Cardiovascular Disease Prognostic Models in Latin America and the Caribbean : A Systematic Review

Abstract

Background

Cardiovascular prognostic models guide treatment allocation and support clinical decisions. Whether there are valid models for Latin American and Caribbean (LAC) populations is unknown.

Objective

This study sought to identify and critically appraise cardiovascular prognostic models developed, tested, or recalibrated in LAC populations.

Methods

The systematic review followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) framework (PROSPERO [International Prospective Register of Systemic Reviews]: CRD42018096553). Reports were included if they followed a prospective design and presented a multivariable prognostic model; reports were excluded if they studied symptomatic individuals or patients. The following search engines were used: EMBASE, MEDLINE, Scopus, SciELO, and LILACS. Risk of bias assessment was conducted with PROBAST (Prediction model Risk Of Bias ASsessment Tool). No quantitative summary was conducted due to large heterogeneity.

Results

From 2,506 search results, 8 studies (N = 130,482 participants) were included for qualitative synthesis. We could not identify any cardiovascular prognostic model developed for LAC populations; reviewed reports evaluated available models or conducted a recalibration analysis. Only 1 study included a Caribbean population (Puerto Rico); 3 studies were retrieved from Chile; 2 from Argentina, Brazil, Colombia, and Uruguay; and 1 from Mexico. Four studies included population-based samples, and the other 4 included people affiliated to a health facility (e.g., prevention clinics). Most studied participants were older than 50 years, and there were more women in 5 reports. The Framingham model was assessed 6 times, and the American College of Cardiology/American Heart Association pooled equation was assessed twice. Across the prognostic models assessed, calibration varied widely from one population to another, showing great overestimation particularly in some subgroups (e.g., highest risk). Discrimination (e.g., C-statistic) was acceptable for most models; for Framingham it ranged from 0.66 to 0.76. The American College of Cardiology/American Heart Association pooled equation showed the best discrimination (0.78). That there were few outcome events was the most important methodological limitation of the identified studies.

Conclusions

No cardiovascular prognostic models have been developed in LAC, hampering key evidence to inform public health and clinical practice. Validation studies need to improve methodological issues.

Highlights

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  There has never been a cardiovascular prognostic model developed in LAC.

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  Few studies have tested available models, but they have methodological limitations.

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  Discrimination estimates were acceptable across studies.

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  Calibration estimates showed important overestimation across studies.

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  Many countries in Latin America do not have tools for cardiovascular prevention.