The Dutch SCORE-based risk charts seriously underestimate the risk of cardiovascular disease

Cost-effectiveness of applying high-sensitivity troponin I to a score for cardiovascular risk prediction in asymptomatic population

INTRODUCTION

Risk stratification scores such as the European Systematic COronary Risk Evaluation (SCORE) are used to guide individuals on cardiovascular disease (CVD) prevention. Adding high-sensitivity troponin I (hsTnI) to such risk scores has the potential to improve accuracy of CVD prediction. We investigated how applying hsTnI in addition to SCORE may impact management, outcome, and cost-effectiveness.

METHODS

Characteristics of 72,190 apparently healthy individuals from the Biomarker for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project were included into a discrete-event simulation comparing two strategies for assessing CVD risk. The standard strategy reflecting current practice employed SCORE (SCORE); the alternative strategy involved adding hsTnI information for further stratifying SCORE risk categories (S-SCORE). Individuals were followed over ten years from baseline examination to CVD event, death or end of follow-up. The model tracked the occurrence of events and calculated direct costs of screening, prevention, and treatment from a European health system perspective. Cost-effectiveness was expressed as incremental cost-effectiveness ratio (ICER) in € per quality-adjusted life year (QALYs) gained during 10 years of follow-up. Outputs were validated against observed rates, and results were tested in deterministic and probabilistic sensitivity analyses.

RESULTS

S-SCORE yielded a change in management for 10.0% of individuals, and a reduction in CVD events (4.85% vs. 5.38%, p<0.001) and mortality (6.80% vs. 7.04%, p<0.001). S-SCORE led to 23 (95%CI: 20-26) additional event-free years and 7 (95%CI: 5-9) additional QALYs per 1,000 subjects screened, and resulted in a relative risk reduction for CVD of 9.9% (95%CI: 7.3-13.5%) with a number needed to screen to prevent one event of 183 (95%CI: 172 to 203). S-SCORE increased costs per subject by 187€ (95%CI: 177 € to 196 €), leading to an ICER of 27,440€/QALY gained. Sensitivity analysis was performed with eligibility for treatment being the most sensitive.

CONCLUSION

Adding a person's hsTnI value to SCORE can impact clinical decision making and eventually improves QALYs and is cost-effective compared to CVD prevention strategies using SCORE alone. Stratifying SCORE risk classes for hsTnI would likely offer cost-effective alternatives, particularly when targeting higher risk groups.

Performance of the SCORE and Globorisk cardiovascular risk prediction models: a prospective cohort study in Dutch general practice

BACKGROUND

GPs frequently use 10-year-risk estimations of cardiovascular disease (CVD) to identify high- risk patients.

AIM

To assess the performance of four models for predicting the 10-year risk of CVD in Dutch general practice.

DESIGN AND SETTING

Prospective cohort study. Routine data (2009- 2019) was used from 46 Dutch general practices linked to cause of death statistics.

METHOD

The outcome measures were fatal CVD for SCORE and first diagnosis of fatal or non- fatal CVD for SCORE fatal and non-fatal (SCORE- FNF), Globorisk-laboratory, and Globorisk-office. Model performance was assessed by examining discrimination and calibration.

RESULTS

The final number of patients for risk prediction was 1981 for SCORE and SCORE-FNF, 3588 for Globorisk-laboratory, and 4399 for Globorisk- office. The observed percentage of events was 18.6% (n = 353) for SCORE- FNF, 6.9% (n = 230) for Globorisk-laboratory, 7.9% (n = 323) for Globorisk-office, and 0.3% (n = 5) for SCORE. The models showed poor discrimination and calibration. The performance of SCORE could not be examined because of the limited number of fatal CVD events. SCORE-FNF, the model that is currently used for risk prediction of fatal plus non-fatal CVD in Dutch general practice, was found to underestimate the risk in all deciles of predicted risks.

CONCLUSION

Wide eligibility criteria and a broad outcome measure contribute to the model applicability in daily practice. The restriction to fatal CVD outcomes of SCORE renders it less usable in routine Dutch general practice. The models seriously underestimate the 10-year risk of fatal plus non-fatal CVD in Dutch general practice. The poor model performance is possibly because of differences between patients that are eligible for risk prediction and the population that was used for model development. In addition, selection of higher-risk patients for CVD risk assessment by GPs may also contribute to the poor model performance.

Prevalence and Clinical Impact of Electrocardiographic Abnormalities in Patients with Chronic Kidney Disease

Chronic kidney disease (CKD) is a strong risk factor for cardiovascular disease. An electrocardiogram (ECG) is a basic test for screening cardiovascular disease. However, the impact of ECG abnormalities on cardiovascular prognosis in patients with CKD is largely unknown. A total of 2442 patients with CKD (stages 3−5) who underwent ECG between 2013 and 2015 were selected from the electronic health record database of the Korea University Anam Hospital. ECG abnormalities were defined using the Minnesota classification. The five-year major adverse cerebrocardiovascular event (MACCE), the composite of death, myocardial infarction (MI), and stroke were analyzed. The five-year incidences for MACCE were 27.7%, 20.8%, and 17.2% in patients with no, minor, and major ECG abnormality (p < 0.01). Kaplan−Meier curves also showed the highest incidence of MI, death, and MACCE in patients with major ECG abnormality. Multivariable Cox regression analysis revealed age, sex, diabetes, CKD stage, hsCRP, antipsychotic use, and major ECG abnormality as independent risk predictors for MACCE (adjusted HR of major ECG abnormality: 1.39, 95% CI: 1.09−1.76, p < 01). Among the detailed ECG diagnoses, sinus tachycardia, myocardial ischemia, atrial premature complex, and right axis deviation were proposed as important ECG diagnoses. The accuracy of cardiovascular risk stratification was improved when the ECG results were added to the conventional SCORE model (net reclassification index 0.07). ECG helps to predict future cerebrocardiovascular events in CKD patients. ECG diagnosis can be useful for cardiovascular risk evaluation in CKD patients when applied in addition to the conventional risk stratification model.

Prevalence of ECG abnormalities in people with type 2 diabetes: The Hoorn Diabetes Care System cohort

AIMS

The American Diabetes Association, and the joint European Society of Cardiology and European Association for the Study of Diabetes guidelines recommend a resting ECG in people with type 2 diabetes with hypertension or suspected cardiovascular disease (CVD). However, knowledge on the prevalence of ECG abnormalities is incomplete. We aimed to analyse the prevalence of ECG abnormalities and their cross-sectional associations with cardiovascular risk factors in people with type 2 diabetes.

METHODS

We used data of the Diabetes Care System cohort obtained in 2018. ECG abnormalities were defined using the Minnesota Classification and categorised into types of abnormalities. The prevalence was calculated for the total population (n = 8068) and the subgroup of people without a history of CVD (n = 6494). Logistic regression models were used to asses cross-sectional associations.

RESULTS

Approximately one-third of the total population had minor (16.0%) or major (13.1%) ECG abnormalities. Of the participants without a CVD history, approximately one-quarter had minor (14.9%) or major (9.1%) ECG abnormalities, and for those with hypertension or very high CVD risk, the prevalence was 27.5% and 39.6%, respectively. ECG abnormalities were significantly and consistently associated with established CVD risk factors.

CONCLUSIONS

Resting ECG abnormalities are common in all people with type 2 diabetes (29.1%), including those without a history of CVD (24.0%), and their prevalence is related to traditional cardiovascular risk factors such as older age, male sex, hypertension, lower HDL cholesterol, higher BMI, and smoking behaviour.

Estimation of cardiovascular risk based on total cholesterol versus total cholesterol/high-density lipoprotein within different ethnic groups: The HELIUS study

Aims

European guidelines recommend estimating cardiovascular disease risk using the Systematic COronary Risk Evaluation (SCORE) algorithm. Two versions of SCORE are available: one based on the total cholesterol/high-density lipoprotein cholesterol ratio, and one based on total cholesterol alone. Cardiovascular risk classification between the two algorithms may differ, particularly among ethnic minority groups with a lipid profile different from the ethnic majority groups among whom the SCORE algorithms were validated. Thus in this study we determined whether discrepancies in cardiovascular risk classification between the two SCORE algorithms are more common in ethnic minority groups relative to the Dutch.

Methods

Using HELIUS study data (Amsterdam, The Netherlands), we obtained data from 7572 participants without self-reported prior cardiovascular disease of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan ethnic origin. For both SCORE algorithms, cardiovascular risk was estimated and used to categorise participants as low (<1%), medium (1–5%), high (5–10%) or very high (≥10%) risk. Odds of differential cardiovascular risk classification were determined by logistic regression analyses.

Results

The percentage of participants classified differently between the algorithms ranged from 8.7% to 12.4% among ethnic minority men versus 11.4% among Dutch men, and from 1.9% to 5.5% among ethnic minority women versus 6.2% among Dutch women. Relative to the Dutch, only Turkish and Moroccan women showed significantly different (lower) odds of differential cardiovascular risk classification.

Conclusion

We found no indication that discrepancies in cardiovascular risk classification between the two SCORE algorithms are consistently more common in ethnic minority groups than among ethnic majority groups.