SCORE2 working group and ESC Cardiovascular risk collaboration. Eur Heart J. 2021 Jul 1;42(25):2439-2454.

SCORE incorporates only fatal CVD outcomes, underrates total CVD burden, but in recent decades has moved towards non-fatal outcomes, particularly for younger people. SCORE does not allow for significant differences of risk over countries from the same risk region, means it may mis-evaluate risk in these circumstances. Risk prediction models recommended for other global regions, may not be freely relevant to European populations since they typically incorporate risk factors not available in routine European data sources required for risk model recalibration. Thus, SCORE2 working group, et al. conducted a study to develop, certify, and demonstrate an updated prediction model (SCORE2) to evaluate 10-year fatal and non-fatal cardiovascular disease (CVD) risk in individuals without previous CVD or diabetes aged 40–69 years in Europe.

677,684 participants from 45 groups without previous CVD enrolled in the model derivation. A total of 30 121 CVD events and 33 809 non-CVD deaths were reported in median follow-up of 10.7 (5th, 95th percentile; 5.0, 18.6) years. A sex-specific and competing risk-adjusted models were used incorporating age, smoking status, systolic blood pressure, and total- and HDL-cholesterol. 4 risk regions were described in Europe as per the country-specific CVD mortality, recalibrating models to each region using expected incidences and risk factor distributions. CVD mortality and incidence data of 10,776,466 individuals was used to evaluate region-specific incidence. For external validation, the data was analysed from 25 additional groups in 15 European countries (1,133,181 individuals, 43,492 CVD events). The primary outcome was CVD, described as a composite of cardiovascular mortality, non-fatal myocardial infarction and non-fatal stroke.

There was a significant difference in the estimated absolute risk for a given age and combination of risk factors over regions. For example, the estimated 10- year CVD risk was 5.9% in low-risk countries however, 14.0% in very high-risk countries for a 50-year-old male smoker and with a systolic blood pressure of 140mmHg, total cholesterol of 5.5mmol/L and HDL-cholesterol of 1.3mmol/L. Correspondingly, the 10-year risk was 4.2% in low-risk countries and 13.7% in very high-risk countries for a 50-year-old woman with the same risk factor profile (Figure 1).

Figure 1: SCORE2 charts for estimation of CVD risk in four European risk regions

A data from 1,133,181 individuals without previous CVD or diabetes in 25 prospective studies from 15 European countries was used to estimate C-indices from External validation of risk models (43,492 CVD events were observed). C-indices exhibited moderate-to good differentiation in all regions with group-specific values ranging from 0.67 (0.65–0.68) to 0.81 (0.76–0.86) (Figure 2).

Figure 2: C-index upon assessing ability of the SCORE2model to discriminate cardiovascular disease in external validation cohorts.

Graphical Abstract

In conclusion, SCORE2, a new algorithm procured, assessed, and approved to predict 10-year risk of first-onset CVD in European populations, improves the recognition of individuals at greater risk of increasing CVD over Europe.