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Performance of the American Heart Association’s PREVENT risk score for cardiovascular risk prediction in a multiethnic population

Nature Medicine volume 31, pages 2655–2662 (2025)Cite this article

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Abstract

The Predicting Risk of Cardiovascular EVENTS (PREVENT) equations, created and endorsed by the American Heart Association, provide cardiovascular risk estimates for the general population, but have not yet been tested in multiethnic populations. In the present study, in a large nationwide multiethnic sample of US veterans, the utility of PREVENT to predict the risk of total cardiovascular disease (CVD: fatal and nonfatal myocardial infarction, stroke or heart failure; PREVENT-CVD), atherosclerotic cardiovascular disease (ASCVD: fatal and nonfatal myocardial infarction or stroke; PREVENT ASCVD) and heart failure was evaluated. We assessed the discrimination and calibration performance of ASCVD prediction with PREVENT ASCVD compared with a previous risk-prediction score, pooled cohort equations (PCEs). Among 2,500,291 veterans aged 30–79 years (93.9% men and 6.1% women), 407,342 total CVD events occurred over a median (interquartile range (IQR)) follow-up of 5.8 (IQR = 3.1–8.3) years. The Concordance index (C-index) (95% confidence interval (CI)) for PREVENT-CVD was 0.65 (95% CI = 0.65–0.65) in the overall sample and was similar across different race and ethnic groups (Asian, Native Hawaiian or Pacific Islander, 0.70 (95% CI = 0.69–0.71); Hispanic, 0.70 (95% CI = 0.69–0.70); non-Hispanic Black. 0.68 (95% CI = 0.68–0.69) and non-Hispanic White, 0.65 (95% CI = 0.64–0.65)). C-indices were similar between PREVENT ASCVD and PCEs and ranged from 0.61 to 0.63. Calibration slopes for PREVENT-CVD and -ASCVD in the overall sample were 1.09 (s.e. = 0.04) and 1.15 (s.e. = 0.04), respectively. In contrast, PCEs demonstrated overprediction for ASCVD with a calibration slope of 0.51 (s.e. = 0.06). Calibration slopes for PREVENT and PCEs were similar across race and ethnic groups. Among US veterans, the PREVENT equations accurately estimated CVD and ASCVD risk with some variability across race and ethnicity groups and outperformed PCEs for ASCVD risk prediction.

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Fig. 1: Patient flow into the cohort.
Fig. 2: Calibration plots of predicted versus observed composite outcomes.

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Data availability

Given the privacy restrictions of the VHA data, data used for this analysis are not available for sharing. Source data are provided with this paper.

Code availability

Analytical coding can be shared after request to the corresponding author and after data use agreements have been established. Approved requests will be fulfilled within an agreed upon time frame but not exceeding 90 days from approval of request and signing of data use agreement by all parties.

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Acknowledgements

T.M.P.-W. is funded by the Division of Intramural Research of the National Heart, Lung, and Blood Institute and the Intramural Research Program of the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH). K.R.T. is supported by NIH research grants (nos. R01MD014712, U2CDK114886, UL1TR002319, U54DK083912, U01DK100846, OT2HL161847, UM1AI109568 and OT2OD032581) and the Centers for Disease Control and Prevention (CDC; project nos. 75D301-21-P-12254 and 75D301-23-C-18264). She has also received investigator-initiated grant support from Travere Therapeutics Inc., Bayer and the Doris Duke Charitable Foundation. J.E.H. is supported by NIH research grants (nos. T32 HL160522, R01 160003 and K24 HL153669). J.C. is supported by NIH grants (nos. 2R01DK100446, 2U01HL096812 and AHA-1258966), co-funded by the Doris Duke Foundation. R.O.M. and J.R. are employees of the US Department of Veterans Affairs. The views expressed in this manuscript are our own and do not necessarily represent the views of the US Department of Veterans Affairs, the National Heart, Lung, and Blood Institute, the National Institute on Minority Health and Health Disparities, the NIH or the US Department of Health and Human Services.

Author information

Author notes

  1. These authors contributed equally: Roy O. Mathew, Sadiya S. Khan, Janani Rangaswami.

Authors and Affiliations

  1. Department of Medicine, Division of Nephrology, Loma Linda VA Healthcare system, Loma Linda, CA, USA

    Roy O. Mathew

  2. Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA

    Roy O. Mathew

  3. Department of Medicine, Division of Cardiology, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA

    Sadiya S. Khan

  4. Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA

    Katherine R. Tuttle

  5. Nephrology Division and Kidney Research Institute, University of Washington School of Medicine, Seattle, WA, USA

    Katherine R. Tuttle

  6. Department of Medicine, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Jennifer E. Ho

  7. Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA

    Dmitry Abramov

  8. Division of Cardiovascular Medicine, NYU Grossman School of Medicine, New York, NY, USA

    Sripal Bangalore

  9. Department of Medicine, Division of Cardiology, Albany Medical College, Albany, NY, USA

    Mandeep S. Sidhu

  10. Division of Cardiovascular Medicine, Johns Hopkins Medicine, Baltimore, MD, USA

    Chiadi E. Ndumele

  11. Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, Division of Intramural Research National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA

    Tiffany M. Powell-Wiley

  12. Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA

    Tiffany M. Powell-Wiley

  13. Harrington Heart and Vascular Institute, University Hospitals Cleveland and Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Ian J. Neeland

  14. Departments of Population Health and Medicine, NYU Grossman School of Medicine, New York, NY, USA

    Josef Coresh

  15. American Heart Association, Dallas, TX, USA

    Mitchell S. V. Elkind

  16. Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA

    Mitchell S. V. Elkind

  17. Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA

    Mitchell S. V. Elkind

  18. Department of Medicine, Division of Nephrology, Washington DC VA Medical Center, Washington, DC, USA

    Janani Rangaswami

  19. George Washington University School of Medicine, Washington, DC, USA

    Janani Rangaswami

Authors
  1. Roy O. Mathew
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Contributions

R.O.M. undertook regulatory approvals, data steward and data acquisition. R.O.M., S.S.K., J.R., C.N. and J.C. were responsible for study inception, the analytical plan, data analysis and preparation of the first draft of the manuscript. All authors thoroughly reviewed and provided critical analysis of the drafts and gave final approval for manuscript submission.

Corresponding author

Correspondence to Roy O. Mathew.

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Competing interests

R.O.M., S.S.K., M.S.S., C.N. and T.M.P.-W. declare no competing interests. K.R.T. is supported by NIH research grants and CDC projects. She has also received an investigator-initiated grant support from Travere Therapeutics Inc., Bayer and the Doris Duke Charitable Foundation. She reports consultancy fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Travere Therapeutics Inc. and Pfizer and speaker fees from Novo Nordisk. J.E.H. is supported by NIH research grants (see above). D.A. has received speaker fees from Bayer and AstraZeneca. S.B. is a consultant or on the advisory board of Abbott Vascular, Boston Scientific, Medtronic, Amgen, Pfizer, Inari, Truvic and Shockwave. J.C. is supported by NIH grants co-funded by the Doris Duke Foundation (see above). I.J.N. has received speaker fees from Boehringer Ingelheim/Lilly Alliance and Bayer, and is on the consulting or advisory board of Novo Nordisk, Lilly and Boehringer Ingelheim. M.S.V. is an employee of the AHA. J.R. has been a consultant for Boehringer Ingelheim, Bayer and is on the Medical Advisory Board for Procyrion.

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Nature Medicine thanks Quyen Ngo-Metzger, Boback Ziaeian and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Primary Handling Editor: Michael Basson, in collaboration with the Nature Medicine team.

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Extended data

Extended Data Fig. 1 Calibration plots of predicted versus observed individual outcomes.

Calibration for the individual components of total cardiovascular disease: (a) non-fatal and fatal coronary heart disease (CHD), (b) non-fatal and fatal cerebrovascular accident (CVD), and (c) non-fatal and fatal heart failure (HF), by race/ethnicity group. AHA PREVENT: American Heart Association Predicting Risk of Cardiovascular Disease EVENTs. Individual data points and error bars are representing mean and standard error of the mean. The individual data points represent the population number within deciles of predicted risk.

Extended Data Fig. 2 Calibration plots of predicted versus observed outcomes for recalibrated equation.

Calibration curves for the recalibrated Predicting Risk of Cardiovascular EVENTs (PREVENT) in the (a) overall population and (b) by race/ethnicity group. Individual data points and error bars are representing mean and standard error of the mean. The individual data points represent the population number within deciles of predicted risk.

Extended Data Table 1 Outcomes by race and ethnicity groups
Full size table
Extended Data Table 2 Performance characteristics in those with SDI
Full size table
Extended Data Table 3 Recalibrated estimates for the VA Population
Full size table
Extended Data Table 4 Operational characteristics of the original PREVENT total CVD equation and the VA Recalibrated equation
Full size table

Supplementary information

Supplementary Information

Supplementary Tables 1–3 and Fig. 1a,b.

Reporting Summary

Source data

Source Data Extended Data Tables 1–4

The source data for the Extended Data tables.

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Mathew, R.O., Khan, S.S., Tuttle, K.R. et al. Performance of the American Heart Association’s PREVENT risk score for cardiovascular risk prediction in a multiethnic population. Nat Med 31, 2655–2662 (2025). https://doi.org/10.1038/s41591-025-03789-2

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