Cardiovascular disease risk prediction in multi-ethnic Asian populations: evidence from two population-based cohorts in Singapore
Open accessAbstract
Background: The rising burden of cardiovascular diseases (CVD) in Asia requires risk assessment tools tailored to Asian populations. Therefore, we recalibrated the ACC/AHA Pooled Cohort Equations for non-Hispanic Whites (PCE-W) and compared its performance in predicting 10-year CVD risk with two other established CVD prediction models that have been recently recalibrated for Asian populations. Methods: We used data from the Singapore Multi-Ethnic Cohort (MEC1) and the Singapore Epidemiology of Eye Diseases (SEED) cohort comprising ethnic Chinese, Indian, and Malay participants. The PCE-W was recalibrated using data from MEC1, externally validated in the SEED cohort, and compared against the Singapore-modified Framingham Risk Score (SG-FRS-2023) and the SCORE2 Asia-Pacific model using the concordance index (C-index). Calibration was assessed using the calibration-in-the-large method, the calibration slope, and a goodness-of-fit test. Findings: All three models demonstrated possibly helpful to clearly useful discrimination in MEC1 and SEED, with overall C-indices ranging from 0.728 to 0.811. The recalibrated PCE-W outperformed the original PCE-W in MEC1 and SEED, although some misestimations remained among Chinese men and women and Malay women (calibration-in-the-large ranged from -0.479 to 0.260). The SG-FRS-2023 displayed generally satisfactory calibration across both MEC1 and SEED but tended to overestimate risk in Chinese (calibration-in-the-large -0.671) and Indian men (calibration-in-the-large -0.214) in the SEED cohort. The SCORE2 Asia-Pacific model performed satisfactorily among Indians but overestimated risk in Chinese (calibration-in-the-large ranged from -0.570 to -1.185) and showed poor model fit in Malays. Interpretation: The recalibrated PCE-W, SG-FRS-2023, and SCORE2 Asia-Pacific model demonstrated possibly helpful to clearly useful discrimination across two multi-ethnic cohorts in Singapore. In terms of calibration, the recalibrated PCE-W and SG-FRS-2023, both recalibrated using local data, performed better than the SCORE2 Asia-Pacific model. Our study supports the use of the established CVD prediction models in Asian populations following appropriate local recalibration. Funding: This work was supported by the Singapore Ministry of Health's National Medical Research Council and the Singapore Biomedical Research Council.
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Even within the same geographic region, cardiovascular risk characteristics vary markedly across ethnic and healthcare subgroups.
“Taken together, the evidence points to a central conclusion: even within the same geographic region, cardiovascular risk characteristics vary markedly across ethnic and healthcare subgroups.”
From AI-driven cardiovascular risk prediction in patients with diabetes: bridging algorithmic innovation to equitable clinical application (2026) · cites this paper as [4]
The Discussion (page not provided) says CVD risk differs among Asian ethnic groups in Singapore, supporting variation within one geographic setting. The paper studies two population-based cohorts, but the passages do not establish differences across healthcare subgroups; that part of the claim is unsupported. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe transportability of traditional risk assessment tools across Asian populations is imperfect, and local recalibration is often necessary to maintain acceptable calibration and clinical usefulness.
“Although these tools are clinically familiar and easy to apply, their transportability across Asian populations is imperfect, and recent evidence suggests that local recalibration is often necessary to maintain acceptable calibration and clinical usefulness (4).”
From AI-driven cardiovascular risk prediction in patients with diabetes: bridging algorithmic innovation to equitable clinical application (2026) · cites this paper as [4]
Established cardiovascular risk models can remain useful in Asian populations only after appropriate local recalibration, and calibration performance may still differ across models and subgroups.
“Recent evidence from two population-based multi-ethnic cohorts in Singapore indicates that established cardiovascular risk models can remain useful in Asian populations only after appropriate local recalibration, and calibration performance may still differ across models and subgroups (4).”
From AI-driven cardiovascular risk prediction in patients with diabetes: bridging algorithmic innovation to equitable clinical application (2026) · cites this paper as [4]
Evidence from Singapore demonstrates that recalibration using local data can substantially enhance model performance and improve calibration in multi-ethnic Asian populations.
“Evidence from Singapore demonstrates that recalibration using local data can substantially enhance model performance and improve calibration in multi-ethnic Asian populations (4).”
From AI-driven cardiovascular risk prediction in patients with diabetes: bridging algorithmic innovation to equitable clinical application (2026) · cites this paper as [4]
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“Although these tools are clinically familiar and easy to apply, their transportability across Asian populations is imperfect, and recent evidence suggests that local recalibration is often necessary to maintain acceptable calibration and clinical usefulness (4).”
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- Authors
- Lim, C. G. Y., Chong, C. C. Y., Wong, Y. H. M., Yao, J., Ma, S., Chambers, J. C., Yeo, K. K., Tai, E. S., Tromp, J., van Dam, R. M., Hilal, S., Sabanayagam, C., Cheng, C.-Y., & Sim, X.
- Affiliations
- National University of Singapore (SG)
- Singapore National Eye Center (SG)
- Ministry of Health (SG)
- Nanyang Technological University (SG)
- University Medical Center Groningen (NL)
- Corresponding author
- Sim, Xueling
- ORCID
- Venue
- The Lancet Regional Health - Western Pacific
- Publisher
- Elsevier BV
- Published
- 2026-01
- Volume
- 66
- Pages
- 101794
- ISSN
- 2666-6065 (ISSN-L)
- PMC
- PMC12805090
- OpenAlex
- W7117963695
- Cited by
- 3
- References
- 27
- Citations by year
- 2026: 3
- FWCI
- 19.29
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- The Lancet Regional Health - Western Pacific (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DR-NTU (Nanyang Technological University) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion, cc-by)
- Funders
- Biomedical Research Council (BMRC/08/1/35/19/550)
- National University of Singapore
- National Medical Research Council (MOH-001792-00, MOH-000271-00)
- Government of Singapore Ministry of Health
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
- Keywords
- cardiovascular risk prediction, multi-ethnic Asian population, ethnic Chinese, ethnic Indians, ethnic Malays, model calibration, model discrimination, Singapore, Singapore Malay
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