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Estimating the performance of three cardiovascular disease risk scores: the Estonian Biobank cohort study
  1. Aet Saar1,2,
  2. Kristi Läll3,4,
  3. Maris Alver4,5,
  4. Toomas Marandi1,2,
  5. Tiia Ainla1,2,
  6. Jaan Eha1,6,
  7. Andres Metspalu4,5,
  8. Krista Fischer3,4
  1. 1 Heart Clinic, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
  2. 2 Cardiology Centre, North Estonia Medical Centre, Tallinn, Estonia
  3. 3 Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
  4. 4 Institute of Genomics, University of Tartu, Tartu, Estonia
  5. 5 Department of Biotechnology, Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
  6. 6 Heart Clinic, Tartu University Hospital, Tartu, Estonia
  1. Correspondence to Dr Aet Saar, Heart Clinic, Institute of Clinical Medicine, University of Tartu; aet.saar{at}


Background We aim to investigate the predictive ability of PCE (Pooled Cohort Equations), QRISK2 and SCORE (Systematic COronary Risk Estimation) scoring systems for atherosclerotic cardiovascular disease (ASCVD) risk prediction in Estonia, a country with one of the highest ASCVD event rates in Europe.

Methods Seven-year risk estimates were calculated in risk score–specific subsets of the Estonian Biobank cohort. Calibration was assessed by standardised incidence ratios (SIRs) and discrimination by Harrell’s C-statistics. In addition, a head-to-head comparison of the scores was performed in the intersection of the three score-specific subcohorts.

Results PCE, QRISK2 and SCORE risk estimates were calculated for 4356, 7191 and 3987 eligible individuals, respectively. During the 7-year follow-up, 220 hard ASCVD events (PCE outcome), 671 ASCVD events (QRISK2 outcome) and 94 ASCVD deaths (SCORE outcome) occurred among the score-specific subsets of the cohort. While PCE (SIR 1.03, 95% CI 0.90 to 1.18) and SCORE (SIR 0.99, 95% CI 0.81 to 1.21) were calibrated well for the cohort, QRISK2 underestimated the risk by 48% (SIR 0.52, 95% CI 0.48 to 0.56). In terms of discrimination, PCE (C-statistic 0.778) was inferior to QRISK2 (C-statistic 0.812) and SCORE (C-statistic 0.865). All three risk scores performed at similar level in the head-to-head comparison.

Conclusion Of three widely used ASCVD risk scores, PCE and SCORE performed at acceptable level, while QRISK2 underestimated ASCVD risk markedly. These results highlight the need for evaluating the accuracy of ASCVD risk scores prior to use in high-risk populations.

  • cardiovascular disease
  • Eastern Europe
  • preventive medicine
  • artherosclerosis
  • CHD/coronorary heart

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  • Patient consent for publication Not required.

  • AS and KL contributed equally.

  • Contributors AS, KL, MA, TM, TA, JE, AM and KF participated in the design of the study and in writing the manuscript. KL and KF performed the statistical analysis. All authors read and approved the final manuscript.

  • Funding This work was supported by Institutional Research Grants (IUT 20-60, IUT 2-7); Personal Research Funding Grant to KF (PUT-1665) from the Estonian Research Council; and from the European Regional Development Fund (ERDF) for the development of CoE for Genomics and Translational Medicine to AM.

  • Competing interests None declared.

  • Ethics approval The study was approved by the Research Ethics Committee of the University of Tartu (application no. 230/M-19) and complies with the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.