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Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2
Open accessAbstract
OBJECTIVE: To develop and validate version two of the QRISK cardiovascular disease risk algorithm (QRISK2) to provide accurate estimates of cardiovascular risk in patients from different ethnic groups in England and Wales and to compare its performance with the modified version of Framingham score recommended by the National Institute for Health and Clinical Excellence (NICE). DESIGN: Prospective open cohort study with routinely collected data from general practice, 1 January 1993 to 31 March 2008. SETTING: 531 practices in England and Wales contributing to the national QRESEARCH database. PARTICIPANTS: 2.3 million patients aged 35-74 (over 16 million person years) with 140,000 cardiovascular events. Overall population (derivation and validation cohorts) comprised 2.22 million people who were white or whose ethnic group was not recorded, 22,013 south Asian, 11,595 black African, 10,402 black Caribbean, and 19,792 from Chinese or other Asian or other ethnic groups. MAIN OUTCOME MEASURES: First (incident) diagnosis of cardiovascular disease (coronary heart disease, stroke, and transient ischaemic attack) recorded in general practice records or linked Office for National Statistics death certificates. Risk factors included self assigned ethnicity, age, sex, smoking status, systolic blood pressure, ratio of total serum cholesterol:high density lipoprotein cholesterol, body mass index, family history of coronary heart disease in first degree relative under 60 years, Townsend deprivation score, treated hypertension, type 2 diabetes, renal disease, atrial fibrillation, and rheumatoid arthritis. RESULTS: The validation statistics indicated that QRISK2 had improved discrimination and calibration compared with the modified Framingham score. The QRISK2 algorithm explained 43% of the variation in women and 38% in men compared with 39% and 35%, respectively, by the modified Framingham score. Of the 112,156 patients classified as high risk (that is, >or=20% risk over 10 years) by the modified Framingham score, 46,094 (41.1%) would be reclassified at low risk with QRISK2. The 10 year observed risk among these reclassified patients was 16.6% (95% confidence interval 16.1% to 17.0%)-that is, below the 20% treatment threshold. Of the 78 024 patients classified at high risk on QRISK2, 11,962 (15.3%) would be reclassified at low risk by the modified Framingham score. The 10 year observed risk among these patients was 23.3% (22.2% to 24.4%)-that is, above the 20% threshold. In the validation cohort, the annual incidence rate of cardiovascular events among those with a QRISK2 score of >or=20% was 30.6 per 1000 person years (29.8 to 31.5) for women and 32.5 per 1000 person years (31.9 to 33.1) for men. The corresponding figures for the modified Framingham equation were 25.7 per 1000 person years (25.0 to 26.3) for women and 26.4 (26.0 to 26.8) for men). At the 20% threshold, the population identified by QRISK2 was at higher risk of a CV event than the population identified by the Framingham score. CONCLUSIONS: Incorporating ethnicity, deprivation, and other clinical conditions into the QRISK2 algorithm for risk of cardiovascular disease improves the accuracy of identification of those at high risk in a nationally representative population. At the 20% threshold, QRISK2 is likely to be a more efficient and equitable tool for treatment decisions for the primary prevention of cardiovascular disease. As the validation was performed in a similar population to the population from which the algorithm was derived, it potentially has a "home advantage." Further validation in other populations is therefore advised.
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“Many risk assessment systems are available and have been comprehensively reviewed, including different Framingham models, 41 Systemic Coronary Risk Estimation (SCORE), 42 ASSIGN (CV risk estimation model from the Scottish Intercollegiate Guidelines Network), 43 Q-Risk, 44 Prospective Cardiovascular Munster Study (PROCAM), 45 Reynolds, 46,47 CUORE, 48 the Pooled Cohort equations 49 and Globorisk. 5”
From 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias (2016) · cites this paper as [44]
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3-year risk prediction of Coronary Heart Disease in hypertension patients: A preliminary study
Chen, R., Yang, Y., Miao, F., Cai, Y., Lin, D., Zheng, J., & Li, Y. (2017) · Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) · doi:10.1109/embc.2017.8037041 · Cited by 17
“Multiple studies indicated that an elevated triglycerides, low-density lipoprotein cholesterol (LDL-C), or TC would contribute greatly to a higher risk of CHD [9,10,16-19].”
BackgroundInfluentialGenome-Wide Association Studies and Risk Scores for Coronary Artery Disease: Sex Biases
Byars, S., & Inouye, M. (2018) · Advances in experimental medicine and biology · doi:10.1007/978-3-319-77932-4_38 · Cited by 16
Betts, M. B., Milev, S., Hoog, M. M., Jung, H., Milenković, D., Qian, Y., Tai, M., Kutikova, L., Villa, G., & Edwards, C. (2018) · Value in Health · doi:10.1016/j.jval.2018.08.003 · Cited by 16
Multi‐domain analysis of microvascular flow motion dynamics in NAFLD
Chipperfield, A. J., Thanaj, M., Scorletti, E., Byrne, C. D., & Clough, G. F. (2019) · Microcirculation · doi:10.1111/micc.12538 · Cited by 16
Stenling, A., Häggström, C., Norberg, M., & Norström, F. (2020) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2020.08.014 · Cited by 16
Electronic Health Record Technology
Cresswell, K. M., & Sheikh, A. (2012) · JAMA · doi:10.1001/jama.2012.3520 · Cited by 15
Self-citationArnold, N., Rehm, M., Büchele, G., Peter, R. S., Brenner, R. E., Günther, K., Brenner, H., Köenig, W., & Rothenbacher, D. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9103107 · Cited by 15
Martins, T., Walter, F. M., Penfold, C., Abel, G., & Hamilton, W. T. (2021) · European Journal of Cancer Care · doi:10.1111/ecc.13482 · Cited by 17
Hypertension mediated kidney and cardiovascular damage and risk stratification: Redefining concepts
Márquez, D. F., Rodríguez‐Sánchez, E., Segura, J., Ruilope, L. M., & Ruiz‐Hurtado, G. (2022) · Nefrología (English Edition) · doi:10.1016/j.nefroe.2021.10.008 · Cited by 18
Remfry, E., Ardissino, M., McCracken, C., Szabó, L. E., Neubauer, S., Harvey, N. C., Mamas, M. A., Robson, J. P., Petersen, S. E., & Raisi‐Estabragh, Z. (2023) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcad029 · Cited by 15
“Lower socioeconomic status (SES) is known to be associated with CVD, 33 although in a previous study on the UK Biobank no sex difference was found.”
Self-citationEvidence supporting the choice of a new cardiovascular risk equation for Australia
Brown, S., Banks, E., Woodward, M., Raffoul, N., Jennings, G., & Paige, E. (2023) · The Medical Journal of Australia · doi:10.5694/mja2.52052 · Cited by 15
Urbut, S., Yeung, M., Khurshid, S., Cho, S. J., Schuermans, A., German, J., Taraszka, K., Paruchuri, K., Fahed, A., Ellinor, P., et al. (2024) · Nature Communications · doi:10.1038/s41467-024-49296-9 · Cited by 16
“Existingscores 26,39 implythatthelevelsofcovariateswillstay fi xedover the life course or require recalculation, which ignores the information within transitions through the life course.”
Overview of cardiac toxicity from radiation therapy
Chin, V., Finnegan, R., Keall, P., Otton, J. M., Delaney, G. P., & Vinod, S. K. (2024) · Journal of Medical Imaging and Radiation Oncology · doi:10.1111/1754-9485.13757 · Cited by 15
Begh, R. A., Aveyard, P. N., Upton, P., Bhopal, R. S., White, M. J., Amos, A., Prescott, R. J., Bedi, R., Barton, P. M., Fletcher, M. J., et al. (2011) · BMC Public Health · doi:10.1186/1471-2458-11-452 · Cited by 16
Self-citationJi, J., Pan, E., Li, J., Chen, J., Cao, J., Sun, D., Lu, X., Chen, S., Gu, D., Duan, X., et al. (2011) · BMC Public Health · doi:10.1186/1471-2458-11-497 · Cited by 15
Consensus statement on the management of dyslipidemia in Indian subjects: A different perspective
Enas, E. A., Dharmarajan, T. S., & Varkey, B. (2015) · Indian Heart Journal · doi:10.1016/j.ihj.2015.03.020 · Cited by 16
“(such as angina and transient ischemic attack).(41,42) As result,”
BackgroundAhmed, A. A., Alsharief, E., & Alsharief, A. (2013) · Diabetes & Metabolic Syndrome Clinical Research & Reviews · doi:10.1016/j.dsx.2013.06.012 · Cited by 15
Carotid Intima-media Thickness Determined Vascular Age and the Framingham Risk Score
Adolphe, A., Huang, X., & Cook, L. S. (2011) · Critical Pathways in Cardiology A Journal of Evidence-Based Medicine · doi:10.1097/hpc.0b013e31823a31f0 · Cited by 15
Zambon, A., Arfè, A., Corrao, G., & Zanchetti, A. (2013) · Journal of Hypertension · doi:10.1097/hjh.0000000000000077 · Cited by 15
“Unauth Journal of Hypertension the full guideline [13], in which they find a comparison of the Framingham, ASSIGN and QRISK scores applied to a large UK population, the results of which appear to favour QRISK [14], which defines cardiovascular outcomes as myocardial infarction, coronary heart disease, stroke and trans…”
ResultNovel biomarkers with potential for cardiovascular risk reclassification
Mallikethi‐Reddy, S., Briasoulis, Α., Akintoye, E. O., & Afonso, L. (2016) · Biomarkers · doi:10.1080/1354750x.2016.1201540 · Cited by 16
“The QRISK2 score added variables such as diabetes, chronic renal disease, atrial fibrillation, ethnicity and socioeconomic status to the modified Framingham/ATP III model, and accurately predicted cardiovascular risk in different ethnic groups from England and Wales (Hippisley-Cox et al., 2008).”
MethodHu, W., Lee, J. H., Tsai, M., & Wen, C.-P. (2017) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2017.07.016 · Cited by 14
Stevens, S., McManus, R. J., & Stevens, R. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-020589 · Cited by 15
“In particular, the recommended cardiovascular risk calculator in the UK, QRISK2 15 was derived using such data.”
MethodSwainson, M. G., Ingle, L., & Carroll, S. (2019) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.13468 · Cited by 15
“UK clinical practice is now routinely adopting the QRISK prediction model, a UK-specific and validated predictor of 10-year CVD risk in representative cohorts (9), but European alternative risk algorithms (SCORE) are also advised (10).”
MethodHosein, A., Stoute, V., Chadee, S., & Singh, N. R. (2020) · PeerJ · doi:10.7717/peerj.8232 · Cited by 15
“These weights, based on established population data, which are used to calculate a risk score, which is used in further analyses (Hippisley-Cox et al., 2008; Sullivan, Massaro & D’Agostino, 2004; Woodward, Brindle & Tunstall-Pedoe, 2007).”
BackgroundMethodInfluentialSo, H., & Tam, L. (2021) · Best Practice & Research Clinical Rheumatology · doi:10.1016/j.berh.2021.101689 · Cited by 17
Devani, R., Kirubakaran, A., & Molokhia, M. (2022) · Health and Technology · doi:10.1007/s12553-022-00651-0 · Cited by 15
“Framingham Risk Score (FRS) was the most common risk score—reported in 4 of the included studies; D’Agostino risk score (based on FRS) and QRISK2 (an earlier version of QRISK3 previously used in UK Primary Care) reported by Gonzalez-Sanchez [26] and Salisbury [27] respectively.”
MethodInfluentialKouwenhoven-Pasmooij, T. A., Djikanović, B., Robroek, S. J., Helmhout, P. H., Alex Burdorf, A., & Hunink, M. G. M. (2015) · BMC Public Health · doi:10.1186/s12889-015-2059-9 · Cited by 16
“Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2.”
BackgroundInfluentialKeyworth, C., Nelson, P. A., Chew-Graham, C. A., Kane, K., Pearce, C. J., Griffiths, C. E. M., Chisholm, A., & Cordingley, L. (2015) · International Journal of Behavioral Medicine · doi:10.1007/s12529-015-9517-8 · Cited by 15
Blackburn, R. M., Osborn, D., Walters, K. R., Nazareth, I., & Petersen, I. (2017) · Schizophrenia Research · doi:10.1016/j.schres.2017.05.028 · Cited by 15
“However, differences in age and sex (key predictors of CVD (D'Agostino et al., 2008; Hippisley-Cox et al., 2008)) were controlled for at both the study design and analysis stage and data on diabetes and antihypertensive medication were fully observed, thereby improving control for confounding.”
Lam, C. S. P., Castillo, R., Ho, D. T., Kasliwal, R. R., Khurana, R., Naik, S. R., Omland, T., Parsonage, W. A., Phrommintikul, A., Tobing, D., et al. (2019) · International Journal of Cardiology · doi:10.1016/j.ijcard.2019.01.107 · Cited by 15
“Current CVD risk stratification strategies cited by group members include risk factor counting and estimation based on experience, the American College of Cardiology/ American Heart Association (ACC/AHA) risk calculator [11], the Framingham risk score [12,13], SCORE (Systematic Coronary Risk Evaluation) risk charts [1…”
BackgroundCardiovascular risk assessment models: Have we found the perfect solution yet?
Abidov, A., & Chehab, O. (2019) · Journal of Nuclear Cardiology · doi:10.1007/s12350-019-01642-x · Cited by 15
Rodríguez‐Sánchez, E., Navarro‐García, J. A., Aceves‐Ripoll, J., González‐Lafuente, L., Corbacho-Alonso, N., Martínez, P., Calvo‐Bonacho, E., Álvarez‐Llamas, G., Barderas, M. G., Ruilope, L. M., et al. (2019) · Translational research · doi:10.1016/j.trsl.2019.06.002 · Cited by 15
Personalized E-Coaching in Cardiovascular Risk Reduction: A Randomized Controlled Trial
Khanji, M. Y., Balawon, A., Boubertakh, R., Hofstra, L., Narula, J., Hunink, M. G. M., Pugliese, F., & Petersen, S. E. (2019) · Annals of Global Health · doi:10.5334/aogh.2496 · Cited by 15
Pitisuttithum, P., Chan, W., Goh, G. B., Fan, J., Song, M. J., Charatcharoenwitthaya, P., Duseja, A. K., Dan, Y.-Y., Imajo, K., Nakajima, A., et al. (2020) · World Journal of Gastroenterology · doi:10.3748/wjg.v26.i19.2416 · Cited by 15
Chapter 2: Pharmacological cholesterol-lowering treatment in adults
(2013) · Kidney International Supplements · doi:10.1038/kisup.2013.34 · Cited by 16
Metadata
- Authors
- Hippisley-Cox, J., Coupland, C., Vinogradova, Y., Robson, J., Minhas, R., Sheikh, A., & Brindle, P.
- Affiliations
- University of Nottingham (GB)
- Queen Mary University of London (GB)
- Medway NHS Foundation Trust (GB)
- University of Edinburgh (GB)
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2008-06-23
- Volume
- 336
- Issue
- 7659
- Pages
- 1475-1482
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC2440904
- OpenAlex
- W2055838663
- Cited by
- 1,459
- References
- 55
- Citations by year
- 2026: 25 · 2025: 49 · 2024: 58 · 2023: 86 · 2022: 100 · 2021: 108 · 2020: 108 · 2019: 106 · 2018: 94 · 2017: 102 · 2016: 101 · 2015: 95 · 2014: 90 · 2013: 64 · 2012: 80
- FWCI
- 62.43
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- BMJ (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, other-oa)
- Funders
- University of Nottingham
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipoproteins and Cardiovascular Health
- Keywords
- QRISK2, cardiovascular risk prediction, risk reclassification, coronary artery disease, stroke, transient ischemic attack, ethnic groups, South Asian patients, risk discrimination and calibration, cardiovascular disease prevention, NICE guidelines, QResearch database, England and Wales, general practice records, family history of coronary heart disease
- MeSH terms
- Adult, Aged, Algorithms, Cardiovascular Diseases, England, Female, Humans, Male, Middle Aged, Prognosis, Wales, Epidemiologic Studies, Age Distribution, Sex Distribution
About these checks
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