The new European SCORE2 risk model for cardiovascular events and the lipidological experiences of the related ESC guideline
MHEK Honvédkórház, II. sz. Belgyógyászati Osztály, Budapest
SCORE1, published in 2003, was the first cardiovascular disease (CVD) risk prediction algorithm based on European data, which was a significant step in primary prevention for identification of individuals at higher risk. Age- and sex-specific mean risk factor levels (total cholesterol, systolic blood pressure, and smoking) used for the estimation of 10-year fatal CVD risk. SCORE1 includes only fatal CVD outcomes, meaning it underestimates total CVD burden.
The new SCORE2 model released in 2021 addressed the limitations and at the same time extended the values to the 70–89 age groups and to non-HDL cholesterol values. The magnitude of the risk according to age was divided into three degrees of severity (low-to-moderate, high, and very high) Furthermore, the European countries were classified into four risk groups according to CVD mortality and a specific recalibration of their own national CVD incidents rate was carried out. Hungary was placed in the middle part of the high-risk block.
The lipidological profile of the 2021 ESC CVD guideline, which is based on the SCORE2, states that statin treatment can be given in primary prevention in cases of high and very high risk according to the evidence classification I, IIa and IIb, and the goal in the first step is an LDL cholesterol level of 2.6 mmol/l. If the risk status worsens, it may be justified to reach 1.8 or 1.4 mmol/l values.
Two studies conducted in low-risk populations analyzed the practical benefits of the new recommendation described. In a French study the cardiovascular risk category of individuals admitted for first STEMI was evaluated to assess whether they would have been eligible for primary prevention statins. According to the new recommendation it was 61.8%, whereas 38.7% in 2019, and 23.6% in 2016 guidelines. It means a more extensive detection and treatment of individuals at risk for first myocardial infarction. The other is a Danish analysis with a large number of cases, where all CV events were followed. Based on their assessment, the proportion of those in need of statin treatment is low (19%), which is in contradiction with other Danish cohort results, as well as data from American and British risk assessment systems. Nevertheless, the authors agree with the broad professional opinion that the SCORE2 model is a better risk assessment program than SCORE1, since it also includes non-fatal CV events, is a national calibrated form and more reliably indicates the probability of the occurrence of CV events.