Differences in estimates for ten-year risk of cardiovascular disease in Black versus white persons with identical risk factor profiles using pooled cohort equations

Background Sex- and race-specific pooled cohort equations (PCE) are recommended for estimating the 10-year risk of cardiovascular disease (CVD), with an absolute risk >7.5% indicating a clinical decision threshold. Methods We generated in silico 30,565 risk profiles in men and 29,515 in women by combining numerical (age, total and high-density lipoprotein cholesterol, systolic blood pressure) and binary risk factors (smoking, diabetes, antihypertensive treatment). We compared PCE-estimated 10-year CVD risk in Black versus white individuals with identical risk profiles. We performed similar comparisons in participants in the Framingham Third Generation cohort and the National Health and Nutrition Examination Survey 2017-2018. Results There were 6357 risk profiles associated with 10-year CVD risk >7.5% for Black but not for white men (median risk difference [RD] 6.25%, range 0.15-22.8%; median relative risk [RR] 2.40, range 1.02-12.6). There were 391 profiles with 10-year CVD risk >7.5% for white but not for Black men (median RD 2.68%, range 0.07-16.9%; median RR 1.42, range 1.01-3.57). There were 6543 risk profiles associated with 10-year estimated CVD risk >7.5% for Black but not for white women (median RD 6.14%, range 0.35-26.8%; median RR 2.29, range 1.05-12.6). There were 318 profiles with 10-year CVD risk >7.5% for white but not for Black women (median RD 3.71%, range 0.22-20.1%; median RR 1.66, range 1.03-5.46). The population-based samples demonstrated similar risk differences. Conclusions The PCE may generate substantially divergent CVD risk estimates for Black versus white individuals with identical risk profiles, which could introduce race-related variations in clinical recommendations for CVD prevention.