What primary end point should be identified by QRISK2 score for cardiovascular disease?
We read with great interest the manuscript by Collins GS et al. (1)
where the performance in identifying a high risk population for
cardiovascular disease (CVD) of the QRISK2 risk score has been compared
with the risk prediction approach (NICE Framingham) recently recommended
by the National Institute for Health and Clinical Excellence in the United
On May 3, we wrote a rapid response for Barnett et al. (2) where we
suggested that in the case of deciding whether to start aspirin therapy
and evaluation of benefit versus risk, global risk scores should be used
Summarizing the precedent studies the following estimates were noted:
First, the analysis for primary prevention showed that the highest
incidence of CVD occurred in additional risk individuals such as high low
density lipoprotein cholesterol, high sensitivity C – reactive protein,
gender, age, racial disparities, obesity, cigarette smoking, blood
pressure (including whether the patient is treated or not), diabetes etc.
In fact, the difference in risk was showed in a study that reviewed data
from 366.559 subjects aged 18 to 59 who were entered into two large
prospective studies, the multiple risk factor intervention trial (MRFIT),
and the Chicago Heart Association Project in Industry. Patients at low
risk, defined as serum cholesterol <200 mg/dL, blood pressure ≤
120/80 mmHg, and no current cigarette smoking, comprised 6.9 percent of
the cohort (3). Second, multiple models, including score and QRISK2, have
been developed in an attempt to provide better predictive accuracy for
European patients (4, 5, 6), and the risk increased progressively with the
number and intensity of risk factors. Third the determination of a CVD
patient's risk profile should improve physician recognition and treatment
of modifiable risk factors following an algorithm model. Finally the
estimation of CVD risk is useful in individuals at increased risk both for
patient education and for deciding when to initiate preventative
In this context, we would like to ask to Collins et al. when
recommend the application of QRISK2: i) in the assessment of cardiac risk
in the screening of asymptomatic patients without CVD, ii) in clinical
practice as best approach risk score for quantifying the assessment of
risk in CVD patients, iii) in United Kingdom only, or also in areas of the
world of limited resources where finding low-cost strategies for risk
scores is essential.
1.Collins GS, Altman DG. An independent and external validation of
QRISK2 cardiovascular disease risk score: a prospective open cohort study
2.Rizzo S, Carbone RG and Paredi P. Should risk estimates guide
aspirin therapy in primary prevention? BMJ May 3 2010 in reply to: Helen
Barnett, Peter Burrill, and Ike Iheanacho. Don¡¯t use aspirin for primary
prevention of cardiovascular disease BMJ 2010; 340: c1805
3.Stamler, J, Stamler, R, Neaton, JD, et al. Low risk-factor profile
and long-term cardiovascular and noncardiovascular mortality and life
expectancy: findings for 5 large cohorts of young adult and middle-aged
men and women. JAMA 1999; 282:2012.
4.Hippisley-Cox, J, Coupland, C, Vinogradova, Y, et al. Derivation
and validation of QRISK, a new cardiovascular disease risk score for the
United Kingdom: prospective open cohort study. BMJ 2007; 335:136.
5.Hippisley-Cox, J, Coupland, C, Vinogradova, Y, et al. Predicting
cardiovascular risk in England and Wales: prospective derivation and
validation of QRISK2. BMJ 2008;336:1475.
6.Ridker, PM, Paynter, NP, Rifai, N, et al. C-reactive protein and
parental history improve global cardiovascular risk prediction: the
Reynolds Risk Score for men. Circulation 2008; 118:2243.
Competing interests: No competing interests