{"id":"7a9c7daa9230","type":"article","url":"https://hartvaat.nl/2026/02/16/smart2-risicomodel-onderschat-het-recidiefrisico-bij-kwetsbare-groepen-leids-haa/","title":"SMART2-risicomodel onderschat het recidiefrisico bij kwetsbare groepen (Leids-Haagse validatie)","title_en":"External validation of the SMART2 model for recurrent cardiovascular risk: performance in socioeconomic, ethnic and psychiatric subgroups","category":"algemeen","category_label":"Algemeen","professions":["cardioloog","huisarts","internist"],"tags":["primaire-preventie"],"journal":"Open Heart","doi":"http://openheart.bmj.com/cgi/content/short/13/1/e003882?rss=1","source_url":"https://doi.org/http://openheart.bmj.com/cgi/content/short/13/1/e003882?rss=1","authors":["van Egeraat","J. W. A.","van Geloven","N.","Hageman","S. H. J.","Bonten","T. N.","Cahn","W.","Vos","R. C.","Kist","J.","Mairuhu","A.","van Os","H."],"significance":7,"published":"2026-02-16","source_date":"2026-02-16","image":"","kennis":["https://hartvaat.nl/kennis/cardiometabool/diabetes-type-1-en-hart/","https://hartvaat.nl/kennis/cardiometabool/obesitas-en-hart/"],"congress":"","summary_en":"The SMART2 model predicts recurrent atherosclerotic event (ASCVD) risk in patients with established cardiovascular disease, but does not account for psychiatric disorders, socioeconomic deprivation or ethnicity. In this external validation using records from the Leiden-The Hague region (15,528 patients aged 40-80 with established ASCVD, median follow-up 6 years), overall discrimination was moderate (AUC 0.63) and overall calibration good (OE ratio 0.96). However, the model underestimated risk in patients with low socioeconomic status (OE 1.09) and in non-Western patients (OE 1.16), most strongly in those combining multiple vulnerabilities (low SES, non-Western ethnicity and psychiatric history; OE 1.19-1.29). The SMART2 model is thus well-calibrated in the general population but underestimates risk in vulnerable subgroups — who may need intensified monitoring. Clinicians should weigh social, ethnic and psychiatric factors when interpreting the risk estimate.","created":"2026-07-03T10:32:25Z","updated":"2026-07-03T13:31:22Z","licence":"Citeer vrij, met bronvermelding en een link naar hartvaat.nl (de url van het record). Samenvattingen zijn redactioneel werk van HartVaat; de oorspronkelijke publicaties blijven van hun uitgevers (doi). Geen medisch advies.","body_markdown":"Het SMART2-model voorspelt het risico op een nieuw atherosclerotisch event (ASCVD) bij patiënten met bestaande hart- en vaatziekten, maar houdt geen rekening met psychiatrische aandoeningen, sociaaleconomische achterstand of etniciteit. In deze externe validatie met dossiers uit de regio Leiden-Den Haag (15.528 patiënten van 40-80 jaar met bestaande ASCVD, mediane follow-up 6 jaar) was de algehele discriminatie matig (AUC 0,63) en de kalibratie overall goed (OE-ratio 0,96). Het model onderschatte het risico echter bij patiënten met een lage sociaaleconomische status (OE 1,09) en bij niet-westerse patiënten (OE 1,16), en het sterkst bij wie meerdere kwetsbaarheden combineerde (lage SES, niet-westerse etniciteit en psychiatrische voorgeschiedenis; OE 1,19-1,29). Het SMART2-model is dus goed gekalibreerd in de algemene populatie maar onderschat het risico bij kwetsbare subgroepen — die mogelijk intensievere monitoring nodig hebben. Behandelaars zouden sociale, etnische en psychiatrische factoren moeten meewegen bij het interpreteren van de risicoschatting.","abstract_original":"Background\n

Secondary prevention is critical for patients with established atherosclerotic cardiovascular diseases (ASCVD). The SMART2 model predicts recurrent ASCVD risk but does not account for psychiatric disorders, socioeconomic deprivation or ethnicity. We aimed to evaluate SMART2 model performance overall and in subgroups defined by these factors.

\n\nMethods\n

SMART2 was externally validated using electronic health records of patients aged 40–80 in the Leiden-The Hague region. Patients hospitalised for cardiovascular disease or coronary interventions between 1 January 2010 and 31 December 2021 were included. Model performance was assessed using discrimination (10-year area under ROC curve (AUC)) and calibration (observed/expected (OE) ratios and plots, adjusted for competing risks), both overall and in subgroups defined by three factors: psychiatric history, socioeconomic status (SES) and ethnicity.

\n\nResults\n

Among 15 528 patients (66% male, mean age 65) with established ASCVD, median follow-up was 6.0 years. Recurrent cardiovascular events occurred in 2220 patients, and 1820 had competing events. Overall AUC was 0.63 (95% CI 0.61 to 0.65). OE ratio was 0.96 (95% CI 0.92 to 1.00). The model underestimated risk in patients with low SES (OE 1.09, 95% CI 1.02 to 1.17) and in non-Western patients (OE 1.16, 95% CI 1.02 to 1.31). Calibration was adequate in patients with psychiatric history, but the model was substantially underestimating for patients with multiple vulnerabilities—combinations of low SES, non-Western ethnicity and psychiatric history—with OE ranging from 1.19 to 1.29, depending on the combination.

\n\nConclusion\n

The SMART2 model is well-calibrated in the general population but underestimates risk, especially in subgroups with multiple vulnerabilities. Patients in these vulnerable subgroups may require intensified monitoring. Clinicians should consider social, ethnic and psychiatric factors when interpreting risk estimates.

\n"}