The ability of the SCORE high-risk model to predict 10-year cardiovascular disease mortality in Norway

SCORE and SCORE2 in East Asian Population: A Performance Comparison

Background

Systematic COronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons (OP) models have been proposed as new cardiovascular risk evaluation tools.

Objectives

This study evaluated the performance of SCORE/SCORE-OP and SCORE2/SCORE2-OP in the East Asian population by using population-based cohort data from the National Health Insurance Service (NHIS) Health Screening Cohort of Korea.

Methods

A total of 324,384 NHIS examinees from 2004 to 2005 were divided into 5 age groups: 40-49 years, 50-59 years, 60-69 years,70-79 years, and more than 80 years. The examinees had their predicted cardiovascular disease risks calculated by using SCORE, SCORE2, SCORE-OP, and SCORE2-OP models. The low-risk model was applied on the basis of the cohort's observed event rates. The observed and predicted cardiovascular risks were compared.

Results

A total of 324,384 subjects were included (mean age 51.4 ± 7.3 years; women, 37.9% for the SCORE/SCORE2 group and mean age 73.0 ± 2.8 years; women, 47.5% for the SCORE/SCORE2-OP group). Over a median follow-up of 9 years, cardiovascular events occurred in 15.0% and 28.9% in SCORE/SCORE2 and SCORE/SCORE2-OP groups, respectively. The SCORE/SCORE-OP model underestimated cardiovascular disease risk in young men (aged 40-49 years) and women (aged 40-59 years) and overestimated it in older age groups. In contrast, SCORE2/SCORE2-OP invariably overestimated the risk in all age groups and sexes. SCORE2/SCORE2-OP showed no improvement in Harrell's concordance index (C-index) compared with SCORE/SCORE-OP. Calibration plots favored SCORE2 over SCORE but not SCORE2-OP over SCORE-OP.

Conclusions

Both SCORE2/SCORE2-OP and SCORE/SCORE-OP overestimated cardiovascular disease risk with low performance. SCORE2/SCORE2-OP showed slight improvement over older versions, but modifications are necessary for the East Asian population.

Evidence supporting the choice of a new cardiovascular risk equation for Australia

This article reviews the risk equations recommended for use in international cardiovascular disease (CVD) primary prevention guidelines and assesses their suitability for use in Australia against a set of a priori defined selection criteria. The review and assessment were commissioned by the National Heart Foundation of Australia on behalf of the Australian Chronic Disease Prevention Alliance to inform recommendations on CVD risk estimation as part of the 2023 update of the Australian CVD risk assessment and management guidelines. Selected international risk equations were assessed against eight selection criteria: development using contemporary data; inclusion of established cardiovascular risk factors; inclusion of ethnicity and deprivation measures; prediction of a broad selection of fatal and non-fatal CVD outcomes; population representativeness; model performance; external validation in an Australian dataset; and the ability to be recalibrated or modified. Of the ten risk prediction equations reviewed, the New Zealand PREDICT equation met seven of the eight selection criteria, and met additional usability criteria aimed at assessing the ability to apply the risk equation in practice in Australia.

Assessing Cardiovascular Risk in Patients with Diabetes: An Update

The globalization of the Western lifestyle has resulted in increase of diabetes mellitus, a complex, multifactorial disease. Diabetes mellitus is a condition often related to the disorders of the cardiovascular system. It is well established that three quarters of diabetics, aged over 40, will die from cardiovascular disease and are more likely than non-diabetics to die from their first cardiovascular event. Therefore, it is of paramount importance to individualize treatment via risk stratification. Conditions that increase cardiovascular risk in people with diabetes include age more than 40 years, male gender, history of relative suffering from premature CHD, blood pressure and high LDL levels, presence of microalbuminuria, obstructive sleepapnea, erectile dysfunction and other conditions.

Several models have been developed in order to assess cardiovascular risk in people with and without diabetes. Some of them have been proven to be inadequate while others are widely used for years. An emerging way of risk assessment in patients with diabetes mellitus is the use of biomarkers but a lot of research needs to be done in this field in order to have solid conclusions.

Comparison of the ATRIA, CHA2DS2-VASc, and Modified Scores ATRIA-HSV, CHA2DS2-VASc-HS, for the Prediction of Coronary Artery Disease Severity

Many parameters included in the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) and CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, sex category) scores also predict coronary artery disease (CAD). We modified the ATRIA score (ATRIA-HSV) by adding hyperlipidemia, smoking, and vascular disease and also male sex instead of female. We evaluated whether the CHA₂DS₂-VASc, CHA₂DS₂-VASc-HS, ATRIA, and ATRIA-HSV scores predict severe CAD. Consecutive patients with coronary angiography were prospectively included. A ≥50% stenosis in ≥1epicardial coronary artery (CA) was defined as severe CAD. Patient with normal CA (n = 210) were defined as group 1, with <50% CA stenosis (n = 178) as group 2, and with ≥50% stenosis (n = 297) as group 3. The mean ATRIA, ATRIA-HSV, CHA₂DS₂-VASc, and CHA₂DS₂VASc-HS scores increased from group 1 to group 3. A correlation was found between the Synergy between PCI with Taxus and Cardiac Surgery score and ATRIA (r = 0.570), ATRIA-HSV (r = 0.614), CHA₂DS₂-VASc (r = 0.428), and CHA₂DS₂-VASc-HS (r = 0.500) scores (Ps < .005). Pairwise comparisons of receiver operating characteristics curves showed that ATRIA-HSV (>3 area under curve [AUC]: 0.874) and ATRIA (>3, AUC: 0.854) have a better performance than CHA₂DS₂-VASc (>1, AUC: 0.746) and CHA₂DS₂-VASc-HS (>2, AUC: 0.769). In conclusion, the ATRIA and ATRIA-HSV scores are simple and may be useful to predict severe CAD.

Re-calibration of coronary risk prediction: an example of the Seven Countries Study

We aimed at performing a calibration and re-calibration process using six standard risk factors from Northern (NE, N = 2360) or Southern European (SE, N = 2789) middle-aged men of the Seven Countries Study, whose parameters and data were fully known, to establish whether re-calibration gave the right answer. Greenwood-Nam-D'Agostino technique as modified by Demler (GNDD) in 2015 produced chi-squared statistics using 10 deciles of observed/expected CHD mortality risk, corresponding to Hosmer-Lemeshaw chi-squared employed for multiple logistic equations whereby binary data are used. Instead of the number of events, the GNDD test uses survival probabilities of observed and predicted events. The exercise applied, in five different ways, the parameters of the NE-predictive model to SE (and vice-versa) and compared the outcome of the simulated re-calibration with the real data. Good re-calibration could be obtained only when risk factor coefficients were substituted, being similar in magnitude and not significantly different between NE-SE. In all other ways, a good re-calibration could not be obtained. This is enough to praise for an overall need of re-evaluation of most investigations that, without GNDD or another proper technique for statistically assessing the potential differences, concluded that re-calibration is a fair method and might therefore be used, with no specific caution.

Targeting LDL Cholesterol: Beyond Absolute Goals Toward Personalized Risk

PURPOSE OF REVIEW

The aim of this study was to review and assess the evidence for low-density lipoprotein cholesterol (LDL-C) treatment goals as presented in current guidelines for primary and secondary prevention of cardiovascular disease.

RECENT FINDINGS

Different sets of guidelines and clinical studies for secondary prevention have centered on lower absolute LDL-C targets [<70 mg/dL (<1.8 mmol/L)], greater percent reductions of LDL-C (≥50%), or more intense treatment to achieve greater reductions in cardiovascular risk. Population-based risk models serve as the basis for statin initiation in primary prevention. Reviews of current population risk models for primary prevention show moderate ability to discriminate [with c-statistics ranging from 0.67 to 0.77 (95% CIs from 0.62 to 0.83) for men and women] with poor calibration and overestimation of risk. Individual clinical trial data are not compelling to support specific LDL-C targets and percent reductions in secondary prevention. Increasing utilization of electronic health records and data analytics will enable the development of individualized treatment goals in both primary and secondary prevention.

Validity Assessment of Low-risk SCORE Function and SCORE Function Calibrated to the Spanish Population in the FRESCO Cohorts

INTRODUCTION AND OBJECTIVES

To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population.

METHODS

Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively.

RESULTS

Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women.

CONCLUSIONS

All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate.

Comparison of validation and application on various cardiovascular disease mortality risk prediction models in Chinese rural population

This research aims to assess application of different cardiovascular disease (CVD) mortality risk prediction models in Chinese rural population. Data was collected from a 6-year follow-up survey in rural area of Henan Province, China. 10338 participants aged 40 to 65 years were included. Baseline study was conducted between 2007 and 2008, and followed up from 2013 to 2014. Seven models: general Framingham risk score (general-FRS), simplified-FRS, Systematic Coronary Risk Evaluation for high (SCORE-high), SCORE-low, Chinese ischemic CVD (CN-ICVD), Pooled Cohort Risk Equation for white (PCE-white) and for African-American (PCE-AA) were assessed and recalibrated. The model performance was evaluated by C-statistics and modified Nam-D’Agostino test. 168 CVD deaths occurred during follow-up. All seven models showed moderate C-statics ranging from 0.727 to 0.744. Following recalibration, general-FRS, simplified-FRS, CN-ICVD, PCE-white and PCE-AA had improved C-statistics of 0.776, 0.795, 0.793, 0.779, and 0.776 for men and 0.756, 0.753, 0.755, 0.758 and 0.760 for women, respectively. Calibrations χ² of general-FRS, simplified-FRS, SCORE-high, CN-ICVD and PCE-AA model for men, and general-FRS, CN-ICVD and PCE-white model for women were statistically acceptable, indicating these models predicts CVD mortality risk more accurately than others and could be recommended in Chinese rural population.

An evaluation of the performance of SCORE Sweden 2015 in estimating cardiovascular risk

Background

Risk prediction models for cardiovascular death are important for providing advice on lifestyle and in decision-making regarding primary preventive drug treatment. The latest Swedish version of the Systematic COronary Risk Evaluation (SCORE 2015) has yet not been tested in the population.

Objective

The objective of this study was to estimate the prevalence of high and very high risk of fatal cardiovascular disease (CVD) of the current population according to 2015 SCORE Sweden and to evaluate the predictive accuracy of the 2003 Swedish version of SCORE (2003 SCORE Sweden) and 2015 SCORE Sweden in a population with declining CVD mortality.

Methods

We estimated the high and very high risk group for cardiovascular death for individuals 40–65 years of age in the 2014 Northern Sweden MONICA population survey excluding subjects with known diabetes or previous CVD ( n = 813). Using the 1999 MONICA survey ( n = 3347) followed up for 10 years for CVD mortality, we assessed the calibration of both 2003 and 2015 SCORE Sweden.

Results

In 2014 2.6% of the population was considered at high or very high risk for fatal CVD, 95% were men and 76% were in the age group 60–65 years. Including subjects with a single markedly elevated risk factor, known diabetes or CVD, 12% of the population was at high or very high risk. During 10 years of follow-up of the 1999 cohort, 34 CVD deaths (24 men and 10 women) occurred. The 2003 SCORE overestimated the risk of death from CVD (ratio predicted/observed 2.3, P < 0.001) whereas the 2015 SCORE slightly overestimated the number of deaths (predicted/observed 1.3, P = 0.12). The 2015 SCORE predicted more accurately than the 2003 SCORE the number of deaths in the different risk and age categories.

Conclusion

The 2015 SCORE Sweden more adequately than 2003 SCORE Sweden predicts the number of deaths. In 2014, the proportion of high-risk individuals is small in northern Sweden. The main use of 2015 SCORE Sweden would therefore be as an educational tool between the physician and people without diabetes or CVD in a consultation regarding cardiovascular risk.

Statin prescribing according to gender, age and indication: what about the benefit-risk balance?

RATIONALES, AIMS AND OBJECTIVES

The increasing dispensing of statins has raised concern about the appropriateness of prescribing to various population groups. We aimed to (1) investigate incident and prevalent statin prescribing according to indication, gender and age and (2) relate prescribing patterns to evidence on beneficial and adverse effects.

METHODS

A cohort of Danish inhabitants (n = 4 424 818) was followed in nationwide registries for dispensed statin prescriptions and hospital discharge information. We calculated incidence rates (2005-2009), prevalence trends (2000-2010) and absolute numbers of statin users according to register proxies for indication, gender and age.

RESULTS

In 2010, the prevalence became highest for ages 75-84 and was higher in men than women (37% and 33%, respectively). Indication-specific incidences and prevalences peaked at ages around 65-70, but in myocardial infarction, the prevalence was about 80% at ages 45-80. Particularly, incidences tended to be lower in women until ages of about 60 where after gender differences were negligible. In asymptomatic individuals (hypercholesterolaemia, presumably only indication) aged 50+, dispensing was highest in women. The fraction of statin dispensing for primary prevention decreased with age: higher for incident than prevalent prescribing. Independent of age, this fraction was highest among women, e.g. 60% versus 45% at ages 55-64. The fraction for potential atherosclerotic condition (PAC, e.g. heart failure) increased with age.

CONCLUSION

Prevalence of statin utilization was highest for ages 75-84, although indication-specific measures were relatively low. Despite inconclusive evidence for a favourable risk-benefit balance, statin prescribing was high among people aged 80+, asymptomatic women and PAC patients.

The high-density lipoprotein-adjusted SCORE model worsens SCORE-based risk classification in a contemporary population of 30,824 Europeans: the Copenhagen General Population Study

Aims

Recent European guidelines recommend to include high-density lipoprotein (HDL) cholesterol in risk assessment for primary prevention of cardiovascular disease (CVD), using a SCORE-based risk model (SCORE-HDL). We compared the predictive performance of SCORE-HDL with SCORE in an independent, contemporary, ‘low-risk’ European population, focusing on ability to identify those in need of intensified CVD prevention.

Methods and results

Between 2003 and 2008, 46 092 individuals without CVD, diabetes, or statin use were enrolled in the Copenhagen General Population Study (CGPS). During a mean of 6.8 years of follow-up, 339 individuals died of CVD. In the SCORE target population (age 40–65; n = 30 824), fewer individuals were at baseline categorized as high risk (≥5% 10-year risk of fatal CVD) using SCORE-HDL compared with SCORE (10 vs. 17% in men, 1 vs. 3% in women). SCORE-HDL did not improve discrimination of future fatal CVD, compared with SCORE, but decreased the detection rate (sensitivity) of the 5% high-risk threshold from 42 to 26%, yielding a negative net reclassification index (NRI) of −12%. Importantly, using SCORE-HDL, the sensitivity was zero among women. Both SCORE and SCORE-HDL overestimated risk of fatal CVD. In well-calibrated models developed from the CGPS, HDL did not improve discrimination or NRI. Lowering the decision threshold from 5 to 1% led to progressive gain in NRI for both CVD mortality and morbidity.

Conclusion

SCORE-HDL did not improve discrimination compared with SCORE, but deteriorated risk classification based on NRI. Future guidelines should consider lower decision thresholds and prioritize CVD morbidity and people above age 65.

Independent external validation of cardiovascular disease mortality in women utilising Framingham and SCORE risk models: a mortality follow-up study

BACKGROUND

We conducted an independent external validation of three cardiovascular risk score models (Framingham risk score model and SCORE risk charts developed for low-risk regions and high-risk regions in Europe) on a prospective cohort of 4487 Australian women with no previous history of heart disease, diabetes or stroke. External validation is an important step to evaluate the performance of risk score models using discrimination and calibration measures to ensure their applicability beyond the settings in which they were developed.

METHODS

Ten year mortality follow-up of 4487 Australian adult women from the National Heart Foundation third Risk Factor Prevalence Study with no baseline history of heart disease, diabetes or stroke. The 10-year risk of cardiovascular mortality was calculated using the Framingham and SCORE models and the predictive accuracy of the three risk score models were assessed using both discrimination and calibration.

RESULTS

The discriminative ability of the Framingham and SCORE models were good (area under the curve > 0.85). Although all models overestimated the number of cardiovascular deaths by greater than 15%, the Hosmer-Lemeshow test indicated that the Framingham and SCORE-Low models were calibrated and hence suitable for predicting the 10-year cardiovascular mortality risk in this Australian population. An assessment of the treatment thresholds for each of the three models in identifying participants recommended for treatment were found to be inadequate, with low sensitivity and high specificity resulting from the high recommended thresholds. Lower treatment thresholds of 8.7% for the Framingham model, 0.8% for the SCORE-Low model and 1.3% for the SCORE-High model were identified for each model using the Youden index, at greater than 78% sensitivity and 80% specificity.

CONCLUSIONS

Framingham risk score model and SCORE risk chart for low-risk regions are recommended for use in the Australian women population for predicting the 10-year cardiovascular mortality risk. These models demonstrate good discrimination and calibration performance. Lower treatment thresholds are proposed for better identification of individuals for treatment.

Comparison of the Framingham Risk Score, SCORE and WHO/ISH cardiovascular risk prediction models in an Asian population

BACKGROUND

Cardiovascular risk-prediction models are used in clinical practice to identify and treat high-risk populations, and to communicate risk effectively. We assessed the validity and utility of four cardiovascular risk-prediction models in an Asian population of a middle-income country.

METHODS

Data from a national population-based survey of 14,863 participants aged 40 to 65 years, with a follow-up duration of 73,277 person-years was used. The Framingham Risk Score (FRS), SCORE (Systematic COronary Risk Evaluation)-high and -low cardiovascular-risk regions and the World Health Organization/International Society of Hypertension (WHO/ISH) models were assessed. The outcome of interest was 5-year cardiovascular mortality. Discrimination was assessed for all models and calibration for the SCORE models.

RESULTS

Cardiovascular risk factors were highly prevalent; smoking 20%, obesity 32%, hypertension 55%, diabetes mellitus 18% and hypercholesterolemia 34%. The FRS and SCORE models showed good agreement in risk stratification. The FRS, SCORE-high and -low models showed good discrimination for cardiovascular mortality, areas under the ROC curve (AUC) were 0.768, 0.774 and 0.775 respectively. The WHO/ISH model showed poor discrimination, AUC=0.613. Calibration of the SCORE-high model was graphically and statistically acceptable for men (χ(2) goodness-of-fit, p=0.097). The SCORE-low model was statistically acceptable for men (χ(2) goodness-of-fit, p=0.067). Both SCORE-models underestimated risk in women (p<0.001).

CONCLUSIONS

The FRS and SCORE-high models, but not the WHO/ISH model can be used to identify high cardiovascular risk in the Malaysian population. The SCORE-high model predicts risk accurately in men but underestimated it in women.

SCORE performance in Central and Eastern Europe and former Soviet Union: MONICA and HAPIEE results

Aims

The Systematic COronary Risk Evaluation (SCORE) scale assesses 10 year risk of fatal atherosclerotic cardiovascular disease (CVD), based on conventional risk factors. The high-risk SCORE version is recommended for Central and Eastern Europe and former Soviet Union (CEE/FSU), but its performance has never been systematically assessed in the region. We evaluated SCORE performance in two sets of population-based CEE/FSU cohorts.

Methods and results

The cohorts based on the World Health Organization MONitoring of trends and determinants in CArdiovascular disease (MONICA) surveys in the Czech Republic, Poland (Warsaw and Tarnobrzeg), Lithuania (Kaunas), and Russia (Novosibirsk) were followed from the mid-1980s. The Health, Alcohol, and Psychosocial factors in Eastern Europe (HAPIEE) study follows Czech, Polish (Krakow), and Russian (Novosibirsk) cohorts from 2002–05. In Cox regression analyses, the high-risk SCORE ≥5% at baseline significantly predicted CVD mortality in both MONICA [n = 15 027; hazard ratios (HR), 1.7–6.3] and HAPIEE (n = 20 517; HR, 2.6–10.5) samples. While SCORE calibration was good in most MONICA samples (predicted and observed mortality were close), the risk was underestimated in Russia. In HAPIEE, the high-risk SCORE overpredicted the estimated 10 year mortality for Czech and Polish samples and adequately predicted it for Russia. SCORE discrimination was satisfactory in both MONICA and HAPIEE.

Conclusion

The high-risk SCORE underestimated the fatal CVD risk in Russian MONICA but performed well in most MONICA samples and Russian HAPIEE. This SCORE version might overestimate the risk in contemporary Czech and Polish populations.

Is the high-risk strategy to prevent cardiovascular disease equitable? A pharmacoepidemiological cohort study

BACKGROUND

Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk - i.e. individuals in lower socio-economic position (SEP) - are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.

METHODS

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002-2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).

MAIN OUTCOME MEASURES

Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.

RESULTS

MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40-64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65-84.

CONCLUSION

The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.

Ethnic differences in risk factors and total risk of cardiovascular disease based on the Norwegian CONOR study

BACKGROUND

Risk of cardiovascular disease varies between ethnic groups and the aim of this study was to investigate differences in cardiovascular risk factors, and total cardiovascular risk between ethnic groups in Norway.

DESIGN

Cross-sectional study using data from the Cohort of Norway (CONOR).

METHODS

A sample of 62,145 participants, 40-65 years of age, originating from 11 geographical regions, were included in our study. Self-reported variables, blood samples and physical measurements were used to estimate age- and time-adjusted mean values of cardiovascular risk factors for different ethnic groups. The 10-year risks of cardiovascular mortality and cardiovascular events were calculated using the Framingham and NORRISK risk models.

RESULTS

We observed differences between ethnic groups for cardiovascular risk factors and both Framingham and NORRISK risk scores. NORRISK showed significant differences by ethnicity in women only. Immigrants from the Indian subcontinent had the lowest high-density lipoprotein (HDL) levels, the highest levels of blood glucose, triglycerides, total cholesterol/HDL ratio, waist hip ratio and diabetes prevalence. Immigrants from the former Yugoslavia had the highest Framingham scores, high blood pressure, high total cholesterol/HDL ratio, overweight measures and smoking. Low cardiovascular risk was observed among East Asian immigrants.

CONCLUSION

The previously reported excess cardiovascular risk among immigrants from the Indian subcontinent was supported in this study. We also showed that immigrants from the former Yugoslavian countries had a higher total 10-year risk of cardiovascular events than other ethnic groups. This study adds information about ethnic groups in Norway which needs to be addressed in further research and targeted prevention strategies.

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study

RATIONALE, AIMS AND OBJECTIVES

Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline.

METHODS

We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total).

RESULTS

Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L(-1) increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L(-1) . Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern.

CONCLUSION

Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.

Excess risk attributable to traditional cardiovascular risk factors in clinical practice settings across Europe - The EURIKA Study

Background

Physicians involved in primary prevention are key players in CVD risk control strategies, but the expected reduction in CVD risk that would be obtained if all patients attending primary care had their risk factors controlled according to current guidelines is unknown. The objective of this study was to estimate the excess risk attributable, firstly, to the presence of CVD risk factors and, secondly, to the lack of control of these risk factors in primary prevention care across Europe.

Methods

Cross-sectional study using data from the European Study on Cardiovascular Risk Prevention and Management in Daily Practice (EURIKA), which involved primary care and outpatient clinics involved in primary prevention from 12 European countries between May 2009 and January 2010. We enrolled 7,434 patients over 50 years old with at least one cardiovascular risk factor but without CVD and calculated their 10-year risk of CVD death according to the SCORE equation, modified to take diabetes risk into account.

Results

The average 10-year risk of CVD death in study participants (N = 7,434) was 8.2%. Hypertension, hyperlipidemia, smoking, and diabetes were responsible for 32.7 (95% confidence interval 32.0-33.4), 15.1 (14.8-15.4), 10.4 (9.9-11.0), and 16.4% (15.6-17.2) of CVD risk, respectively. The four risk factors accounted for 57.7% (57.0-58.4) of CVD risk, representing a 10-year excess risk of CVD death of 5.66% (5.47-5.85). Lack of control of hypertension, hyperlipidemia, smoking, and diabetes were responsible for 8.8 (8.3-9.3), 10.6 (10.3-10.9), 10.4 (9.9-11.0), and 3.1% (2.8-3.4) of CVD risk, respectively. Lack of control of the four risk factors accounted for 29.2% (28.5-29.8) of CVD risk, representing a 10-year excess risk of CVD death of 3.12% (2.97-3.27).

Conclusions

Lack of control of CVD risk factors was responsible for almost 30% of the risk of CVD death among patients participating in the EURIKA Study.

Estimating the proportion of Danes at high risk of fatal cardiovascular disease

Aims: It has been recommended by several intervention studies to use a high risk approach for cardiovascular disease (CVD) prevention, and the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (ESC Guidelines) provide a method to identify high risk individuals. Furthermore the ESC Guidelines suggest interventions for the high risk group, with the overall intention to reduce CVD mortality. The ESC Guidelines have not yet been applied in cardiovascular research in Denmark. Therefore, the aim of this study is to estimate the proportion at high risk for fatal CVD in a Danish population. Methods: Data from a population-based cross-sectional study from the Research Centre for Prevention and Health (the former Glostrup Population Studies) from 2006 was used. A total of 2,815 individuals aged 25—64 years were included in the analysis. The criteria listed in ESC Guidelines were used to identify the high risk group. The results were stratified according to age and sex. Results: A total of 21.2% were categorized as high risk for fatal CVD, and 51.6% of the high risk individuals were categorized due to a SCORE risk ≥ 5%. In general more men than women were categorized as high risk within the different age groups. A larger proportion was categorized in high risk in the oldest age groups compared with the younger ones. Conclusions: With the considerably large proportion at high risk —one in five individuals — it is worthwhile considering increasing the attention given to identify high risk individuals. Applying the interventions suggested in the ESC Guidelines to high risk individuals could potentially reduce CVD mortality in Denmark.

Changes in myocardial infarction mortality

BACKGROUND

The incidence of myocardial infarction (MI) in Norway has decreased substantially over the last two decades, according to recent publications based on data from the Norwegian Patient Registry. To better understand the development of cardiovascular disease over time we have investigated the development of MI mortality in light of the decrease in MI incidence.

MATERIAL AND METHODS

Data on MI mortality were retrieved from the Cause of Death Registry (Statistics Norway) for the period 1969-2007 and analyzed. Mortality rates (death per 100,000 inhabitants) were calculated for the total population according to sex and the following age groups: 0-39 years, 10-year groups in the range 40-79 years and 80 years and higher.

RESULTS

Total MI mortality showed a weak increase in the 1970s and the 1980s until 1987. Mortality decreased substantially from 1987 to 2007, 64% for men and 47% for women. The reduction in mortality started first for the youngest age groups. In 2007, the decrease in mortality from the peak years was about 70% for the age groups below 80 years and about 40% in the group above 80 years of age.

INTERPRETATION

After small changes in the 1970s and 1980s, MI mortality has decreased steadily in the 1990 s in all age groups and has continued to do so after 2000.

Risk prediction of incident coronary heart disease in The Netherlands: re-estimation and improvement of the SCORE risk function

AIMS

To re-estimate the SCORE risk function using individual data on risk factors and coronary heart disease (CHD) incidence from the Dutch Cardiovascular Registry Maastricht (CAREMA) population-based cohort study; to evaluate changes that may improve risk prediction after re-estimation; and to compare the performance of the resulting CAREMA risk function with that of existing risk scores.

METHODS AND RESULTS

The cohort consisted of 21,148 participants, born in 1927-1977 and randomly sampled from the Maastricht region in 1987-1997. After follow-up (median 10.9 years), 783 incident CHD cases occurred. Model performance was assessed by discrimination and calibration. The additional value of including other risk factors or current risk factors in a different manner was evaluated using the net reclassification index (NRI). The c statistic of the re-estimated SCORE model was 0.799 (95% CI 0.782-0.816). Separating the total/high-density lipoprotein (HDL) cholesterol ratio into total and HDL cholesterol levels did not improve the c statistic (p = 0.22), but reclassified 6.0% of the participants into a more appropriate risk category (p < 0.001) compared with the re-estimated model. The resulting CAREMA function reclassified 28% of the participants into a more appropriate risk category than the Framingham score. Compared with the SCORE functions for high- and low-risk regions, the NRIs were 28% and 35%, respectively, which can largely be explained by the difference in outcome definition (CHD incidence vs. CHD mortality).

CONCLUSION

In this Dutch population, a re-estimated SCORE function with total and HDL cholesterol levels instead of the cholesterol ratio can be used for the risk prediction of CHD incidence.

Does present use of cardiovascular medication reflect elevated cardiovascular risk scores estimated ten years ago? A population based longitudinal observational study

BACKGROUND

It is desirable that those at highest risk of cardiovascular disease should have priority for preventive measures, eg. treatment with prescription drugs to modify their risk. We wanted to investigate to what extent present use of cardiovascular medication (CVM) correlates with cardiovascular risk estimated by three different risk scores (Framingham, SCORE and NORRISK) ten years ago.

METHODS

Prospective logitudinal observational study of 20,252 participants in The Hordaland Health Study born 1950-57, not using CVM in 1997-99. Prescription data obtained from The Norwegian Prescription Database in 2008.

RESULTS

26% of men and 22% of women aged 51-58 years had started to use some CVM during the previous decade. As a group, persons using CVM scored significantly higher on the risk algorithms Framingham, SCORE and NORRISK compared to those not treated. 16-20% of men and 20-22% of women with risk scores below the high-risk thresholds for the three risk scores were treated with CVM, while 60-65% of men and 25-45% of women with scores above the high-risk thresholds received no treatment. Among women using CVM, only 2.2% (NORRISK), 4.4% (SCORE) and 14.5% (Framingham) had risk scores above the high-risk values. Low education, poor self-reported general health, muscular pains, mental distress (in females only) and a family history of premature cardiovascular disease correlated with use of CVM. Elevated blood pressure was the single factor most strongly predictive of CVM treatment.

CONCLUSION

Prescription of CVM to middle-aged individuals by large seems to occur independently of estimated total cardiovascular risk, and this applies especially to females.

Cardiovascular risk estimation tailored to different clinical settings - the Tromsø study

OBJECTIVE

To develop a cardiovascular risk model simulating different clinical settings using a staged approach.

DESIGN

Using data from 27,477 men and women from the Norwegian Tromsø Study in 1986-1987 and 1994-1995, Cox regression models for either myocardial infarction (MI) or stroke combined with a similar model for the competing event a risk model that assess ten-year risk of MI and stroke was developed. Explanatory variables (questions, simple examinations and blood samples) were added gradually. The model was validated using Hosmer-Lemeshow test, the Brier score, c-index, integrated discrimination improvement (IDI) and Net Reclassification Improvement (NRI).

RESULTS

In total, 1,298 events of MI and 769 events of stroke were registered. For MI the model showed excellent discrimination in each step with c-index from 0.833 to 0.946. For stroke the c-index ranged between 0.817 and 0.898. IDI showed significant increases in discrimination. The Brier scores and goodness of fit test showed well calibrated models in all steps for all sex- and end-point specific models (p>0.05).

CONCLUSIONS

Although the predictive and discriminative ability of the models increased with each step, even the simplest model containing only data from questions or blood samples alone yielded valid estimates of cardiovascular risk.

Recalibration and validation of the SCORE risk chart in the Australian population: the AusSCORE chart

BACKGROUND

Development of a validated risk prediction model for future cardiovascular disease (CVD) in Australians is a high priority for cardiovascular health strategies.

DESIGN

Recalibration of the SCORE (Systematic COronary Risk Evaluation) risk chart based on Australian national mortality data and average major CVD risk factor levels.

METHODS

Australian national mortality data (2003-2005) were used to estimate 10-year cumulative CVD mortality rates for people aged 40-74 years. Average age-specific and sex-specific levels of systolic blood pressure, total cholesterol and prevalence of current smoking were generated from data obtained in eight Australian large-scale population-based surveys undertaken from the late 1980s. The SCORE risk chart was then recalibrated by applying hazard ratios for 10-year CVD mortality obtained in the SCORE project. Discrimination and calibration of the recalibrated model was evaluated and compared with that of the original SCORE and Framingham equations in the Blue Mountains Eye Study in Australia using Harrell's c and Hosmer-Lemeshow chi statistics, respectively.

RESULTS

An Australian risk prediction chart for CVD mortality was derived. Among 1998 Blue Mountains Eye Study participants aged 49-74 years with neither CVD nor diabetes at baseline, the Harrell's c statistics for the Australian risk prediction chart for CVD mortality were 0.76 (95% confidence interval: 0.69-0.84) and 0.71 (confidence interval: 0.62-0.80) in men and women, respectively. The corresponding Hosmer-Lemeshow chi statistics, the measure of calibration, were 2.32 (P = 0.68) and 7.43 (P = 0.11), which were superior to both the SCORE and Framingham equations.

CONCLUSION

This new tool provides a valid and reliable method to predict risk of CVD mortality in the general Australian population.

SCORE should be preferred to Framingham to predict cardiovascular death in French population

BACKGROUND

Numerous studies have examined the validity of available scores to predict the absolute cardiovascular risk.

DESIGN

We developed a virtual population based on data representative of the French population and compared the performances of the two most popular risk equations to predict cardiovascular death: Framingham and SCORE.

METHODS

A population was built based on official French demographic statistics and summarized data from representative observational studies. The 10-year coronary and cardiovascular death risk and their ratio were computed for each individual by SCORE and Framingham equations. The resulting rates were compared with those derived from national vital statistics.

RESULTS

Framingham overestimated French coronary deaths by 2.8 in men and 1.9 in women, and cardiovascular deaths by 1.5 in men and 1.3 in women. SCORE overestimated coronary death by 1.6 in men and 1.7 in women, and underestimated cardiovascular death by 0.94 in men and 0.85 in women. Our results revealed an exaggerated representation of coronary among cardiovascular death predicted by Framingham, with coronary death exceeding cardiovascular death in some individual profiles. Sensitivity analyses gave some insights to explain the internal inconsistency of the Framingham equations.

CONCLUSION

Evidence is that SCORE should be preferred to Framingham to predict cardiovascular death risk in French population. This discrepancy between prediction scores is likely to be observed in other populations. To improve the validation of risk equations, specific guidelines should be issued to harmonize the outcomes definition across epidemiologic studies. Prediction models should be calibrated for risk differences in the space and time dimensions.

Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians

Atherosclerotic cardiovascular diseases (CVDs) are the biggest causes of death worldwide. In most people, CVD is the product of a number of causal risk factors. Several seemingly modest risk factors may, in combination, result in a much higher risk than an impressively raised single factor. For this reason, risk estimation systems have been developed to assist clinicians to assess the effects of risk factor combinations in planning management strategies. In this article, the performances of the major risk estimation systems are reviewed. Most perform usably well in populations that are similar to the one used to derive the system, and in other populations if calibrated to allow for different CVD mortality rates and different risk factor distributions. The effect of adding "new" risk factors to age, sex, smoking, lipid status, and blood pressure is usually small, but may help to appropriately reclassify some of those patients who are close to a treatment threshold to a more correct "treat/do not treat" category. Risk estimation in the young and old needs more research. Quantification of the hoped-for benefits of the multiple risk estimation approach in terms of improved outcomes is still needed. But, it is likely that the widespread use of such an approach will help to address the issues of both undertreatment and overtreatment.

Agreement between the SCORE and D'Agostino Scales for the classification of high cardiovascular risk in sedentary spanish patients

BACKGROUND

To evaluate agreement between cardiovascular risk in sedentary patients as estimated by the new Framingham-D'Agostino scale and by the SCORE chart, and to describe the patient characteristics associated with the observed disagreement between the scales.

DESIGN

A cross-sectional study was undertaken involving a systematic sample of 2,295 sedentary individuals between 40-65 years of age seen for any reason in 56 primary care offices. An estimation was made of the Pearson correlation coefficient and kappa statistic for the classification of high risk subjects (> or =20% according to the Framingham-D'Agostino scale, and > or =5% according to SCORE). Polytomous logistic regression models were fitted to identify the variables associated with the discordance between the two scales.

RESULTS

The mean risk in males (35%) was 19.5% +/- 13% with D'Agostino scale, and 3.2% +/- 3.3% with SCORE. Among females, they were 8.1% +/- 6.8% and 1.2% +/- 2.2%, respectively. The correlation between the two scales was 0.874 in males (95% CI: 0.857-0.889) and 0.818 in females (95% CI: 0.800-0.834), while the kappa index was 0.50 in males (95% CI: 0.44%-0.56%) and 0.61 in females (95% CI: 0.52%-0.71%). The most frequent disagreement, characterized by high risk according to D'Agostino scale but not according to SCORE, was much more prevalent among males and proved more probable with increasing age and increased LDL-cholesterol, triglyceride and systolic blood pressure values, as well as among those who used antihypertensive drugs and smokers.

CONCLUSIONS

The quantitative correlation between the two scales is very high. Patient categorization as corresponding to high risk generates disagreements, mainly among males, where agreement between the two classifications is only moderate.

Current European guidelines for management of arterial hypertension: are they adequate for use in primary care? Modelling study based on the Norwegian HUNT 2 population

BACKGROUND

Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population.

METHODS

Implementation of the current European Guidelines for the Management of Arterial Hypertension was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling.

RESULTS

Among individuals with blood pressure >or=120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults.

CONCLUSION

The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered.

Ethnic differences in SCORE cardiovascular risk in Oslo, Norway

AIM

To compare the estimated 10-year risk of cardiovascular death between ethnic Norwegians and five immigrant groups in Norway, according to the European Systematic Coronary Risk Evaluation (SCORE) system.

METHODS

Data were obtained from the Oslo Health Study and the Oslo Immigrant Health Study (2000-2002). Fourteen thousand eight hundred and fifty-six individuals born between 1940 and 1971 in Norway, Turkey, Iran, Pakistan, Sri Lanka and Vietnam were included in the study. The European SCORE high-risk models, one including total cholesterol and the other including total cholesterol/HDL cholesterol ratio, were used to estimate 10-year cardiovascular mortality risk. A model assuming no smoking was also applied. Age was projected to 60 years and estimates were adjusted for age at screening.

RESULTS

Norwegians had higher total cholesterol and systolic blood pressure, but lower triglycerides and higher HDL cholesterol compared with immigrants. The mean SCORE (total cholesterol model) varied between 6.6% (Turkey) and 5.4% (Sri Lanka) in men, and 2.1% (Norway) and 1.5% (Pakistan, Sri Lanka and Vietnam) in women. Application of the ratio model gave higher estimated risk in all immigrant groups except for Vietnamese, with 10-year risk varying between 7.7% (Turkey/Pakistan) and 5.7% (Vietnam) in men, and 2.0% (Norway) and 1.5% (Vietnam) in women. When the ratio model was applied assuming no smoking in all ethnic groups, the mean SCORE risk was reduced by 30% in Turkish men and 25% in Norwegian women, with less significant reductions observed in the other groups.

CONCLUSION

Norwegians ranked high with the SCORE total cholesterol model and Norwegian men low with the SCORE ratio model. Although the predictive accuracy of the SCORE models for immigrants in Norway remains to be evaluated, our findings suggest that the ratio model could be more applicable to the entire population in Norway.

Construction of an odds model of coronary heart disease using published information: the Cardiovascular Health Improvement Model (CHIME)

Background

There is a need for a new cardiovascular disease model that includes a wider range of relevant risk factors, in particular lifestyle factors, to aid targeting of interventions and improve population models of the impact of cardiovascular disease and preventive strategies. The model needs to be applicable to a wider population including different ethnic groups, different countries and to those with and without cardiovascular disease. This paper describes the construction of the Cardiovascular Health Improvement Model that aims to meet these requirements.

Method

An odds model is used. Information was taken from 2003 mortality statistics for England and Wales, the Health Survey for England 2003 and published data on relative risk in those with and without CVD and mean blood pressure values in hypertensives. The odds ratios used were taken from the INTERHEART study.

Results

A worked example is given calculating the 10-year coronary heart disease risk for a 57 year-old non-diabetic male with no personal or family history of cardiovascular disease, who smokes 30 cigarettes a day and has a systolic blood pressure of 137 mmHg, a total cholesterol (TC) of 6.2 mmol/l, a high density lipoprotein (HDL) of 1.3 mol/l, and a body mass index of 21. He neither drinks regularly nor exercises. He can give no reliable information about his mental health or fruit and vegetable intake. His 10-year risk of CHD death is 2.47%.

Conclusion

This paper demonstrates a method for developing a CHD risk model. Further improvements could be made to the model with additional information. The method is applicable to other causes of death.