Risk prediction of cardiovascular disease in the Asia-Pacific region: the SCORE2 Asia-Pacific model

Abstract

Background and aims: To improve upon the estimation of 10-year cardiovascular disease (CVD) event risk for individuals without prior CVD or diabetes mellitus in the Asia-Pacific region by systematic recalibration of the SCORE2 risk algorithm.

Methods: The sex-specific and competing risk-adjusted SCORE2 algorithms were systematically recalibrated to reflect CVD incidence observed in four Asia-Pacific risk regions, defined according to country-level World Health Organization age- and sex-standardized CVD mortality rates. Using the same approach as applied for the original SCORE2 models, recalibration to each risk region was completed using expected CVD incidence and risk factor distributions from each region.

Results: Risk region-specific CVD incidence was estimated using CVD mortality and incidence data on 8 405 574 individuals (556 421 CVD events). For external validation, data from 9 560 266 individuals without previous CVD or diabetes were analysed in 13 prospective studies from 12 countries (350 550 incident CVD events). The pooled C-index of the SCORE2 Asia-Pacific algorithms in the external validation datasets was .710 [95% confidence interval (CI) .677-.744]. Cohort-specific C-indices ranged from .605 (95% CI .597-.613) to .840 (95% CI .771-.909). Estimated CVD risk varied several-fold across Asia-Pacific risk regions. For example, the estimated 10-year CVD risk for a 50-year-old non-smoker, with a systolic blood pressure of 140 mmHg, total cholesterol of 5.5 mmol/L, and high-density lipoprotein cholesterol of 1.3 mmol/L, ranged from 7% for men in low-risk countries to 14% for men in very-high-risk countries, and from 3% for women in low-risk countries to 13% for women in very-high-risk countries.

Conclusions: The SCORE2 Asia-Pacific algorithms have been calibrated to estimate 10-year risk of CVD for apparently healthy people in Asia and Oceania, thereby enhancing the identification of individuals at higher risk of developing CVD across the Asia-Pacific region.

Keywords: Cardiovascular disease; Primary prevention; Risk prediction; Ten-year CVD risk.

Structured Graphical Abstract

Example of the SCORE2 Asia-Pacific model recalibrated to all four risk regions in the Asia-Pacific region, highlighting regional differences in cardiovascular disease (CVD) risk profiles. HDL-c, high-density lipoprotein cholesterol; SBP, systolic blood pressure; WHO GHE, World Health Organization’s Global Health Estimates.

Figure 1

Study design

Figure 2

Risk regions based on age- and sex-standardized CVD mortality rates from the Global Health Estimates. Countries were grouped upon the most recently available age- and sex-standardized CVD mortality rates from the WHO GEH: low risk (<100 CVD deaths per 100 000), moderate risk (100 to <150 CVD deaths per 100 000), high risk (150 to <300 CVD deaths per 100 000), and very high risk (≥300 CVD deaths per 100 000). The SCORE2 Asia-Pacific writing group takes a neutral position regarding territorial claims in published maps and institutional affiliations

Figure 3

SCORE2 Asia-Pacific risk charts for the prediction of 10-year risk in four Asia-Pacific risk regions

Figure 3

SCORE2 Asia-Pacific risk charts for the prediction of 10-year risk in four Asia-Pacific risk regions

Figure 3

SCORE2 Asia-Pacific risk charts for the prediction of 10-year risk in four Asia-Pacific risk regions

Figure 3

SCORE2 Asia-Pacific risk charts for the prediction of 10-year risk in four Asia-Pacific risk regions

Figure 4

C-index upon assessing the ability of the SCORE2 Asia-Pacific algorithms to discriminate CVD in external validation cohorts

Figure 5

Distribution of 10-year CVD risk according to recalibrated SCORE2 models across Asia-Pacific countries. The proportion of individuals expected in each risk category was estimated to reflect the age-group and sex-specific risk factor values and specific population structure of each country (see Supplementary Methods S1.3)