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Comparisons of established risk prediction models for cardiovascular disease: systematic review

BMJ 2012; 344 doi: (Published 24 May 2012) Cite this as: BMJ 2012;344:e3318
  1. George C M Siontis, research associate1,
  2. Ioanna Tzoulaki, lecturer1,
  3. Konstantinos C Siontis, research associate1,
  4. John P A Ioannidis, professor2
  1. 1Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
  2. 2Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5411, USA
  1. Correspondence to: J P A Ioannidis jioannid{at}
  • Accepted 6 April 2012


Objective To evaluate the evidence on comparisons of established cardiovascular risk prediction models and to collect comparative information on their relative prognostic performance.

Design Systematic review of comparative predictive model studies.

Data sources Medline and screening of citations and references.

Study selection Studies examining the relative prognostic performance of at least two major risk models for cardiovascular disease in general populations.

Data extraction Information on study design, assessed risk models, and outcomes. We examined the relative performance of the models (discrimination, calibration, and reclassification) and the potential for outcome selection and optimism biases favouring newly introduced models and models developed by the authors.

Results 20 articles including 56 pairwise comparisons of eight models (two variants of the Framingham risk score, the assessing cardiovascular risk to Scottish Intercollegiate Guidelines Network to assign preventative treatment (ASSIGN) score, systematic coronary risk evaluation (SCORE) score, Prospective Cardiovascular Münster (PROCAM) score, QRESEARCH cardiovascular risk (QRISK1 and QRISK2) algorithms, Reynolds risk score) were eligible. Only 10 of 56 comparisons exceeded a 5% relative difference based on the area under the receiver operating characteristic curve. Use of other discrimination, calibration, and reclassification statistics was less consistent. In 32 comparisons, an outcome was used that had been used in the original development of only one of the compared models, and in 25 of these comparisons (78%) the outcome-congruent model had a better area under the receiver operating characteristic curve. Moreover, authors always reported better area under the receiver operating characteristic curves for models that they themselves developed (in five articles on newly introduced models and in three articles on subsequent evaluations).

Conclusions Several risk prediction models for cardiovascular disease are available and their head to head comparisons would benefit from standardised reporting and formal, consistent statistical comparisons. Outcome selection and optimism biases apparently affect this literature.


  • Contributors: GCMS, IT, KCS, and JPAI conceived the study, analysed the data, interpreted the results, and drafted the manuscript. GCMS and IT extracted the data. JPAI is the guarantor.

  • Funding: This study received no additional funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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