Abstract
SummaryBackgroundEvaluation of cardiovascular disease risk in primary care, which is recommended every 5 years in middle-aged and older adults (typical age range 40–75 years), is based on risk scores, such as the European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE) and American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease (ASCVD) algorithms. This evaluation currently uses only the most recent risk factor assessment. We aimed to examine whether 5-year changes in SCORE and ASCVD risk scores are associated with future cardiovascular disease risk.MethodsWe analysed data from the Whitehall II longitudinal, prospective cohort study for individuals with no history of stroke, myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, definite angina, heart failure, or peripheral artery disease. Participants underwent clinical examinations in 5-year intervals between Aug 7, 1991, and Dec 6, 2016, and were followed up for incident cardiovascular disease until Oct 2, 2019. Levels of, and 5-year changes in, cardiovascular disease risk were assessed using the SCORE and ASCVD risk scores and were analysed as predictors of cardiovascular disease. Harrell’s C index, continuous net reclassification improvement, the Akaike information criterion, and calibration analysis were used to assess whether incorporating change in risk scores into a model including only a single risk score assessment improved the predictive performance. We assessed the levels of, and 5-year changes in, SCORE and ASCVD risk scores as predictors of cardiovascular disease and disease-free life-years using Cox proportional hazards and flexible parametric survival models.Findings7574 participants (5233 [69·1%] men, 2341 [30·9%] women) aged 40–75 years were included in analyses of risk score change between April 24, 1997, and Oct 2, 2019. During a mean follow-up of 18·7 years (SD 5·5), 1441 (19·0%; 1042 [72·3%] men and 399 [27·7%] women) participants developed cardiovascular disease. Adding 5-year change in risk score to a model that included only a single risk score assessment improved model performance according to Harrell’s C index (from 0·685 to 0·690, change 0·004 [95% CI 0·000 to 0·008] for SCORE; from 0·699 to 0·700, change 0·001 [0·000 to 0·003] for ASCVD), the Akaike information criterion (from 17 255 to 17 200, change −57 [95% CI −97 to −13] for SCORE; from 14 739 to 14 729, change −10 [−28 to 7] for ASCVD), and the continuous net reclassification index (0·353 [95% CI 0·234 to 0·447] for SCORE; 0·232 [0·030 to 0·344] for ASCVD). Both favourable and unfavourable changes in SCORE and ASCVD were associated with cardiovascular disease risk and disease-free life-years. The associations were seen in both sexes and all age groups up to the age of 75 years. At the age of 45 years, each 2-unit improvement in risk scores was associated with an additional 1·3 life-years (95% CI 0·4 to 2·2) free of cardiovascular disease for SCORE and an additional 0·9 life-years (95% CI 0·5 to 1·3) for ASCVD. At age 65 years, this same improvement was associated with an additional 0·4 life-years (95% CI 0·0 to 0·7) free of cardiovascular disease for SCORE and 0·3 life-years (95% CI 0·1 to 0·5) for ASCVD. These models were developed into an interactive calculator, which enables estimation of the number of cardiovascular disease-free life-years for an individual as a function of two risk score measurements.InterpretationChanges in the SCORE and ASCVD risk scores over time inform cardiovascular disease risk prediction beyond a single risk score assessment. Repeat data might allow more accurate cardiovascular risk stratification and strengthen the evidence base for decisions on preventive interventions.FundingUK Medical Research Council, British Heart Foundation, Wellcome Trust, and US National Institute on Aging.
Highlights
We searched PubMed for research articles, with no language restriction, published up to Oct 30, 2020, using the following search terms: “cardiovascular disease”, “myocardial infarction”, “risk score”, “risk algorithm”, “change”, “improvement”, “reduction”, and “decline”, but found no studies examining the extent to which changes in cardiovascular risk scores are associated with changes in the number of cardiovascular disease-free life-years, or any studies examining an association between changes in risk scores and cardiovascular disease events
We aimed to assess whether changes in risk scores computed with the European Society of Cardiology’s Systematic Coronary Risk Evaluation (SCORE)[3] and the American College of Cardiology/American Heart Asso ciation’s Atherosclerotic Cardiovascular Disease (ASCVD) risk algorithms2—the two most commonly used risk models—were associated with subsequent cardiovascular disease event rates and life-years free of cardiovascular disease, and whether any associations were affected by increasing age
7996 participants aged [40–63] years between Aug 7, 1991, and May 10, 1993, were included in the baseline analyses. Both SCORE and ASCVD risk scores increased over time
Summary
Guidelines for cardiovascular disease prevention recom mend assessment of an individual’s future risk to inform decisions on lifestyle and medical interventions.[1,2,3] The risk of a cardiovascular disease event is computed using risk scores that require entry of data for multiple risk factors, commonly including age, sex, blood pressure, smoking, cholesterol, and diabetes status.[1,2,3] . Current prevention guidelines recommend health checks every 5 years to evaluate risk and, if needed, appropriate lifestyle interventions are recommended and drug therapies prescribed. Since lifestyle and medical interventions alter cardiovascular disease risk, changes in risk assessment scores following interventions could potentially be used to improve risk stratification compared with a single updated risk assessment alone, as well as to set targets for such interventions. We searched PubMed for research articles, with no language restriction, published up to Oct 30, 2020, using the following search terms: “cardiovascular disease”, “myocardial infarction”, “risk score”, “risk algorithm”, “change”, “improvement”, “reduction”, and “decline”, but found no studies examining the extent to which changes in cardiovascular risk scores are associated with changes in the number of cardiovascular disease-free life-years, or any studies examining an association between changes in risk scores and cardiovascular disease events
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