Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2.

Description

Given the fact that current cardiovascular disease (CVD) risk algorithms do not take into account ethnicity and deprivation, Hippisley-Cox et al. wanted to develop and validate a new CVD risk algorithm, which they called QRISK2. A total of 531 practices in England contributed to recruit 2.3 million patients 35-74 years of age. During the follow-up period (January 1993-March 2008), 140,000 CVD events were reported. QRISK2, which takes into account ethnicity, age, sex, smoking, systolic blood pressure (or treatment for hypertension), cholesterol/HDL cholesterol ratio, body mass index, family history of CVD, a deprivation score, as well as the presence of rheumatoid arthritis, chronic renal disease, type 2 diabetes, and atrial fibrillation, was compared to the Framingham risk score in a validation cohort. The QRISK2 algorithm was found to explain 43% of the variation in women and 38% in men compared with 39% and 35%, respectively, for the modified Framingham risk score. Moreover, at the 10-year risk threshold of 20%, the population identified by QRISK2 was at higher CVD risk than the population identified by the modified Framingham risk score. Although the authors recognized that the QRISK2 algorithm needs to be validated in other population studies, they suggested that the many advantages of this new CVD risk algorithm could make it an appropriate tool to assist in the delivery of public health programs that recognize the broader determinants of CVD. This paper was accompanied by an editorial by Thierry Christiaens who welcomed the novel algorithm developed by Hippisley-Cox et al. However, he qualified his remarks, noting that even if we could achieve proper CVD risk estimation, the question of CVD treatment would still be unresolved. In his editorial, Christiaens tries to answer two important questions: 1) when does a “risk” become a “high-risk” and 2) when does a “high risk” justify starting lifelong drug treatment. In his opinion, the focus of primary care physicians should be on CVD treatment rather than CVD risk estimation.