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The Dutch SCORE-based risk charts seriously underestimate the risk of cardiovascular disease
H T Jørstad1, S M Boekholdt2, N J Wareham3
1Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. h.t.jorstad@amc.uva.nl.
Insights
Current Dutch cardiovascular disease (CVD) risk charts underestimate patient risk. Updated charts reveal true 10-year CVD risks are more than double current estimates, necessitating guideline revisions.
Area of Science:
- Cardiology
- Public Health
- Epidemiology
Background:
- Dutch guidelines use modified SCORE risk charts for 10-year cardiovascular disease (CVD) risk estimation.
- These charts combine mortality risk with multipliers, which may underestimate overall CVD risk.
- Existing multipliers do not fully account for fatal and nonfatal CVD events.
Purpose of the Study:
- To compare current Dutch CVD risk charts with updated charts using recent multipliers.
- To assess the impact of updated multipliers on CVD risk stratification.
- To determine if current charts underestimate clinical CVD risk.
Main Methods:
- Constructed new 10-year CVD risk charts using updated multipliers from the EPIC-Norfolk study.
- Multipliers were based on ratios of fatal CVD to clinically relevant CVD (fatal plus nonfatal).
- Compared the proportion of 'high risk' (>20%), 'intermediate risk' (10-19%), and 'low risk' (<10%) categories between old and new charts.
Main Results:
- Updated multipliers significantly increased the proportion of individuals in the 'high risk' category (27% vs. 61%).
- The 'high risk' category saw a 229% absolute increase.
- The proportion of individuals in the 'low risk' category decreased substantially (48% vs. 20%).
Conclusions:
- Current Dutch risk charts significantly underestimate clinical CVD risk within 10 years.
- Even considering only hospitalised CVD events, actual 10-year risks are more than double current estimates.
- Findings suggest a need for revision of future CVD prevention guidelines.
Introduction:
Dutch cardiovascular disease (CVD) prevention guidelines recommend the use of modified SCORE risk charts to estimate 10-year risk of fatal and nonfatal CVD (myocardial infarction, cerebrovascular disease and congestive heart failure). This combined risk is derived from the SCORE mortality risk using multipliers. These multipliers have been shown to underestimate overall CVD risk. We aimed to compare the current Dutch risk charts with charts that estimate a broader range of clinically relevant CVD using updated multipliers.
Methods:
We constructed new risk charts for 10-year CVD using updated, recently published multipliers from the EPIC-Norfolk study, based on ratios of fatal CVD to clinically relevant CVD (fatal plus nonfatal CVD requiring hospitalisation for ischaemic heart disease, cardiac failure, cerebrovascular disease, peripheral artery disease, and aortic aneurysm). Our primary outcome was the proportion of the three risk categories, i. e. 'high risk' (>20% 10-year risk), 'intermediate risk' (10-19%) and 'low risk' (<10%) in the new risk charts as compared with the current risk charts.
Results:
Applying the updated fatal CVD/clinical CVD multipliers led to a marked increase in the high-risk categories (109 (27%) vs. 244 (61%), (p < 0.001)), an absolute increase of 229%. Similarly, the number of low-risk categories decreased (190 (48%) vs. 81 (20%) (p < 0.001)).
Conclusion:
The current Dutch risk charts seriously underestimate the risk of clinical CVD, even in the first 10 years. Even when analyses are restricted to CVD events that required hospitalisation, true 10-year risks are more than double the currently estimated risks. Future guidelines may be revised to reflect these findings.
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