External validation and recalibration of office- and laboratory-based cardiovascular risk scores for prediction of 10-year risk of fatal cardiovascular disease in 112,262 adults in Mexico City

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality in Latin America, yet most CVD risk prediction models were developed in high-income countries with limited validations in these settings. OBJECTIVES: To externally validate CVD risk prediction models for 10-year fatal CVD, and recalibrate the Globorisk-fatal model in Mexican population. METHODS: We analyzed 112,262 adults ≥40 years from the Mexico City Prospective Study. Outcomes were restricted to fatal CVD, including myocardial infarction (MI) and stroke, censored at 10 years. CVD risk was estimated using the laboratory- and office-based Framingham, Globorisk, Globorisk-LAC, WHO, and SCORE2 equations. Discrimination was assessed with Harrell's c-statistic and AUROCs, calibration with mean estimates, slopes, and calibration curves, and overall performance with Brier scores. Sex-specific recalibration of the Globorisk-fatal model was performed using observed 10-year risks. RESULTS: During 10 years of follow-up, 2,429 fatal CVD events were recorded (1,667 MI, 762 stroke). All models showed good discrimination, with c-statistics ranging from 0.761-0.805 in men and 0.797-0.831 in women. The Globorisk-fatal model had the highest c-statistic in women (0.831, 95%CI 0.821-0.841), and the laboratory-based WHO-MI model in men (0.805, 95%CI 0.783-0.827). Despite this, all equations consistently overestimated CVD risk, particularly in women. Calibration analyses revealed systematic overprediction at higher risk levels, more pronounced in men. Recalibration of the Globorisk-fatal model improved agreement between predicted and observed risks, reducing overestimation. CONCLUSIONS: CVD risk models showed good discrimination but consistently overestimated risk in this Mexican cohort. The recalibrated Globorisk-fatal model improves risk estimation of fatal CVD in Mexican adults.