Three separate tools, (1) the Framingham Risk Score (FRS), (2) the American College of Cardiology/American Heart Association (AHA) Pooled Cohort Risk Equation (PCE) for atherosclerotic cardiovascular disease, and (3) the International Diabetes Federation (IDF) definition of metabolic syndrome (MetS), were compared and used to estimate immigrants’ CVD risk. The component parts of each risk measurement tool are compared with one another in Table 1.

The FRS is perhaps the most well-known measure of 10-year risk of a cardiac event.^8,10 In the FRS, traditional risk factors for coronary disease (eg, age, gender) are assigned weights and then converted into an absolute probability of developing coronary disease.¹⁰ The C-statistic for the FRS ranges from 0.75 to 0.8 indicating a near-excellent predictive value.⁸ The FRS has limitations, however. It has not been validated in diverse populations and tends to overestimate risk in minority populations.^10,11 The FRS does not account for plasma glucose levels and consequently has less predictive power in individuals with type 2 diabetes mellitus (DM2).¹⁰ It also cannot predict heart or vascular diseases beyond coronary disease.⁸

The PCE partially addresses these shortcomings.¹² It was developed using a large heterogenous multicohort sample that included African American men and women.¹² The PCE predicts an individual’s 10-year risk of atherosclerotic CVD (ASCVD) events, including myocardial infarction and stroke, and includes race and diabetes as risk determinants.¹² It also accounts for whether an individual is being treated for hypertension and is used in the clinical setting to determine the appropriateness of initiating statin therapy in patients.¹³ In validation studies using racially diverse cohorts, however, the PCE demonstrated borderline/ unacceptable C-statistics, ranging from 0.56 to 0.77.¹⁴ It has also been criticized for overestimating risk; in a nationally representative sample, the PCE classified 99% of people older than 70 years as needing statin therapy.¹³

Metabolic syndrome, defined as a cluster of risk factors, including obesity, hypertension, hyperglycemia, and dyslipidemia, has been proposed as an additional means of assessing CVD risk.^15,16 It is associated with a significantly increased risk of developing DM2 and has been widely promoted as a means of identifying patients for lifestyle intervention to reduce risk factors and incident CVD,^17,18 particularly in ethnically diverse populations.¹⁹ The presence of MetS has also been found to increase the risk of cerebrovascular accident (CVA) and peripheral vascular disease, which are among the complications older immigrants experience.²⁰

This study had 2 main findings: (1) each risk measure yields a different estimate of the proportion of individuals at an elevated risk of CVD, and (2) there is a gap in the proportion of older immigrants at a high risk for CVD and those receiving pharmacologic treatment for CVD prevention. With respect to the former, the PCE estimated that 58% of older immigrants were at a high risk for ASCVD, whereas the FRS high/moderately high (48%) and MetS (23%) yielded lower estimates. These differences were somewhat expected given differences in the component parts of each outcome measure. Among the 3 outcome measures, the PCE is the most comprehensive in the risk factors it accounts for; it includes self-reported diagnosis of diabetes and treatment of hypertension in addition to clinical measures of cardiometabolic risk. This makes the PCE tool more likely than the FRS or MetS to capture those individuals who have pharmacologically controlled blood pressure and plasma glucose but have underlying diagnoses of diabetes and hypertension. Although the PCE tool also accounts for race unlike the others, this was less likely to have factored into our results given that race-specific equations only apply to African Americans. Our sample, consistent with the broader US immigrant population, was disproportionately Hispanic.²⁹

Previous studies have found, however, that both the PCE model and FRS overestimate risk, especially in diverse samples containing Asians and Hispanics, who were not well represented in the cohorts used to derive the original tool.³⁰ For example, in a study that compared predicted and observed CVD events using the FRS and PCE in a diverse sample from the Multi-Ethnic Study of Atherosclerosis cohort (mean age, 61 years; 53.5% female), both the FRS and the PCE were said to have overestimated risk by as much as 154% in men and 67% in women.¹⁴

Compared with general samples of middle-aged and older adults, our findings suggest that middle-aged and older immigrants have a lower overall risk of CVD. In a similarly aged cohort of European adults, 96% of men and 66% of women were candidates for statin therapy based on the PCE.³¹ In our sample, the proportions were lower—76% of men and 42% of women. However, in another study using NHANES,³² with younger (mean, 53 years old), predominately white participants, 29.9% of the participants were at an elevated risk compared with 59% overall in our study. This difference can likely be attributed to age differences between the latter sample and our own, because age is a dominant factor in 10-year risk using the PCE.¹⁷

Data from a nationally representative sample of men and women aged 50 to 79 years in the United States³³ showed that 82% of men and 45% of women had either moderately high or high risk of CVD using the FRS. In our study, proportions were lower using the FRS, with 76.4% of men and only 17.4% of women falling into those categories. Notably, despite different component parts, both the FRS and the PCE were in agreement on the proportion of men at a high risk but not women.

Metabolic syndrome, although arguably the least comprehensive of the 3 measures used in this study, is based entirely on objective clinical measurements and does not rely on self-reported diagnoses, which are potentially less reliable. Metabolic syndrome also does not account for the advanced age of our sample; again, age may partially explain the higher proportions of individuals at a high risk of CVD using the FRS and PCE. It is estimated that 44% of Americans 50 years and older have MetS.³⁴ In our cohort, 23% had MetS, suggesting that our immigrant sample may have a health advantage. However, there was poor agreement between MetS and the other measures. Among those who had MetS, 42% fell into the lowest risk category using the FRS, and 14% were designated as low risk using the PCE. Metabolic syndrome is said to confer a 5-fold increase in the risk of type 2 diabetes, doubles 10-year risk of CVD, and is associated with a 2- to 4-fold increase in the risk of stroke.³⁵ Thus, inability of these other risk calculators to capture those with MetS is problematic because many of the individuals who are truly at risk based on objective clinical measures are not being treated.

Without other nationally representative samples of older immigrants to provide reference, it is unclear how accurately these tools capture older immigrants’ risk and whether their risk is actually lower than general samples of adults 50 years and older. However, the failure of the PCE tool, in particular, to capture those with MetS may reflect the fact that many immigrants, especially women, are unaware as to whether they have diabetes or hypertension, which are components of this calculator. Immigrant populations have been found to demonstrate low levels of CVD risk factor awareness and are less likely to receive treatment.³⁶

There were minor differences between the percentage of those with diagnoses of hypertension and DM and the percentage receiving treatment of those disorders. However, the discrepancy was greater with respect to blood cholesterol levels. Although 42% of the sample self-reported a diagnosis of hypercholesterolemia, only 24% were receiving medication. Or, using the FRS and PCE categorizations, which are indications for cholesterol-lowering therapy, less than half of individuals who qualified for statin therapy actually reported getting it. This may be a reflection of health access barriers. It may also be a consequence of racial bias that has historically contributed to disparities in the quality and intensity of care for minorities.^37,38 This area warrants further analysis among aging immigrants.

This study has several limitations, beyond the crosssectional design that prohibits causal inference. The data are limited by reliance on participant self-report without corroboration from a formal medical record. This has implications for prevalence estimates. For example, the proportion of persons with hypertension and DM is based on self-reported diagnoses and awareness of these conditions. This is known to be problematic in immigrant populations, where health advantages are illusory and partially attributable to diseases that go undiagnosed in the sending country.³⁹ Thus, rates of hypertension and DM may be higher than reported. The most significant limitation was the inability to capture meaningful clinical differences among racial/ethnic subgroups using these particular cycles of NHANES data. This is especially important in light of the fact that Hispanics and Asians represent two of the largest immigrant groups in the United States, and there is significant heterogeneity in clinical risk between them.⁴⁰ Moreover, country of origin was not assessed in 2 of 3 NHANES cycles. Whereas Hispanics were oversampled in all 3 data cycles, Asians were only oversampled in 1 cycle of data, and proportions were too small to support subgroup analysis. Aggregating Asians and Hispanics may have inadvertently biased the findings.

The authors estimated CVD risk factors in a diverse population using 3 different measures and uniquely provided population estimates of the proportion of middle-aged and older immigrants at risk of heart disease in the United States. This study suggests that, in immigrants, mainstream measures of CVD risk are not reliable when used in isolation. None of the 3 outcome measures used in this study fully captures individuals’ risk of CVD. Rather, clinicians need to analyze the estimates and indications put forth by the PCE, FRS, and MetS in a holistic context. Not only does CVD risk need to be explored using objective clinical measures, including the increasingly used coronary artery calcification scan, but also within the context of patients’ family and social history. Other factors that may heighten immigrants’ health risks and reduce the likelihood that they are receiving appropriate therapy, including low socioeconomic status, limited English proficiency, and discrimination by providers, must also be included as part of immigrants’ broader CVD risk assessment.