: 0.74 for all models), calibration (slope: 1.06 for all), nor reclassification (continuous total NRI: -8.8 to 2.5%). In contrast, adding both lifestyle factors to SCORE2-OP improved discrimination (Harrell’s C: 0.63 to 0.66), calibration (slope: 1.34 to 1.16) and reclassification (continuous total NRI: 41% (95%CI 7–74%) with event (ASCVD) NRI of 28% and non-event (non-ASCVD) NRI of 13%). The addition of self-reported physical activity and Mediterranean diet may be clinically useful to improve ASCVD risk prediction in older adults beyond the traditional SCORE2-OP.