How to calculate vascular age with the SCORE risk evaluation

CLINICAL RESEARCH
European Heart Journal (2010) 31, 2351–2358
doi:10.1093/eurheartj/ehq205
Prevention and epidemiology
How to calculate vascular age with the SCORE
project scales: a new method of cardiovascular
risk evaluation
Jose´ I. Cuende 1*, Natividad Cuende 2, and Javier Calaveras-Lagartos 3
1
Department of Internal Medicine, Complejo Asistencial de Palencia, Avda. Donantes de Sangre s/n, 34005 Palencia, Spain; 2Andalusian Initiative for Advanced Therapies, Junta de
Andalucı´a, Seville, Spain; and 3Primary Health Service, Palencia, Spain
Received 14 February 2010; revised 11 May 2010; accepted 25 May 2010; online publish-ahead-of-print 28 June 2010
In 2008, a new cardiovascular risk table from the Framingham Heart Study was published, which incorporated the
new concept ‘vascular age’. The aim of the present study was to determine the vascular age calculated from the
two SCORE project scales and to determine the degree of agreement in vascular age between the two scales.
.....................................................................................................................................................................................
Methods
Vascular age was calculated according to its definition, but using the SCORE scale equations (for low- and high-risk
and results
countries) instead of the Framingham equations. Vascular age calculations were obtained covering all the absolute risk
values in the SCORE charts, obtaining results of vascular age beyond 65 years of age. To determine the degree of
agreement between vascular age calculated with the two SCORE scales (for high- and low-risk countries), the intraclass correlation coefficient was calculated. Of the 400 boxes in the SCORE charts, the vascular age differed between
high- and low-risk countries by 1 year or less in 347 boxes (86.75%). In just six boxes (1.5%), the difference was
3 years. Agreement between the scales was very high, as demonstrated by their intraclass correlation coefficient
of 0.997.
.....................................................................................................................................................................................
Conclusion
Vascular age is a new concept derived from Framingham risk tables that can be calculated with other risk scales, like
SCORE. Agreement of vascular age calculated from the SCORE equations for high- and low-risk countries was extremely high, in contrast to the poor agreement in absolute risk.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Vascular age † SCORE † Agreement
Introduction
According to the WHO, cardiovascular diseases (CVD) are the
leading cause of death on the European continent,1 accounting
for 44% of all deaths in men and 57% in women in 2004. CVD
are responsible for 4.7 million deaths annually in Europe,2 with
over 2 million deaths in the European Union in 2008.3 CVD are
also responsible for a very important health-care problem in
terms of both direct economic costs as well as social repercussions
resulting from incapacity, causing direct costs of over 100 000
million Euros yearly in the European Union.3
As a cause of CVD, cardiovascular risk factors have a high prevalence in our setting, and whilst some factors have been reduced,
such as smoking, the prevalence of others, such as diabetes and
obesity, is increasing.3 Additionally, the degree of control of the
various cardiovascular risk factors is very low, in both the
primary care and the specialized care settings.4
Clinical care guidelines for the management of patients with cardiovascular risk factors currently require the measurement of cardiovascular risk as the starting point to establish therapeutic aims
and treatment strategies.5,6 The Third and Fourth Joint European
Task Forces on Cardiovascular Prevention established the
SCORE system7 as the instrument to quantify the absolute
cardiovascular risk.6,8 The level of risk is used to determine the
objectives for control of the various risk factors and the need or
otherwise for pharmacological intervention, in addition to lifestyle
measures.
Therapeutic strategies based on cardiovascular risk afford the
same or greater benefits than strategies based on the isolated
control of each individual risk factor, as well as being cheaper.9
* Corresponding author. Tel: +34 658 525 502, Fax: +34 979 167 014, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: [email protected]
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Aims
2352
Methods
Vascular age was calculated according to the definition of D’Agostino
in the tables from the 2008 FHS,12 who defined the vascular age of a
person as the age a person would be with the same calculated cardiovascular risk but whose risk factors were all within normal ranges, i.e.
with a risk solely due to age and gender. The risk factors considered
were age, gender, smoking, total cholesterol (T-Chol) level, systolic
blood pressure (SBP) and diabetes.
The FHS defines 10-year absolute CVD risk as the risk at 10 years of
suffering a CVD, defined as a composite of coronary heart disease
(coronary death, myocardial infarction, coronary insufficiency and
angina), cerebrovascular events (including ischaemic stroke, haemorrhagic stroke and transient ischaemic attack), peripheral artery
disease (intermittent claudication) and heart failure. To calculate this
CVD risk, FHS evaluated 8941 participants (4522 women) from
original and offspring cohorts with a maximum follow-up period of
12 years.
Unlike the FHS, the SCORE project calculates 10-year fatal CVD
risk as the probability of cardiovascular death. With this aim, the
SCORE project assembled a pool of databases from 12 European
cohort studies (Finland, Russia, Norway, British region, Scotland,
Denmark, Sweden and Germany [for high-risk countries], and
Belgium, Italy, France and Spain [for low-risk countries]), mainly relating to the general population. The total involved 205 178 persons
(88 080 women) representing 2.7 million person-years of follow-up.
There were 7934 cardiovascular deaths, of which 5652 were deaths
from coronary heart disease. The risk factors considered by the
SCORE project were age, gender, smoking, and T-Chol and SBP levels.
We calculated vascular age from SCORE project equations for
different situations of the combination of age, gender, smoking, and
T-Chol and SBP levels (as can be seen in the SCORE project tables).
We considered 120 mmHg as a normal pressure because it is the
limit between normal and optimal SBP according to the 2007 Guidelines for the Management of Arterial Hypertension by the European
Societies5 and the Fourth Joint Task Force on Cardiovascular
Disease Prevention.6 The normal level of T-Chol was established at
5 mmol/L (190 mg/dL) as this is the high limit of normality established
by the Fourth Joint European Task Force.
Data on diabetes were not collected uniformly in the SCORE study
cohorts, so we decided not to include a dichotomous diabetes variable
in the risk equations and suggest that among persons with clinically
established type 2 diabetes, the increase in CVD risk is at least
2-fold in men and even higher, as much as 4-fold, in women.7
The risk of fatal CVD was calculated according to the SCORE
project with the risk factors controlled for each combination of age
and gender. The mathematical equations used to calculate the risk
were the originally published equations7 and the risk was calculated
for low-risk countries and high-risk countries. The calculations were
extended beyond the age of 65 years to cover the highest risks in
the fatal CVD tables of the SCORE project.
The data on vascular age are presented as tables in order to be able
to use them in combination with the risk tables of fatal CVD. The data
are also presented as charts relating vascular age with cardiovascular
risk. Colour tables were also created for vascular age, similar to the
SCORE tables, to be able to use them directly with the data from
each patient, such that with the data on cardiovascular risk factors
we can calculate the vascular age directly.
To determine the degree of agreement between vascular age calculated with the two SCORE scales (for high- and low-risk countries),
the difference in vascular age between both scales was calculated for
each situation of age, gender, smoking, T-Chol and SBP, as well as
the intraclass correlation coefficient. Finally, the regression line was calculated between the two vascular ages. The statistical calculations
were made with SPSS 15.0.
Results
Table 1 shows the vascular age corresponding to each absolute risk
value calculated with the risk equations for high-risk countries, for
both men and women. Table 2 shows the same information for
low-risk countries.
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One of the limitations of any system that estimates risk, and in
particular the SCORE system, is that when it is applied to
middle-aged persons to calculate the absolute risk, this is not
high even though their relative risk may be high. This situation
can lead to no preventive or therapeutic decisions being taken in
these persons. Accordingly, the Third Joint European Task
Force8 recommended extrapolating the risk for the age of
60 years, though the literal application of this recommendation
may result in pharmacological overtreatment in these persons.6
The Fourth Joint Task Force recommended the use of the relative
risk together with the absolute risk, although no cut point was
established above which the relative risk is considered high.6
Another alternative to solve this limitation is the use of percentiles
of cardiovascular risk to place each person within the context of
risk for persons of the same age and gender.10
Among other physician-patient aspects, the Fourth Task Force
established that preventive measures should be based on a patientcentred approach, where the therapeutic decisions are taken in
collaboration with the patient in order for the patient to assume
them personally and where an evaluation is made of how to communicate the risk.6
In addition to the SCORE system, based on a European population, many other methods exist to quantify cardiovascular risk,
most originating with the Framingham Heart Study (FHS),11
started in 1948, and based on an American population, whose
overall risk is higher than that of Europeans. In 2008, as a result
of the Framingham study, cardiovascular risk tables were published,12 which incorporated a new concept: the age of the heart
or the vascular age, i.e. the age of the vascular system of a
patient with different cardiovascular risk factors. This age is calculated as the age a person would be with the same calculated cardiovascular risk but whose risk factors were all within normal
ranges.
Absolute cardiovascular risk is a statistical and epidemiological
concept that many patients may find difficult to understand.
However, the concept of vascular age as the age of the arteries
is a concept related to risk that might be more easily understood
by all patients. The use of vascular age may thus help the physician
explain the risk status of the patient and therefore improve patient
compliance with therapeutic decisions.
The aim of this study was to determine the vascular age calculated from a different scale to that of the original 2008 Framingham
scale, i.e. with the two SCORE project scales (for high- and
low-risk European countries) and to determine whether vascular
age is similar with the two SCORE scales.
J.I. Cuende et al.
2353
How to calculate vascular age with the SCORE project scales
Table 1 Vascular age according to the 10-year risk
of fatal cardiovascular disease in the SCORE project
for high-risk countries, according to gender
Risk score (%)
.........................................
Vascular age
Table 1 Continued
Risk score (%)
.........................................
Women
0.06
0.40
40
17.30
0.08
0.10
0.46
0.53
41
42
≥18.51
0.11
0.61
43
0.14
0.16
0.69
0.78
44
45
0.19
0.88
46
0.23
0.27
0.99
1.11
47
48
0.31
1.24
49
0.36
0.42
1.39
1.54
50
51
Risk score (%)
0.48
1.71
52
Women
0.55
0.63
1.88
2.08
53
54
0.72
2.28
55
0.81
0.92
2.50
2.74
56
57
1.04
2.99
58
1.18
1.32
3.26
3.55
59
60
1.48
3.86
1.66
1.85
2.06
20.62
21.70
87
88
22.80
89
≥23.95
≥90
Table 2 Vascular age according to the 10-year risk
of fatal cardiovascular disease in the SCORE project
for low-risk countries, according to gender
.........................................
Vascular age
Men
................................................................................
0.04
0.05
0.20
0.23
40
41
0.06
0.27
42
0.07
0.08
0.30
0.35
43
44
0.10
0.40
45
61
0.12
0.14
0.45
0.51
46
47
4.18
62
0.17
0.57
48
4.53
4.89
63
64
0.20
0.23
0.64
0.72
49
50
2.29
5.28
65
0.27
0.81
51
2.54
2.81
5.69
6.12
66
67
0.31
0.36
0.90
1.00
52
53
3.10
6.57
68
0.41
1.10
54
3.42
3.76
7.05
7.55
69
70
0.47
0.54
1.22
1.34
55
56
4.13
8.08
71
0.61
1.48
57
4.52
4.95
8.64
9.22
72
73
0.69
0.78
1.62
1.77
58
59
5.41
9.83
74
0.88
1.94
60
5.90
6.43
10.47
11.14
75
76
0.99
2.12
61
7.00
11.84
77
1.12
1.25
2.31
2.51
62
63
7.60
8.24
12.57
13.33
78
79
1.40
2.72
64
8.93
14.12
80
1.56
1.74
2.95
3.19
65
66
9.66
10.43
14.95
15.81
81
82
1.93
3.45
67
11.25
16.70
83
2.14
2.36
3.72
4.01
68
69
12.13
13.05
17.63
18.59
84
85
2.61
4.31
70
14.03
19.59
86
2.88
3.16
4.63
4.97
71
72
Continued
Continued
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15.06
16.15
Men
Men
................................................................................
................................................................................
Women
Vascular age
2354
J.I. Cuende et al.
Table 2 Continued
Risk score (%)
.........................................
Women
Vascular age
Men
................................................................................
3.47
3.81
5.33
5.71
73
74
4.17
6.11
75
4.56
4.98
6.52
6.96
76
77
5.42
7.42
78
5.90
7.90
79
6.41
6.96
8.41
8.94
80
81
9.49
82
8.17
8.83
10.07
10.67
83
84
9.53
11.30
85
10.28
11.07
11.96
12.65
86
87
11.91
13.36
88
14.10
≥14.87
89
≥90
12.80
≥13.74
The data from each table were used to create Figures 1 and 2,
which clearly show how vascular age increases with the increase
in absolute risk, for both men and women and in both high- and
low-cardiovascular-risk countries. The figures also show that the
risk did not have a linear relation with age, but rather that the
increase in risk was greater the older the person, with an almost
exponential relation.
These charts can be used together with the classical colour
tables for cardiovascular risk from the SCORE project. Figure 3
shows an example of this possibility: if we consider a non-diabetic
50-year-old man living in a low-risk country who smokes, has a SBP
of 160 mmHg and a T-Chol level of 7 mmol/L, we can calculate his
absolute risk to be 4%. With the new figure we can see that this
corresponds to a vascular age of 69 years (Figure 3).
Figures 4 and 5, for high- and low-risk countries, show the vascular age using the format of the original absolute risk tables, in
which each box corresponds to a particular gender, age, smoking
status, SBP level and T-Chol concentration. The vascular age calculations were extended beyond 65 years of age, thereby covering all the absolute risk values for men and women in the SCORE
tables for high- and low-risk countries. In these new figures, the
colour of each box corresponds to the original absolute risk and
the number of each box corresponds to vascular age, grouping
together in the same table the information for absolute risk
and vascular age.
To analyze the differences in vascular age for the same T-Chol
concentration, systolic blood pressure, age, gender and smoking
status between the tables for the high- and the low-risk countries,
we provide a new table with the differences in the corresponding
boxes of the two tables for vascular age (Figure 6). Of the 400
boxes, 347 (86.75%) differed by 1 year or less, 47 (11.75%) by
Figure 1 Vascular age in men and women according to the
absolute risk of fatal cardiovascular disease in the SCORE
project for high-risk countries.
Figure 2 Vascular age in men and women according to the
absolute risk of fatal cardiovascular disease in the SCORE
project for low-risk countries.
2 years and 6 (1.5%) by 3 years. The intraclass correlation coefficient was 0.997.
Figure 7 shows the regression line analysis. The Pearson correlation coefficient was 0.999, with a line determined by the
equation: (vascular age in low-risk countries) ¼ 1.496 + 0.967 ×
(vascular age in high-risk countries).
Discussion
In this study, we present the calculation of vascular age with a
different cardiovascular risk evaluation scale from the original
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7.54
How to calculate vascular age with the SCORE project scales
2355
Figure 4 Colour table of vascular age. Each box contains a number corresponding to vascular age and a colour corresponding to the overall
absolute risk of fatal cardiovascular disease according to the SCORE project for high-risk countries. SBP, systolic blood pressure.
scale that gave rise to the concept, in such a way as to be able to
extend the use of vascular age together with the scale most used in
Europe. A review of the literature shows this to be the first time
that vascular age has been extended for use with other scales
apart from the original 2008 Framingham model,12 and its use
with the SCORE project is therefore new.
Cardiovascular risk evaluation is an imprecise tool, not only
because the result is a higher or lower populational probability
of presenting a cardiovascular event, but also no adequate
agreement exists between the various different systems for stratifying or calculating the risk.13,14 This lack of agreement is due,
among other reasons, to the various underlying mathematical
models used to evaluate cardiovascular risk, e.g. the Cox proportional hazards model in the Framingham study or the Weibull
model in the SCORE project, the different event-defining variables
(coronary heart disease in most Framingham-based systems, cardiovascular death in the SCORE project), different variables introduced into the models and different baseline study populations
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Figure 3 Example of the use of the vascular age chart for a non-diabetic 50-year-old male smoker with systolic blood pressure of 160 mmHg
and total cholesterol of 7 mmol/L. Absolute risk: 4%; vascular age: 69 years. Tables for low-risk countries (modified with permission from
Conroy RM7).
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J.I. Cuende et al.
Figure 6 Differences in calculated vascular age between the two vascular risk models of the SCORE project for high- and low-risk countries.
SBP, systolic blood pressure.
used to calculate the scores. This last factor is of particular importance, because it means that application of a risk evaluation system
to a different population from the original study population
requires recalibrating the model,15 or, as with the SCORE
project, starting from two models, one for countries with a high
cardiovascular risk and another for countries with a low cardiovascular risk.
An important limitation of the use of the SCORE system to
evaluate the risk concerns the effect of age. Middle-aged persons
do not have a high risk even though their risk factors may be
high, whereas older persons have a high risk with just slight
increases in their risk factors. A 40-year-old man, even if he
smokes, has a SBP of 180 mmHg and a T-Chol of 8 mmol/L, still
only has an overall risk of cardiovascular death of less than 5%,
whether he lives in a high-risk country (4%) or low-risk country
(2%). A 65-year-old man from a high-risk country, however, who
does not smoke, has a SBP of 140 mmHg and a T-Chol of
4 mmol/L nevertheless has a risk of 6%, which is high. In order
to palliate this effect in middle-aged persons the use of the relative
risk has been suggested,6 though no consensus has yet been
reached about a cut point to define the relative risk as high.
Another alternative is the application of risk percentiles,10 which
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Figure 5 Colour table of vascular age. Each box contains a number corresponding to vascular age and a colour corresponding to the overall
absolute risk of fatal cardiovascular disease according to the SCORE project for low-risk countries. SBP, systolic blood pressure.
How to calculate vascular age with the SCORE project scales
places each person within the context of the risk for persons of
similar age and gender, thereby enabling identification of those
persons at greater risk for their age, at the same time as it
improves the agreement between risk calculation systems.16
Another limitation of the use of cardiovascular risk is that it is
not clear that all patients understand what a high risk represents
in terms of a high likelihood of having a cardiovascular event,
which makes it more difficult to communicate this risk. Patients
tend to respond to the risk more according to their emotions
than facts, overestimating low risks and underestimating common
risks.17 CVD are very common, and patients may underestimate
the information received concerning their own cardiovascular
risk. Although patients are aware that lifestyle modification may
considerably reduce their cardiovascular risk, they still maintain
unhealthy lifestyles. For instance, four of every five persons in
North America lead lifestyles that place them at an increased
risk for coronary and cerebral ischaemic events.18 Identifying a
risk as ‘natural’ is common, which may explain why patients fail
to take sufficiently seriously their own cardiovascular risk, which
they may partly be able to control, whereas they worry about
other ‘unnatural’ risks, which they cannot control, even though
the risk may be almost nil, like living near electricity power stations
or mobile telephone antennas. Patients also respond very differently according to how risk is presented, for instance relative
reduction in risk, absolute reduction or number necessary to
treat.19
The use of vascular age with the data presented here may be a
very useful tool in the management of patients with cardiovascular
risk factors. The concept of vascular age may be a more reasonable
concept for the patient than that of risk, and the patient may thus
be able to understand what a particular risk means in terms of life.
It therefore represents a valuable instrument to enable patients to
assimilate their situation and thus be more likely to comply with
therapeutic measures. The 40-year-old male smoker with high
blood pressure and high cholesterol, whose risk was lower than
5%, has a vascular age of 63 years. This patient can thus understand
that despite not having a high absolute risk, his risk factors make
him 23 years older from the vascular point of view. Although
the aim of this study was not to show that the concept of vascular
age is easier to understand than absolute or relative risk, age would
seem to be a more natural concept to comprehend than risk.
Notably, the agreement in vascular age between the two
SCORE project scales was almost total. Whichever scale we use,
the result in terms of vascular age is practically the same. This
agreement permits the use of either scale in all European
countries. This finding is completely new. The absolute risk
differs greatly according to whether we use the SCORE tables
for high- or low-risk countries,7 but vascular age is the same.
This very high level of agreement was demonstrated by an extraordinarily high intraclass correlation coefficient of 0.997. The
great majority, 86.75%, of the different situations of the combination of age, gender, smoking, T-Chol level and SBP differed by
no more than 1 year when vascular age was compared between
the two SCORE scales. The most discordant values were found
in the boxes corresponding to the highest vascular age. The
1.5% of cases where vascular age differed by 3 years showed vascular age to be 30 or nearly 40 years greater than biological age.
Thus, the clinical importance of this difference is low.
Analysis according to gender showed a greater agreement for
women, as in no case there was a difference of 3 years between
the vascular ages calculated with the two scales. In men the agreement was still very high and the differences of 3 years were found
in situations where the SBP and the T-Chol level were both high,
with a T-Chol level of 8 mmol/L or SBP of 180 mmHg, situations
associated with a high cardiovascular risk.
The presentation of vascular age in the form of a coloured chart,
similar to that presenting the absolute risk in the SCORE project,7
besides using a conversion table between absolute risk and vascular age, enables both the physician and the patient to evaluate the
absolute risk and vascular age rapidly.
To obtain all vascular ages we used the equations of the SCORE
project beyond 65 years, which is the maximum biological age in
the SCORE tables. This may therefore represent an over- or
under-estimation of cardiovascular risk. Nevertheless, this calculation was not done to determine the risk in persons older than
65 years of age, but rather to determine the vascular age of
persons up to the age of 65 years with a high cardiovascular
risk. Even if an error occurred in the evaluation of risk with this
group of persons, the main usefulness of the vascular age
tables is to help the patients understand that their particular cardiovascular risk factors make their vascular age much higher than
their actual biological age, thus retaining their invaluable benefit
in patient care.
In summary, we can state that we are able to obtain much more
information from the calculation of the absolute risk with the
SCORE project tables. The application of the concept of vascular
age provides a new use for the risk tables that might be more practical for both the patient and the physician, and its use can even be
encouraged among middle-aged persons, for whom there were no
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Figure 7 Correlation between vascular age calculated with the
equations for high-risk countries (VAhigh) and for low-risk
countries (VAlow).
2357
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satisfactory solutions for the problems associated with the evaluation of absolute risk. The second main finding of this study is
that the agreement in vascular age between the two SCORE
project scales was almost total. Vascular age may be a practical
instrument for patient health education and favour patient compliance concerning cardiovascular status.
Conflict of interest: none declared.
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