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PONE-D-24-23025Assessing cardiovascular disease risk and social determinants of health: a comparative analysis of five risk estimation instruments using data from the Eastern Caribbean Health Outcomes Research NetworkPLOS ONE

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This is a well-written article comparing cardiovascular risk assessment tools in the Eastern Caribbean Health Outcomes Research Network Cohort Study. This study further assesses the association of social determinants of health with high cardiovascular risk. Some general questions and thoughts are as immediately below followed by line comments. I wonder if this would be best suited for PLOS ONE or PLOS Global Public Health? The article will need statistical review.

General questions and thoughts:

--Are the "significant discrepancies in CVD risk assessment across tools" similarly discrepant in other cohorts or more/less discrepant in the ECHORN cohort?

--Table 4, Lines 401-402: I admittedly go back and forth with regards to wanting an analysis similar to Table 4 between participants who identified as Black and Other (including White in Other here given lower n numbers).. Or having a model that includes race/ethnicity with the age and sex adjustments if statistically appropriate. It may be somewhat unaligned with the described goal to develop "race- and ethnicity-free CVD risk estimates" but it also seems important to understand and interpret similarities or differences. I defer to the authors' expertise and preferences here.

--To note, BMI also has limitations in assessing cardiovascular risk in diverse populations (https://pubmed.ncbi.nlm.nih.gov/26149446/) and was curious how BMI categories here align with cardiovascular risk, understanding however that the focus here is on SDoH and that this can be a future study. Studies of cardiovascular health (rather than CVD risk) could also be a future study as it seems AHA Life's Simple 7 scores (but perhaps not Life's Essential 8) can be calculated from the ECHORN data..

Line comments:

--Line 77, Line 331, Line 406: what determines "strong association" since food insecurity was associated with higher CVD risk in two out of the 5 risk tools (and high school graduate alone was associated in lower CVD risk for one out of the five tools)?

--Line 78, Lines 405-406: did analyses really show association between lower educational attainment and increased CVD risk? or rather, i believe from Table 4, lower odds of high CVD risk for people with a college degree (compared to people with less than high school education)? i understand that these are similar, but they do not seem quite the same (especially in the relative absence of differences compared to reference group for the high school graduate and associate degree/some college groups).

--Line 123: is this e.g. necessary or appropriately placed?

--Lines 134-135: assuming these are both supposed to be em dashes, they appear to be different..

--Line 147: semi-permanent (no space needed)

--Line 154: audio-assisted (no space needed)

--Line 157: A1c

--Line 159: capitalize to align with other section headings

--Line 161: no need for comma

--Line 174: is there a reason why A1c >=6.5% was not included here (since included in measurements per line 157)?

--Line 195: Is there a reason why Globorisk (or Globorisk-LAC if available, https://pubmed.ncbi.nlm.nih.gov/35711683/) was not included? somewhat answered in Lines 428-430..

--Lines 199, Line 202, Lines 376-378: It includes White, African American, and Other, correct?

--Lines 207-208: why were participants who selected white classified as other and not white?

--Line 212: tools?

--Line 234: de-identified (no space needed)

--Line 261: suggest adding "in the full sample" to be clear

--Table 2: I'm assuming the total cholesterol and HDL were appropriately converted between mg/dL and mmol/L for the respective CVD risk tools?

--Table 3, Table 4, Supplementary Table 3: suggest ASCVD rather than AHA/ASCVD

--Table 4: To my understanding, income relative to population was not measured rather perceived social status or subjective socioeconomic status. Advised changing the references to income here.

--Table 4: suggest associate or associate's

--Line 333: https://pubmed.ncbi.nlm.nih.gov/37648706/ compared the WHO instrument performance against another instrument, correct?

--Lines 345-346: suggest a clearer and simpler word that disclaim and adding a reference

--Line 364: suggest COVID-19

--Line 399: ZIP

--Lines 399-400: including PREVENT (as it currently is) for analyses in non-US settings will not be possible since based on U.S. Postal Service ZIP code (and associated deprivation indices) though, correct? This sentence could be removed if desired or adapted.

--Line 447: I don't see a "Research in Context" section?

Reviewer #2: There are some minor comments:

- Line 227: The authors state that in their sensitivity analysis they compare demographics and outcomes among included and excluded participants. But the Supplementary Table 1 only includes data on some demographics and they do not include any data about outcomes of the study. And in line 432 they state that their sensitivity analysis demonstrate that missing data did not affect the risk score. As this is hard to believe (if they do not have data about these participants, they cannot calculate the risk scores, and unless they provide data on the incidence of Cardiovascular events or on disease prevalence among excluded individuals) they cannot assume that the sesnsitivity analysis discards bias in this study.

Methodology: It would be better if the authors describe more thoroughly the multivariable regression models they use (at least in the supplementary material) and the results of these models.

In the results displayed on table 4, there is a remarkable great range on the CI in the WHO non-lab model. This aspect deserves some explanation in the Discussion, as ther is no such result in the Framingham non-lab model, despite they include roughly the same variables (except Blood-pressure treatment and diabetes).

In line 355 the authors state thate reference 10 suggest that Framngham may underestimate CVD in Caribbean population, when they should speak about CVD risk.

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Reviewer #2: No

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Assessing cardiovascular disease risk and social determinants of health: a comparative analysis of five risk estimation instruments using data from the Eastern Caribbean Health Outcomes Research Network

PONE-D-24-23025R1

Dear Dr. Schwartz,

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Kind regards,

Paulo Santos, PhD

Academic Editor

PLOS ONE