Comparative Analysis of Machine Learning Models vs. Traditional Clinical Calculators for Cardiovascular Risk Prediction

Background: Cardiovascular diseases (CVD) remain the leading global cause of mortality, responsible for approximately 31% of all deaths worldwide in 2021. Traditional risk calculators, including Framingham, ASCVD, SCORE, and SCORE2, have long constituted the cornerstone of primary prevention strategies; however, they were derived predominantly from high-income European and North American populations, thereby limiting their predictive accuracy in diverse epidemiological contexts, particularly among Hispanic/Latino communities. Machine learning (ML) offers an alternative to capture the non-linear interactions inherent in biomedical data. Objective: The present study develops and validates ML-based models for cardiovascular mortality prediction using the National Health and Nutrition Examination Survey (NHANES) 1999-2018 dataset, and systematically compares their discriminative performance against eleven conventional clinical CVD risk calculators. Materials and Methods: A dedicated software platform, "CardioPrediQ," was designed to integrate multiple CVD calculators with ML-based risk assessment. A cohort of 12,847 participants with 16 predictor variables was derived from NHANES. Six algorithms (Logistic Regression, Cox Proportional Hazards, Gradient Boosting, AdaBoost, Random Forest, and Extra Trees) were trained in combination with six class-balancing strategies, yielding 36 model configurations. All models were trained on a stratified 70/30 split and calibrated using the Saerens prior probability adjustment method. Performance was evaluated using AUC-ROC, sensitivity, specificity, F1-score, and a weighted composite score. DeLong's test was employed to assess the statistical significance of AUC differences between the best-performing ML model and each conventional calculator. Results: Gradient Boosting with 2:1 oversampling and Saerens calibration achieved the best overall performance (AUC = 0.8934; composite score = 0.7904), outperforming all traditional calculators in composite ranking. The top six positions were occupied exclusively by ML and statistical models. The mean age of cardiovascular decedents was 67.43 years compared with 47.74 years among survivors. DeLong's test confirmed statistical superiority over six traditional CVD calculators (p < 0.05), whereas the difference against the top-performing calculators (ASCVD, HEARTS Caribbean, ASCVD Colombia, SCORE2, HEARTS North America) did not reach statistical significance. Age dominated feature importance at 41.2% relative weight, followed by systolic blood pressure (18.7%). Saerens calibration reduced the Brier score from 0.1286 to 0.1158, substantially improving probability calibration. Conclusions: ML models demonstrated superior composite performance over traditional calculators. The statistical equivalence with the highest-performing conventional calculators in the NHANES cohort is context-dependent and validates the methodological pipeline. The CardioPrediQ platform addresses the critical need for integrated, scalable CVD risk assessment tools, which is particularly relevant for Latin American populations where calculator validation remains limited. These findings support the integration of calibrated ML-based risk prediction into clinical practice while underscoring the importance of probability calibration for informed clinical decision-making.