Cardiovascular disease (CVD) is an important public health problem worldwide that is responsible for a high proportion of the morbidity and mortality of any given population. Portugal is no exception and in addition to the high prevalence of risk factors for cerebrovascular and cardiovascular diseases, these are not optimally managed, especially hypertension and diabetes.1

The need to account for different populations when estimating cardiovascular risk has led to the development of multiple scoring systems, such as PROCAM, SCORE, QRISK, and the Reynolds risk score. Since 2003, the scoring system recommended by the European Society of Cardiology (ESC) has been Systematic COronary Risk Estimation (SCORE). The SCORE system assesses the 10-year risk of fatal cardiovascular disease for people aged 40 through 65 years.2,3 However, this method underestimates CVD morbidity, as it only targets mortality. In recent decades the focus has shifted toward the prevention of nonfatal outcomes, especially for younger people. In 2021, new ESC guidelines introduced two models to estimate individual 10-year risk of fatal and nonfatal CVD in otherwise healthy people: SCORE2 and SCORE2-OP. The SCORE2 risk model is intended for people aged 40 through 69 years, while SCORE2-OP is used for risk assessment in people aged 70 through 89 years.4

The Portuguese primary health care (PHC) system uses SClínico, developed by the Ministry of Health's Shared Services, as its main clinical support software. This program is used to manage medical appointments, test results and parametric patient data. It is currently used in 300 PHC institutions by 13000 healthcare professionals.5 SClínico currently uses the International Classification of Primary Care, second edition (ICPC-2) for disease coding. This system was developed by the World Organization of Family Doctors (WONCA) and adopted by the World Health Organization. Its main objective is to codify clinical activity in PHC, enabling the use of a common international language by the professionals involved.6,7 Calculation of cardiovascular risk is recommended by the Portuguese Directorate-General of Health's Clinical Guidance Standards.8 In SClínico, the calculation is still performed using SCORE, by inserting the required variables in the fields designed for this purpose. Certain medical conditions, such as myocardial infarction, when present and coded, automatically determine a patient's risk category without the need for the standard variables.

The aim of this study is to determine whether there is a significant difference in the assessment of cardiovascular risk between the use of the original SCORE scale and the more recent SCORE2 in the same patient population.

A total of 1642 patients were included in the study. Most were female (55.3%) and the mean age was 55 years; 16.5% were smokers. Demographic data and cardiovascular risk factors across SCORE2 categories can be found in Table 1. In Tables 2 and 3, we present the distribution of cardiovascular risk categories by gender for patients below 50 years of age and between 50 and 65 years of age, respectively.

Applying SCORE, as shown in Table 4, 37.76% of patients were categorized as low risk, 60.23% as moderate risk, 1.95% as high risk and 0.06% as very high risk. Using SCORE2, 55.48% of patients were found to be in the low to moderate risk category, and 39.83% and 4.69% in the high and very high categories, respectively. Therefore, using the SCORE scale, 98% of patients were in the low and moderate risk categories and 2% in the high or very high risk categories. Looking at the corresponding categories calculated by SCORE2, the percentages were 55% and 45%, respectively (Table 4 and Figure 1). This difference was statistically significant between the two risk assessment tools (chi-square [2,n=1642] 831.42, p<0.0001). This observation appears to be confirmed by the strong positive correlation between the SCORE and SCORE2 scales (r=0.8225; p<0.0001) (Figure 2).

Figure 1.

Distribution of patients in all categories of SCORE and SCORE2 scales (p<0.0001).

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Figure 2.

Correlation of SCORE and SCORE2 scales (r=0.8225; p<0.0001).

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Setting aside absolute numbers and delving deeper (Table 4), it can be seen that the higher the risk category, the larger the percentage of reclassified patients. Of the 620 patients in the low-risk category, 454 stayed in the low to moderate category and 166 (26.7%) were reclassified into the high (164) or very high (2) categories. Of the 989 patients in the moderate category, 456 stayed in the low to moderate category and 533 (53.8%) were reclassified into the high (487) and very high (46) categories. Of the 32 patients in the high category, three stayed in the high category and 29 (90.6%) were reclassified into the low to moderate (one) and very high (28) categories. The only patient in the very high category stayed in the same category. This reclassification is visually represented in a Sankey diagram (Figure 3). For the sake of simplicity, the low and moderate SCORE categories were merged into a low to moderate category, matching the one used in SCORE2.

Figure 3.

Sankey diagram showing reclassification flow from SCORE to SCORE2.

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We also analyzed the data to determine the number of patients in the cohort who achieved their target LDL-C level in both scoring systems. The number of on-target patients was higher with SCORE. Out of the 1642 patients, 38.61% reached the desired threshold with the SCORE classification system, compared to only 20.28% with SCORE2. The difference was found to be statistically significant (chi-square [1,n=1642]=662.420, p<0.0001). Further details and a breakdown of cardiovascular risk categories can be found in Table 5.

The 2021 ESC guidelines for the prevention of cardiovascular disease introduced significant changes compared to the previous version. The updated calculator, SCORE2, was recalibrated to four distinct European regions rather than the two-level stratification provided by SCORE, using the most recent and representative CVD rates. Previously, Portugal was classified among the low-risk countries, but new guidelines have now placed it in a category of countries with moderate risk.4 This change implies a significant increase in the potential for CVD.

In our study, the number of individuals considered to be at high or very high cardiovascular risk increased from 2% to 45% with the use of SCORE2. These results are in line with similar European studies, such as in Hungary and Serbia.9,10 This change is noteworthy because it indicates that many patients whose risk would otherwise have been disregarded may require more intensive management of their cardiovascular risk.

With SCORE2, age also plays a significantly greater role in risk classification than in the previous SCORE. The same risk percentage can place patients of different ages in separate categories.4,9 As shown in Tables 2 and 3, reclassification with SCORE2 is more often observed in younger patients (under 50 years of age), from low to moderate to high risk, implying that they will need to be treated more aggressively than before. The shift into higher categories was also more frequent for men than for women, at all ages.

While there is little controversy concerning the recommendation for aggressive treatment of cardiovascular risk factors in patients with high and very high cardiovascular risk, the same cannot be said for patients in the low to moderate risk category. In the latter, we find a tendency to limit initial lipid-lowering therapy to selected cases in which lifestyle modifications, the foundation of any treatment plan for dyslipidemia, are unable to achieve the desired LDL-C target. The challenge of convincing these often young and asymptomatic patients to undergo pharmacological treatment cannot be overstated, and may involve a careful balancing act between patient preference, risk to benefit ratio and economic concerns.

As stated by Figorilli et al.,11 the two guiding principles of cholesterol-lowering therapy should be “the lower the better” for patients at higher cardiovascular risk and “the earlier the better, for longer” for those at lower estimated cardiovascular risk. Accordingly, the LDL-C goal of <116 mg/dl for low-risk subjects, put forward in the 2019 ESC/EAS guidelines, has recently been shifted to <100 mg/dl for the new low to moderate risk category.11

In a previous issue of the Journal, Araújo et al.12 performed a retrospective observational study including very high cardiovascular risk Portuguese patients admitted in two periods: the first two years after the 2011 guidelines were introduced (2011/2012) and five years later (2016/2017). They concluded that even after the introduction of specific LDL-C targets, these were still not reached in most patients. Over a five-year period, lipid-lowering therapy prescription only improved slightly. Thus, regardless of the presence of high cardiovascular risk, the rate of achievement of LDL-C targets is often unsatisfactory. Nowadays, with new, more demanding, guidelines and ambitious targets, aimed at ever younger people with lower cardiovascular risk, the challenge will be even more daunting.

In addition to the analysis of SCORE2 risk estimates, a more holistic, case-by-case assessment may be required, especially for individuals in whom certain factors may play a significant role in altering the absolute value of variables used in CVD risk calculators (e.g. taking lipid- or blood pressure-lowering agents, family history of CVD, chronic kidney disease or being part of at-risk socioeconomic and/or ethnic groups). Nevertheless, it is important to keep in mind that the goal of this study was to assess how the two scores perform in a real-life setting, and not just in individuals who are not yet taking medication to prevent cardiovascular disease.

Additionally, it should be noted that SCORE2 provides risk estimates for the combined outcome of both fatal and nonfatal CVD events, in contrast to SCORE's exclusive assessment of CVD mortality. As a result, more frequent categorization in higher risk brackets might be expected through SCORE2. At first glance this might seem like an ‘apples and oranges’ comparison, but for the clinician, it is of critical importance for the optimization of a patient's short- and long-term quality of life.

We were unable to exclude patients with left ventricular hypertrophy caused by hypertension or with documented significant (≥50%) plaque stenosis, both of which are among the ESC criteria for automatic classification into high and very high CVD risk categories, respectively, because this would have required an individual analysis of diagnostic imaging tests for each participant with hypertension and peripheral vascular disease. This may be considered a limitation of the study.

Our findings show that a significant number of patients in this cohort who would be classified by SCORE at lower risk levels were reclassified into higher risk categories with SCORE2. As a better overall tool and considering the practical repercussions, adoption of the SCORE2 scale in the Portuguese PHC system software would enable more accurate assessment of the CVD risk of a significant number of patients, particularly those in lower risk brackets. This is especially important in the PHC system, which is positioned on the frontlines of disease prevention, and particularly in Portugal, where the burden of CVD in negative outcomes is still overwhelming. While delving into this analysis, we also found that a large proportion of patients were above the desired LDL-C target for their category, even more so when using the more stringent SCORE2, which should and will have immediate practical effects in the healthcare units involved.

Therefore, we believe the clinical support software SClínico should be updated as soon as possible, replacing SCORE with SCORE2, which would enable more rigorous and reliable assessment of the cardiovascular risk of each individual. We consider this to be one of the most important preventive strategies that can be implemented in order to reduce long-term morbidity and mortality associated with CVD.

The authors have no conflicts of interest to declare.