Mark Nicholls speaks to Professor Emanuele Di Angelantonio about the new SCORE2 cardiovascular risk calculator.
It is a collaboration of about 200 investigators, including 45 cohorts in 13 countries with 700,000 participants, and has taken almost 2 years to create a meaningful cardiovascular risk score for the next 10 years. But arguably the most important number surrounding the SCORE21 risk prediction tool is that it is designed to save millions of lives.
The new risk calculator incorporates the most comprehensive and up-to-date data and advanced statistical methods, to produce a tool that will help clinicians better predict people at high risk of heart and circulatory diseases and facilitate early and relevant intervention.
Professor Emanuele Di Angelantonio [co-chair of the ESC Cardiovascular Risk Collaboration (CRC)2 with Professor Ian Graham from Trinity College] has co-ordinated the project to produce SCORE2, which updates and replaces the original Systematic Coronary Risk Evaluation (SCORE) risk calculator developed using pre-1986 data.
The SCORE2 risk calculator includes latest epidemiological trends in in risk factors levels and heart and circulatory diseases to deliver a much-needed upgrade from the previous prediction tool—which was only able to estimate cardiovascular mortality and might mis-estimate the cardiovascular risk in some individuals—and can predict both fatal and non-fatal conditions. It is also adaptable to countries with different levels of risk.
Updated prediction model
The aim was to develop, validate, and illustrate an updated prediction model to estimate 10-year fatal and non-fatal CVD risk in individuals without previous CVD or diabetes aged 40–69 in Europe.
Prof. Di Angelantonio (Figure 1), who is Professor of Clinical Epidemiology at the University of Cambridge with an interest in CVD risk prediction, explained: ‘SCORE2 has been designed to estimate risk in the general population and is an advancement on SCORE’.
Professor Emanuele Di Angelantonio.
Key advancements, compared to the original SCORE, are: (i) the extensive data use for derivation, calibration and validation of the models; (ii) the ability to predict fatal and non-fatal outcomes taking into account competing risks from non-cardiovascular events; and (iii) the adaptation of the models to four distinct European regions, and the potential for rapid updates using routinely collected data in the future to further tailor SCORE2 to more accurately estimate risk in individual countries, thereby ensuring its sustained relevance.
‘Furthermore’, he continued, ‘this is one of the first times a risk score has been developed, recalibrated and extensively validated in a single paper.
‘We know that the relationship between some risk factors has changed over time, as has the treatment of some conditions and the incidence of cardiovascular disease. There has been a change in prevention and managements of cardiovascular diseases, a decrease in mortality in many countries, and a change in the number of events presenting as fatal and non-fatal, so being able to capture the non-fatal events is important for modern risk predictions. This information will target the population from now and for the next 10 years’.
Four different regions
SCORE2 covers known risk factors for heart and circulatory diseases such as age, sex, lipids levels, blood pressure, and smoking. In addition, it uses a competing risk model, adjusting the risk for the probability of having another event, which enables better estimation of the risk in a younger and older population.
The further recalibration for four different regions in Europe is a new aspect with the continent divided into low, medium, high, and very high, risk areas according to cardiovascular deaths per 100 000 population.
‘Before, it was only for high and low risk; now we are doing four different regions, but the system we have developed will also allow us to go to calibrate to the level of individual countries and do a country-specific risk score’.
Low-risk areas include countries with less than 100 CVD deaths per 100 000 population such as Spain, France, the UK, and Denmark, with moderate risk countries in areas with 100–150 CVD deaths per 100 000. High-risk countries are with 150–300 cardiovascular deaths per 100 000 and very high risk (over 300 cardiovascular deaths per 100 000) include the Russian Federation, eastern European, and some North African countries. There is even an indication that SCORE2 can have a global application if required.
The SCORE2 risk calculator will be adopted by the upcoming European Guidelines on Cardiovascular Disease Prevention in Clinical Practice, to be unveiled at the European Society of Cardiology (ESC) congress in August, with a mobile app and website that will allow clinicians to use SCORE2 and calculate cardiovascular disease risk, and the public too.
Cardiovascular risk collaboration
This study was carried out by the SCORE2 Working Group and the ESC CRC.
‘This has been a large and long collaboration of experts with diverse but complimentary skills’, said Prof. Di Angelantonio. ‘We have tried to identify the best sources of data and most appropriate analysis and tested different methods against each other for the most appropriate solutions.
‘I am really glad there has been many hours of working together in a truly European collaboration, with people involved from different countries having an input and being able to comment, and I hope that this has resulted in a good scientific product’.
The project brought together key experts and extensive data sources to develop improved risk prediction tools for CVD with calculators that are relevant to current day rates of CVD in different regions of Europe.
Benefits for patients and clinicians
So, what will the benefit be for cardiologist?
‘These new risk prediction algorithms are essential for communicating the risk of CVD and assessing potential benefit from risk factor treatment and may facilitate shared decision-making and risk management in middle age and older persons’, he said.
‘We hope that this tool will help cardiologists and general practitioners to identify people who are likely to benefit the most from preventive actions aimed at reducing cardiovascular events, such as behavioural change, lifestyle modification, and medical treatment. It will allow clinicians to discuss with their patient about cardiovascular risk and how to better prevent them. For public health doctors it will also allow to understand how the risks vary in their country or population. It is not only a tool for individuals, it is a tool for population’.
For patients, it will provide improved estimation for risk, meaning their treatment will be more targeted to what is of most benefit for them and to identify people at a younger age that could potentially benefit from early intervention or lifestyle change, added Prof. Di Angelantonio.
He also believes it will inform discussion, particularly between a patient and their physician, on the direction and type of treatment, such as personalised preventative treatment, or lifestyle advice to lower risk.
Real-world impact
He hopes that SCORE2 will be fully utilised by clinicians, cardiologists, general practitioners, and all physicians that act on primary prevention.
‘The rationale is simple, because we want it to be used across different European countries’, he added. ‘We are looking at basic information that is easy to obtain from medical records—age and sex, smoking status, blood pressure and lipids levels—so a clinician can actually automate some of those calculations of risk, and estimate treatment to prevent cardiovascular disease’.
The researchers believe that this upgrade will better estimate the cardiovascular risk amongst younger people and will improve how treatment is tailored for older people and those in high-risk regions across Europe.
Prof. Angelantonio concluded: ‘This risk tool is much more powerful and superior than what doctors have used for decades. It will fit seamlessly into current prevention programmes with substantial real-world impact by improving the prevention of cardiovascular diseases across Europe before they strike’.
