Prediction of incident heart failure in established atherosclerotic cardiovascular disease: the SMART2-HF model

Journal article

Background and aims: Patients with established atherosclerotic cardiovascular disease (ASCVD) are at high risk of developing heart failure (HF). However, incident HF is not part of the risk assessment of current guideline-recommended models. The aim of this study was to develop and externally validate the SMART2-HF model for prediction of incident HF in patients with ASCVD. Methods: SMART2-HF was developed in 7698 individuals with established ASCVD (coronary, cerebrovascular, or peripheral artery disease, or abdominal aortic aneurysm) but without prior HF from the UCC-SMART cohort. Cox proportional hazards models including sex-predictor interactions and with age as the time scale were derived to estimate the 10-year and lifetime risk of incident HF (hospitalization for HF or HF-related death), accounting for competing non-HF mortality. Predictors, limited to routinely available clinical characteristics, were aligned with the SMART2 risk model for recurrent cardiovascular risk in the same population. External validation was performed in 240 741 patients with ASCVD from six data sources: the Clinical Practice Research Datalink, the HUNT3 study, the SWEDEHEART Registry, the ASCVD-Particles cohort, the Estonian Biobank and the international REACH Registry. Results: During a median follow-up of 11.2 years (interquartile range 6.1–16.4 years), 1031 incident HF events (13%) occurred in the UCC-SMART cohort. In the external validation data sources, a total of 24 885 incident HF events (10%) occurred. The pooled C-statistic was 0.696 (95% confidence interval 0.674–0.717), with consistent performance in subgroups by sex and type of ASCVD. Predicted risks matched observed incidence in external validation. Conclusions: The SMART2-HF model enables the prediction of incident HF in patients with ASCVD. Aligned with the guideline-recommended SMART2 model for recurrent cardiovascular risk, SMART2-HF can be used as a complementary tool in this population.

Authors: Reitsma, TH; Lim, C; Gynnild, MN; Kaptoge, S; Lõo, L

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: Oxford University Press
• Journal: European Heart Journal
• Article number: ehag153
• Publication date: 2026-03-11
• DOI: 10.1093/eurheartj/ehag153
• EISSN: 1522-9645
• ISSN: 0195668X, 0195-668X
• Language: English