Related Experiment Video
Updated: Aug 9, 2025
An R-Based Landscape Validation of a Competing Risk Model
Published on: September 16, 2022
Stroke risk in older British men: Comparing performance of stroke-specific and composite-CVD risk prediction tools
Ayesha Ahmed1, Gareth Ambler2, Snehal M Pinto Pereira3
1Department of Primary Care and Population Health, University College London, UK.
Insights
Assessing stroke risk in older men requires specific tools. While common cardiovascular disease (CVD) risk calculators show limitations, QRISK3 offers better stroke risk calibration for older adults, even with competing risks.
Area of Science:
- Gerontology
- Epidemiology
- Cardiovascular Medicine
Background:
- Stroke risk prediction is typically integrated within composite cardiovascular disease (CVD) risk assessment.
- Existing risk prediction tools were primarily developed using data from middle-aged populations.
Purpose of the Study:
- To evaluate the accuracy of composite CVD risk prediction tools (QRISK3, Pooled Cohort Equations-PCE) versus stroke-specific tools (Framingham Stroke Risk Profile-FSRP, QStroke) in older men.
- To assess the performance of these tools for predicting 10-year stroke outcomes in older adults.
Main Methods:
- External validation of FSRP, QStroke, QRISK3, and PCE using stroke outcome data from older men (60-79 years) in the British Regional Heart Study.
- Assessment of discrimination (C-indices) and calibration, with and without adjustment for competing risks (non-stroke mortality).
- Examination of sensitivity and specificity using observed and clinically recommended risk thresholds.
Main Results:
- All tools exhibited weak discrimination (C-indices 0.63-0.66).
- FSRP and QStroke overestimated stroke risk at higher predicted levels; QRISK3 and PCE showed reasonable overall calibration.
- QRISK3 demonstrated relatively better calibration for stroke events in men without CVD, including the oldest age groups, even after accounting for competing deaths.
- Sensitivity and specificity were similar across tools using observed risk cut-offs, but QRISK3 and PCE showed very high sensitivity (99%) for stroke events when using CVD prevention thresholds, albeit with a high false positive rate (97%).
Conclusions:
- Composite CVD risk tools like QRISK3 and PCE may be more suitable than older stroke-specific tools for assessing stroke risk in older men.
- Current intervention thresholds for CVD prevention may need re-evaluation to better align with the age-related burden of stroke.
- Further research is needed to refine stroke risk prediction models for elderly populations, considering competing risks.
Abstract:
Stroke risk is currently estimated as part of the composite risk of cardiovascular disease (CVD). We investigated if composite-CVD risk prediction tools QRISK3 and Pooled Cohort Equations-PCE, derived from middle-aged adults, are as good as stroke-specific Framingham Stroke Risk Profile-FSRP and QStroke for capturing the true risk of stroke in older adults. External validation for 10y stroke outcomes was performed in men (60-79y) of the British Regional Heart Study. Discrimination and calibration were assessed in separate validation samples (FSRP n = 3762, QStroke n = 3376, QRISK3 n = 2669 and PCE n = 3047) with/without adjustment for competing risks. Sensitivity/specificity were examined using observed and clinically recommended thresholds. Performance of FSRP, QStroke and QRISK3 was further compared head-to-head in 2441 men free of a range of CVD, including across age-groups. Observed 10y risk (/1000PY) ranged from 6.8 (hard strokes) to 11 (strokes/transient ischemic attacks). All tools discriminated weakly, C-indices 0.63-0.66. FSRP and QStroke overestimated risk at higher predicted probabilities. QRISK3 and PCE showed reasonable calibration overall with minor mis-estimations across the risk range. Performance worsened on adjusting for competing non-stroke deaths. However, in men without CVD, QRISK3 displayed relatively better calibration for stroke events, even after adjustment for competing deaths, including in oldest men. All tools displayed similar sensitivity (63-73 %) and specificity (52-54 %) using observed risks as cut-offs. When QRISK3 and PCE were evaluated using thresholds for CVD prevention, sensitivity for stroke events was 99 %, with false positive rate 97 % suggesting existing intervention thresholds may need to be re-examined to reflect age-related stroke burden.
More Related Videos
Related Concept Videos
01:25Imaging Studies for Cardiovascular System VI: Calcium -Scoring CT
01:23Assessment of the Cardiovascular System I: Subjective Data
Initial Enquiry
Ask the patient about their primary concern and thoroughly explore all reported symptoms.
Medical History
Investigate past illnesses affecting the cardiovascular system, such as angina, anemia, rheumatic fever, congenital heart disease, stroke, thrombophlebitis, dysrhythmias, varicosities
Inquire about symptoms...