Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies

Abstract

Aims There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after “re-calibration”, a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied. Methods and Results Using individual-participant data on 360,737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham Risk Score (FRS), Systematic Coronary Risk Evaluation (SCORE), Pooled Cohort Equations (PCE), and Reynolds Risk Score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at “high” 10-year CVD risk. Original risk algorithms were re-calibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before re-calibration, FRS, SCORE and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, while RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high-risk. By contrast, re-calibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with re-calibrated algorithms. Conclusion Before re-calibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple re-calibration nearly equalised their performance and improved modelled targeting of preventive action to clinical need.

World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions

“…43 Recalibration was done separately for men and women (description in appendix 1 pp 16,40-41). 44 This process involved the use of age-specific and sex-specific mean risk factor levels and annual incidence estimates of fatal or non-fatal myocardial infarction and stroke events in each of 21 global regions (appendix 1 p 43). Calibration of the new WHO models was assessed by comparing the predicted 10-year cardiovascular disease risk with the expected 10-year risk estimated from the 2017 GBD annual incidence estimates, across 5-year age groups.…”

Use of polygenic risk scores and other molecular markers to enhance cardiovascular risk prediction: prospective cohort study and modelling analysis

“…We recalibrated risk prediction models derived in UKB to represent 10-year risks that would be expected in a UK primary care setting using CPRD data, 33 using methods previously described. 34 We then modelled a population of 100,000 adults aged 40-75 years, with an age and sex profile as contemporary UK population (2017 mid-year population, https://www.ons.gov.uk/), and CVD incidence rates as observed in individuals without previous CVD and not on statin treatment at registration, in the CPRD. We assumed an initial policy of statin allocation for people at ≥10% predicted 10-year risk as recommended by current National Institute for Health and Care Excellence (NICE) guidelines.…”

Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology

“…There is debate about the optimum algorithm for CVD risk estimation. Although the SCORE risk engine is generally recommended in the current ESC guideline, the use of any risk score is encouraged, if such risk score was developed in a methodologically sound manner and is optimally calibrated for use in particular countries or geographical regions, 11 such as Q-RISK/JBS3 of people in the United Kingdom. 12 However, the need for a revaluation with recalibration of the current risk scores has been underlined.…”

“…It was estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms. 11 Furthermore, two other important issues regarding risk assessment are subject to current debate.…”