Degree of Agreement between Cardiovascular Risk Stratification Tools

Garcia, Guilherme Thomé; Stamm, Ana Maria Nunes de Faria; Rosa, Ariel Córdova; Marasciulo, Antônio Carlos; Marasciulo, Rodrigo Conill; Battistella, Cristian; Remor, Alexandre Augusto de Costa

doi:10.5935/abc.20170057

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Original Articles, Epidemiology • Arq. Bras. Cardiol. 108 (5) • May 2017 • https://doi.org/10.5935/abc.20170057 copy

Degree of Agreement between Cardiovascular Risk Stratification Tools

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in Brazil, and primary prevention care may be guided by risk stratification tools. The Framingham (FRS) and QRISK-2 (QRS) risk scores estimate 10-year overall cardiovascular risk in asymptomatic individuals, but the instrument of choice may lead to different therapeutic strategies.

Objective:

To evaluate the degree of agreement between FRS and QRS in 10-year overall cardiovascular risk stratification in disease-free individuals.

Methods:

Cross-sectional, observational, descriptive and analytical study in a convenience sample of 74 individuals attending the outpatient care service of a university hospital in Brazil between January 2014 and January 2015. After application of FRS and QRS, patients were classified in low/moderate risk (< 20%) or high risk (≥ 20%).

Results:

The proportion of individuals classified as at high risk was higher in FRS than in QRS (33.7% vs 21.6%). A synergic effect of male gender with systemic arterial hypertension was observed in both tools, and with for geriatric age group in QRS (p < 0.05) in high-risk stratum. The Kappa index was 0.519 (95%CI = 0.386-0.652; p < 0.001) between both instruments.

Conclusion:

There was a moderate agreement between FRS and QRS in estimating 10-year overall cardiovascular risk. The risk scores used in this study can identify synergism between variables, and their behavior is influenced by the population in which it was derived. It is important to recognize the need for calibrating risk scores for the Brazilian population.

Keywords:
Cardiovascular Diseases / mortality; Cardiovascular Diseases / morbidity; Risk Assessment; Cardiovascular Diseases / epidemiology; Period Analysis

Score	Local/Studies on instrument derivation	Age	Gender	Variables	Outcomes	Risk
FRS, CVD in 10 years; 2 versions, FRS with lipid levels and FRS with BMI	8,491 participants, Framingham, Massachusetts, United Sates of America, 12 years of follow-up	30-74 years	Male and female	Age, gender, SAP, SAH treatment, TC, HDL-c, DM, smoking, BMI	10-year risk for AMI, coronary insufficiency, angina, ischemic stroke, hemorrhagic stroke, PAOD, heart failure	0-6% low; 6-20% moderate; ≥ 20% high
QRS, CVD in 10 years	2.3 million participants, QRESEARCH database (extracted from primary health care in the United Kingdom), 5.7 years of follow-up	25-84 years	Male and female	Age, gender, ethnics, zip code, smoking, DM, angina, family history of premature CAD in first-degree relative, CKD, AF, SAH treatment, RA, TC / HDL-c ratio, SAP, BMI	10-year risk for AMI, angina, CAD, stroke and TIS	0-10% low; 10‑20% moderate; ≥ 20% high risk

Continuous variables (n = 74)	Mean (± DP)
Age	53.2 (± 11.0)
SAP (mmHg)	141.52 (± 24.3)
BMI (kg/m²)	28.4 (± 5.0)
Continuous variables (n = 60)	Mean (± DP)
CT (mg/dl) ^* * 14 patients did not have recent lipid profile data;	195.46 (± 47.7)
HDL-c^* * 14 patients did not have recent lipid profile data;	52.0 (± 14.4)
Continuous variables (n = 64)	Mean (± DP)
Family income ^† † 10 patients did not declare their family income. SD: standard deviation; TC: total cholesterol; HDL-c: HDL – cholesterol; SAP: systemic arterial pressure; BMI: body mass index; SAH: systemic arterial hypertension.	2073.1 (± 1267.1)
Categorical variables (n = 74)	Total (%)
Elderly age range	21/74 (28.3)
Female gender	48/74 (64.8)
White race	68/74 (91.8)
Low educational attainment	57/74 (77.0)
Smoking	10/74 (13.5)
Elevated SAP	38/74 (51.3)
Elevated BMI	57/74 (77.0)
Treated SAH	35/74 (47.2)
Female	23/48 (47.9)
Male	12/26 (46.1)
Geriatric	13/21 (61.9)
Non-geriatric	22/53 (41.5)
Diabetes Mellitus	18/74 (24.3)
Female	8/48 (16.7)
Male	10/26 (38.5)
Geriatric	8/21 (38.1)
Non-geriatric	10/53 (18.9)
Categorical variables (n = 64)	Total (%)
High family income ^† † 10 patients did not declare their family income. SD: standard deviation; TC: total cholesterol; HDL-c: HDL – cholesterol; SAP: systemic arterial pressure; BMI: body mass index; SAH: systemic arterial hypertension.	37/64 (57.8)

Variables	High risk
Variables	Framingham (n = 25), %[n]	QRISK-2 (n = 16), % [n]
Age
Non-geriatric	48.0 [12]	31.3 [5]
Geriatric	52.0 [13]	68.6 [11]
Gender
Male	64.0 [16]	62.5 [10]
Female	36.0 [9]	37.5 [6]
Race
White	100 [25]	100.0 [16]
Non-white	0.0 [0]	0.0 [0]
Treated SAH
No	24.0 [6]	12.5 [2]
Yes	76.0 [19]	97.5 [14]
Family history of PCAD
No	72.0 [18]	62.5 [10]
Yes	28.0 [7]	37.5 [6]
Smoking
No	88.0 [22]	87.5 [14]
Yes	12.0 [3]	12.5 [2]
Diabetes Mellitus
No	52.0 [13]	68.8 [11]
Yes	48.0 [12]	31.3 [5]
SAP
Normal	24.0 [6]	25.0 [4]
Increased	76.0 [19]	75.0 [12]
BMI
Normal	16.0 [4]	18.8 [3]
Increased	84.0 [21]	81.3 [13]

Variables	Sample (%)[n = 74]	High risk
		Framingham		QRISK-2
		χ²	P^† † chi-squared test;	χ²	p^† † chi-squared test;
Age
Non-geriatric	71.6 [53]	10.36	0.001	16.37	< 0.001
Geriatric	28.4 [21]	10.36	0.001	16.37	< 0.001
Gender
Male	35.1 [26]	13.80	< 0.001	6.70	0.01
Female	64.9 [48]	13.80	< 0.001	6.70	0.01
Race
White	91.9 [68]	^†† †† variables not predicted by Framingham risk score; SAH: systemic arterial hypertension; PCAD: premature coronary artery disease in first‑degree relative; SAP: systemic arterial pressure; BMI: body mass index.	^†† †† variables not predicted by Framingham risk score; SAH: systemic arterial hypertension; PCAD: premature coronary artery disease in first‑degree relative; SAP: systemic arterial pressure; BMI: body mass index.	1.80	0.18
Non-white	8.1 [6]			1.80	0.18
Treated SAH
No	52.7 [39]	12.47	< 0.001	13.23	< 0.001
Yes	47.3 [35]	12.47	< 0.001	13.23	< 0.001
Family history of PCAD
No	20.3 [15]	^†† †† variables not predicted by Framingham risk score; SAH: systemic arterial hypertension; PCAD: premature coronary artery disease in first‑degree relative; SAP: systemic arterial pressure; BMI: body mass index.	^†† †† variables not predicted by Framingham risk score; SAH: systemic arterial hypertension; PCAD: premature coronary artery disease in first‑degree relative; SAP: systemic arterial pressure; BMI: body mass index.	3.75	0.53
Yes	79.7 [59]			3.75	0.53
Smoking
No	86.5 [64]	0.74	0.78	0.18	0.89
Yes	13.5 [10]	0.74	0.78	0.18	0.89
Diabetes Mellitus
No	75.7 [56]	15.71	< 0.001	21.88	< 0.001
Yes	24.3 [18]	15.71	< 0.001	21.88	< 0.001
SAP
Normal	48.6 [36]	9.18	0.002	4.57	0.03
Increased	51.4 [38]	9.18	0.002	4.57	0.03
BMI
Normal	23.0 [17]	1.03	0.30	0.20	0.65
Increased	77.0 [57]	1.03	0.30	0.20	0.65

Variables	Score
	Framingham			Q-RISK 2
	OR	95%CI	p^* * Logistic regression analysis; OR: odds ratio; CI: confidence interval; SAH: systemic arterial hypertension; SAP: systolic arterial pressure.	OR	95%CI	p^* * Logistic regression analysis; OR: odds ratio; CI: confidence interval; SAH: systemic arterial hypertension; SAP: systolic arterial pressure.
Low/Moderate vs. high risk
Male gender	6.93	2.37-20.25	< 0.001	4.37	1.365-14.02	0.013
Geriatric age range	5.55	1.86-16.52	0.002	10.56	3.002-37.14	< 0.001
Treated SAH	6.53	2.18-19.52	0.001	12.33	2.552-59.60	0.002
Increased SAP	5.00	1.69-14.76	0.004	3.69	1.064-12.81	0.04
Diabetes mellitus	9.53	2.83-32.06	< 0.001	16.03	4.283-59.98	< 0.001

Variables	Score
	Framingham			Q-RISK 2
	OR	IC 95%	p^* * Logistic regression analysis;	OR	IC 95%	p^* * Logistic regression analysis;
Low/Moderate vs. High risk
Male gender	14.25	2.65-76.74	0.002	9.56	1.27-71.78	0.028
Geriatric age range	4.74	1.19-18.89	0.028	19.58	2.69-142.78	0.003
Treated SAH	10.79	1.88-61.88	0.008	19.22	1.76-210.41	0.015
Increased SAP^† † increased SAP was removed from the model; OR: odds ratio; SAH: systemic arterial hypertension; SAP: systemic arterial pressure; CI: confidence interval.	-	-	-	-	-	-
Diabetes mellitus	3.52	0.81-15.26	0.092	9.98	1.58-62.98	0.014

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