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Journal of Peking University (Health Sciences) ›› 2020, Vol. 52 ›› Issue (3): 444-450. doi: 10.19723/j.issn.1671-167X.2020.03.008

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Application of the China-PAR stroke risk equations in a rural northern Chinese population

Xun TANG1,Du-dan ZHANG2,Xiao-fei LIU1,Qiu-ping LIU1,Yang CAO1,Na LI3,Shao-ping HUANG3,Hui-dong DOU4,Pei GAO1,△(),Yong-hua HU1,△()   

  1. 1. Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing 100191, China
    2. Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, United Kingdom
    3. Fangshan District Center for Disease Control and Prevention, Beijing 102446, China
    4. The First Hospital of Fangshan District, Beijing 102400, China
  • Received:2020-02-16 Online:2020-06-18 Published:2020-06-30
  • Contact: Pei GAO,Yong-hua HU E-mail:peigao@bjmu.edu.cn;yhhu@bjmu.edu.cn
  • Supported by:
    National Natural Sciences Foundation of China(81973132);National Natural Sciences Foundation of China(81961128006);National Natural Sciences Foundation of China(81872695)

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Abstract:

Objective: To validate five-year risk prediction models for stroke in a contemporary rural Northern Chinese population.Methods: Totally 6 483 rural adults aged 40 to 79 years without cardiovascular diseases were enrolled at baseline between June and August 2010, and followed up through January 2017. Expected prediction risk using the China-PAR (prediction for atherosclerotic cardiovascular disease risk in China) stroke risk equations were compared with the new Framingham stroke risk profile (FSRP). The recalibrated models were applied by adjusting the five-year baseline survival rate and the mean score to our rural northern Chinese population, while keeping other coefficient parameters the same as the original models. Kaplan-Meier analysis was used to obtain the observed event (nonfatal or fatal stroke) rate for the five years, and the expected-observed ratios were calculated to evaluate overestimation or underestimation in the cohort. The models were assessed by discrimination C statistic, calibration χ2, and calibration charts and plots for illustration as well.Results: Over an average of (5.83 ± 1.14) years of the follow-up in this validation cohort with 6 483 rural Chinese participants, 438 subjects deve-loped a first stroke event. Recalibrated China-PAR stroke risk equations and FSRP well-performed for predicting five-year stroke risk in men, and had C statistics of 0.709 (95%CI, 0.675 - 0.743) and 0.721 (95%CI, 0.688 - 0.754), with calibration χ2 values being 5.7 (P = 0.770) and 13.6 (P = 0.137), respectively. However, both China-PAR and FSRP overestimated stroke events by 11.6% and 30.0% in women, and had C statistics of 0.713 (95%CI, 0.684-0.743) and 0.710 (95%CI, 0.679-0.740), respectively. Calibration χ2 values in women were 12.5 (P = 0.188) for China-PAR and 24.0 (P = 0.004) for FSRP. In addition, the calibration charts and plots illustrated good agreement between the observations and the predictions only in the China-PAR stroke risk equations, especially for men.Conclusion: In this validation cohort of rural northern Chinese adults, the China-PAR models had better performance of five-year stroke risk prediction than the FSRP, indicating that recalibrated China-PAR stroke risk equations might be appropriate tools for risk assessment and primary prevention of stroke in China.

Key words: Stroke, Risk prediction, Cohort study, Rural population

CLC Number: 

  • R181.2

Figure 1

Flow chart of inclusion criteria applied to the study participants for the validation of five-year stroke risk prediction models CHD, coronary heart disease; SBP, systolic blood pressure."

Table 1

Baseline characteristics and stroke events of study participants by gender"

Characteristics Men
(n=2 215)		 Women
(n=4 268)		 P value
Age/years, x?±s 55.7 ± 9.0 55.2 ± 8.7 0.027
Current smoker, n (%) 1 310 (59.1) 430 (10.1) <0.001
Waist circumference/cm, x?±s 87.1 ± 10.5 84.2 ± 10.2 <0.001
SBP/mmHg, x?±s 128.9 ± 16.4 128.0 ± 17.1 0.037
DBP/mmHg, x?±s 82.2 ± 9.9 79.9 ± 9.1 <0.001
Anti-hypertensive treatment, n (%) 344 (15.5) 749 (17.6) 0.039
Total cholesterol/ (mg/dL)a, x?±s 180.9 ± 36.8 194.2 ± 37.8 <0.001
HDL-C/ (mg/dL) a, x?±s 44.5 ± 11.6 47.3 ± 11.4 <0.001
Diabetes mellitus, n (%) 192 (8.7) 421 (9.9) 0.119
Atrial fibrillation, n (%) 21 (1.0) 23 (0.5) 0.057
Parental history of stroke, n (%) 475 (21.4) 986 (23.1) 0.130
Incident stroke events, n (%) 202 (9.7) 236 (6.1) <0.001
Incidence of stroke /100 000 person-years 1 653.5 1 008.4
5-year Kaplan-Meier stroke rate /% 6.1 3.8

Table 2

External validation of five-year stroke risk prediction by China-PAR and comparison with the FSRP"

Items Men Women
China-PAR FSRP China-PAR FSRP
Total participants, n 2 215 2 215 4 268 4 268
Actual stroke eventsa , n 202 202 236 236
Kaplan-Meier-adjusted eventsb , n 136.1 136.1 163.5 163.5
Predicted stroke eventsc , n 130.3 125.6 182.4 212.5
Expected-observed ratio 0.957 0.923 1.116 1.300
C statistic 0.709 0.721 0.713 0.710
95%CI 0.675-0.743 0.688-0.754 0.684-0.743 0.679-0.740
Calibration χ2 5.7 13.6 12.5 24.0
P value 0.770 0.137 0.188 0.004

Figure 2

Kaplan-Meier observed and predicted five-year stroke event rates in the external validation cohort using the China-PAR and FSRP China-PAR, prediction for atherosclerotic cardiovascular disease Risk in China; FSRP, Framingham Stroke Risk Profile."

Figure 3

Calibration plots for the external validation of five-year stroke risk prediction using the China-PAR and FSRP China-PAR, prediction for atherosclerotic cardiovascular disease risk in China; FSRP, Framingham stroke risk profile."

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