Therapeutic implications of selecting the SCORE (European) versus the D'AGOSTINO (American) risk charts for cardiovascular risk assessment in hypertensive patients

BackgroundNo comparisons have been made of scales estimating cardiovascular mortality and overall cardiovascular morbidity and mortality. The study objectives were to assess the agreement between the Framingham-D'Agostino cardiovascular risk (CVR) scale and the chart currently recommended in Europe (SCORE) with regard to identification of patients with high CVR, and to describe the discrepancies between them and the attendant implications for the treatment of hypertension and hyperlipidaemia.MethodsA total of 474 hypertensive patients aged 40–65 years monitored in primary care were enrolled into the study. CVR was assessed using the Framingham-D'Agostino scale, which estimates the overall cardiovascular morbidity and mortality risk, and the SCORE chart, which estimates the cardiovascular mortality risk. Cardiovascular risk was considered to be high for values ≥ 20% and ≥ 5% according to the Framingham-D'Agostino and SCORE charts respectively. Kappa statistics was estimated for agreement in classification of patients with high CVR. The therapeutic recommendations in the 2007 European Guidelines on Cardiovascular Disease Prevention were followed.ResultsMean patient age was 54.1 (SD 7.3), and 58.4% were males. A high CVR was found in 17.5% using the SCORE chart (25.3% males, 6.6% females) and in 32.7% using the D'Agostino method (56.9% males, 12,7% females). Kappa coefficient was 0.52, and increased to 0.68 when the high CVR threshold was established at 29% according to D'Agostino. Hypertensive patients with high SCORE and non-high D'Agostino (1.7%) were characterized by an older age, diabetes, and a lower atherogenic index, while the opposite situation (16.9%) was associated to males, hyperlipidaemia, and a higher atherogenic index. Variables with a greater weight in discrepancies were sex and smoking. A 32.0% according to SCORE and 33.5% according to D'Agostino would be candidates to receive antihypertensive treatment, and 15.8% and 27.3% respectively to receive lipid-lowering treatment.ConclusionA moderate to high agreement was found. SCORE may underestimate risk in males with an unfavourable lipid profile, and D'Agostino in diabetics with a lower atherogenic risk. Use of the D'Agostino scale implies treating more patients with lipid-lowering and antihypertensive drugs as compared to SCORE.

[1]  J. Marrugat,et al.  Estimación del riesgo coronario en España mediante la ecuación de Framingham calibrada , 2003 .

[2]  R. D'Agostino,et al.  [Coronary risk estimation in Spain using a calibrated Framingham function]. , 2003, Revista espanola de cardiologia.

[3]  Shah Ebrahim,et al.  European guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by representatives of nine societies and by invit , 2007, European heart journal.

[4]  S. Sans,et al.  [Calibrating the SCORE cardiovascular risk chart for use in Spain]. , 2007, Revista espanola de cardiologia.

[5]  J. B. Cabello,et al.  Las mediciones clínicas en cardiología: validez y errores de medición , 1997 .

[6]  Shah Ebrahim,et al.  European guidelines on cardiovascular disease prevention in clinical practice: executive summary. , 2007, Atherosclerosis.

[7]  J. Marrugat,et al.  Comparación de la función de Framingham original y la calibrada del REGICOR en la predicción del riesgo coronario poblacional , 2003 .

[8]  J. R. González-Juanatey,et al.  Ecuación de Framingham de Wilson y ecuación de REGICOR. Estudio comparativo , 2005 .

[9]  Philip Greenland,et al.  Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations , 1999 .

[10]  F. Buitrago Ramírez,et al.  [Comparison of the SCORE function chart and the Framingham-REGICOR equation to estimate the cardiovascular risk in an urban population after 10 years of follow-up]. , 2006, Medicina clinica.

[11]  Yutaka Imai,et al.  Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement. , 2005, Journal of hypertension.

[12]  J. García,et al.  Comparación de los modelos SCORE y REGICOR para el cálculo del riesgo cardiovascular en sujetos sin enfermedad cardiovascular atendidos en un centro de salud de Barcelona , 2005 .

[13]  J. B. Baena Díez,et al.  [Comparison of the SCORE and REGICOR models for calculating cardiovascular risk in cardiovascular disease-free individuals at a healthcare center in Barcelona, Spain]. , 2005, Revista espanola de salud publica.

[14]  Lourdes Cañón-Barroso,et al.  Comparación de las tablas REGICOR y SCORE para la clasificación del riesgo cardiovascular y la identificación de pacientes candidatos a tratamiento hipolipemiante o antihipertensivo , 2007 .

[15]  S M Grundy,et al.  Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. , 1999, Circulation.

[16]  J. Pascual,et al.  [Cardiovascular risk by Framingham and SCORE in patients 40-65 years old]. , 2006, Medicina clinica.

[17]  J. Marrugat,et al.  [Comparison of population coronary heart disease risk estimated by the Framingham original and REGICOR calibrated functions]. , 2003, Medicina clinica.

[18]  M. Pencina,et al.  General Cardiovascular Risk Profile for Use in Primary Care: The Framingham Heart Study , 2008, Circulation.

[19]  E. Rodilla,et al.  Comparación entre el algoritmo de Framingham y el de SCORE en el càlculo del riesgo cardiovascular en sujetos de 40-65 años , 2006 .

[20]  Emiliano Rodriguez-Sanchez,et al.  Framingham-Grundy, REGICOR y SCORE en la estimación del riesgo cardiovascular del paciente hipertenso. Concordancias y discrepancias (CICLO-RISK) , 2006 .

[21]  J. Redón,et al.  [Agreement between REGICOR and SCORE scales in identifying high cardiovascular risk in the Spanish population]. , 2007, Revista espanola de cardiologia.

[22]  C. Lahoz,et al.  La aplicación de las tablas del SCORE a varones de edad avanzada triplica el número de sujetos clasificados de alto riesgo en comparación con la función de Framingham , 2005 .

[23]  V. Abraira,et al.  [Investigation methods in clinical cardiology. IV. Clinical measurements in cardiology: validity and errors of measurements]. , 1997, Revista espanola de cardiologia.

[24]  J. Mckenney,et al.  Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). , 2001, JAMA.

[25]  J. González-Juanatey,et al.  [Comparison of coronary risk estimates derived using the Framingham and REGICOR equations]. , 2005, Revista espanola de cardiologia.

[26]  I. B. Vintró,et al.  Factores de riesgo y morbimortalidad coronaria en una cohorte laboral mediterránea seguida durante 28 años. Estudio de Manresa , 2001 .

[27]  J. R. Banegas,et al.  Mortalidad relacionada con la hipertensión y la presión arterial en España , 1999 .

[28]  C. McCulloch,et al.  What does my patient's coronary artery calcium score mean? Combining information from the coronary artery calcium score with information from conventional risk factors to estimate coronary heart disease risk , 2004, BMC medicine.

[29]  D. Orozco-Beltrán,et al.  Concordancia de las escalas REGICOR y SCORE para la identificación del riesgo cardiovascular alto en la población española , 2007 .

[30]  F. Ramírez,et al.  Comparación entre la tabla del SCORE y la función Framingham-REGICOR en la estimación del riesgo cardiovascular en una población urbana seguida durante 10 años , 2006 .

[31]  A. Dominiczak,et al.  2007 ESH‐ESC Guidelines for the management of arterial hypertension , 2007 .

[32]  F. Rodríguez‐Artalejo,et al.  [Hypertension-related mortality and arterial pressure in Spain]. , 1999, Medicina clinica.

[33]  A. Galán,et al.  Riesgo cardiovascular del SCORE comparado con el de Framingham. Consecuencias del cambio propuesto por las Sociedades Europeas , 2004 .

[34]  I. Graham,et al.  Calibración de la tabla SCORE de riesgo cardiovascular para España , 2007 .

[35]  C. Brotons,et al.  Consequences of using different methods to assess cardiovascular risk in primary care. , 2006, Family practice.

[36]  A. Dominiczak,et al.  2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) , 2007, European heart journal.

[37]  M. J. Medrano,et al.  Factores de riesgo cardiovascular en la población española: metaanálisis de estudios transversales , 2005 .

[38]  M. Delgado-Rodríguez,et al.  [Cardiovascular risk factors in Spanish population: metaanalysis of cross-sectional studies]. , 2005, Medicina clinica.

[39]  H. Tunstall-Pedoe,et al.  Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. , 2003, European heart journal.

[40]  Hugo C van Woerden,et al.  Healthy Hearts – A community-based primary prevention programme to reduce coronary heart disease , 2008, BMC cardiovascular disorders.

[41]  F. Buitrago,et al.  [Comparison of the REGICOR and SCORE function charts for classifying cardiovascular risk and for selecting patients for hypolipidemic or antihypertensive treatment]. , 2007, Revista espanola de cardiologia.

[42]  N. Unwin,et al.  Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Detection, Evaluation, and Treatment of High Blood Cholesterol Education Program (NCEP) Expert Panel on Executive Summary of the Third Report of the National , 2009 .

[43]  D. Levy,et al.  Prediction of coronary heart disease using risk factor categories. , 1998, Circulation.