Ethnicity and prediction of cardiovascular disease: performance of QRISK2 and Framingham scores in a UK tri-ethnic prospective cohort study (SABRE—Southall And Brent REvisited)
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Objective: To evaluate QRISK2 and Framingham cardiovascular disease (CVD) risk scores in a tri-ethnic UK population. Design: Cohort study. Setting: West London. Participants: Randomly selected from primary care lists. Follow-up data were available for 87% of traced participants, comprising 1866 white Europeans, 1377 South Asians, and 578 African Caribbeans, aged 40–69 years at baseline (1998–1991). Main outcome measures: First CVD events: myocardial infarction, coronary revascularisation, angina, transient ischaemic attack or stroke reported by participant, primary care or hospital records or death certificate. Results: During follow-up, 387 CVD events occurred in men (14%) and 78 in women (8%). Both scores underestimated risk in European and South Asian women (ratio of predicted to observed risk: European women: QRISK2: 0.73, Framingham: 0.73; South Asian women: QRISK2: 0.52, Framingham: 0.43). In African Caribbeans, Framingham over-predicted in men and women and QRISK2 over-predicted in women. Framingham classified 28% of participants as high risk, predicting 54% of all such events. QRISK2 classified 19% as high risk, predicting 42% of all such events. Both scores performed poorly in identifying high risk African Caribbeans; QRISK2 and Framingham identified as high risk only 10% and 24% of those who experienced events. Conclusions: Neither score performed consistently well in all ethnic groups. Further validation of QRISK2 in other multi-ethnic datasets, and better methods for identifying high risk African Caribbeans and South Asian women, are required.
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Sampling bias was a well-known issue with the Framingham Heart Study, which drew its study population from the racially homogeneous town of Framingham, Massachusetts, and consequently can lead to both over- and under-treatment of certain ethnic minorities.
“Sampling bias was a well-known issue with the highly influential Framingham Heart Study, which drew its study population from the racially homogeneous town of Framingham, Massachusetts—and consequently can lead to both over- and under-treatment of certain ethnic minorities25,26.”
From Predictably unequal: understanding and addressing concerns that algorithmic clinical prediction may increase health disparities (2020) · cites this paper as [26]
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- Authors
- Tillin, T., Hughes, A. D., Whincup, P., Mayet, J., Sattar, N., McKeigue, P. M., Chaturvedi, N., & On behalf of the SABRE Study Group
- Affiliations
- Imperial College London (GB)
- St George's, University of London (GB)
- University of Glasgow (GB)
- University of Edinburgh (GB)
- Corresponding author
- Tillin, Therese
- ORCID
- Venue
- Heart
- Publisher
- BMJ
- Published
- 2013-11-01
- Volume
- 100
- Issue
- 1
- Pages
- 60-67
- ISSN
- 1355-6037 (ISSN-L)
- 1468-201X
- PMC
- PMC4869829
- OpenAlex
- W2131603728
- Cited by
- 130
- References
- 24
- Citations by year
- 2026: 6 · 2025: 10 · 2024: 6 · 2023: 11 · 2022: 12 · 2021: 9 · 2020: 14 · 2019: 10 · 2018: 8 · 2017: 7 · 2016: 15 · 2015: 12 · 2014: 8 · 2013: 1 · 2012: 1
- FWCI
- 12.11
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- Heart (publishedVersion, cc-by)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion)
- PubMed Central (acceptedVersion, cc-by)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, cc-by)
- Spiral (Imperial College London) (submittedVersion, other-oa)
- UCL Discovery (University College London) (submittedVersion)
- Apollo (University of Cambridge) (submittedVersion, cc-by)
- Apollo (cc-by)
- Funders
- University of Washington
- Wellcome Trust (082464, 082464/Z/07/Z)
- National Institute for Health and Care Research (NF-SI-0611-10219)
- British Heart Foundation (SP/07/001/23603)
- Diabetes UK
- University of Exeter
- Imperial College London
- University of Oxford
- University of Glasgow
- Medical Research Council (MC_UU_12015/5)
- Menzies Centre for Australian Studies, King's College London, University of London
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Keywords
- cardiovascular risk prediction, QRISK2, Framingham risk score, ethnic differences, South Asian women, Afro-Caribbean population, myocardial infarction, stroke, coronary revascularization, risk score validation
- MeSH terms
- Adult, Aged, Cardiovascular Diseases, Diagnostic Imaging, Ethnicity, Female, Follow-Up Studies, Forecasting, United Kingdom, Humans, Male, Middle Aged, Morbidity, Prospective Studies, Risk Factors, Sex Factors, Survival Rate, Risk Assessment
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