Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2
Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2
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DOI：
10.1136/bmj.39609.449676.25
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发表时间：
2008-06-28
影响因子：
105.7
通讯作者：
Brindle, Peter
中科院分区：
文献类型：
--
作者：
Hippisley-Cox, Julia;Coupland, Carol;Brindle, Peter
目的开发和验证QRISK心血管疾病风险算法（QRISK 2）的第二版，以提供英格兰和威尔士不同种族人群心血管疾病风险的准确估计，并将其性能与美国国家卫生与临床优化研究所（NICE）推荐的改良版Fracket评分进行比较。1993年1月1日至2008年3月31日，在英格兰和威尔士建立了531个国家QRESEARCH数据库，参与者为230万名年龄在35-74岁（超过1600万人年）的患者，发生了14万起心血管事件。总体人群（推导和验证队列）包括222万人，其中白色或其种族群体未记录，22013南亚人，11595非洲黑人，10402加勒比黑人，19792来自中国或其他亚洲或其他种族群体。心血管疾病（冠心病、中风和短暂性脑缺血发作）的（意外）诊断记录在全科医疗记录或国家统计局的相关死亡证明中。危险因素包括自定义的种族、年龄、性别、吸烟状况、收缩压、血清总胆固醇/高密度脂蛋白胆固醇比值、体重指数、60岁以下一级亲属冠心病家族史、汤森剥夺评分、治疗过的高血压、2型糖尿病、肾脏疾病、房颤和类风湿关节炎。QRISK 2算法解释了43%的女性和38%的男性变异，相比之下，修改后的Fragrance评分分别为39%和35%。在112156例被改良Fragrance评分归类为高风险（即10年内风险≥ 20%）的患者中，46094例（41.1%）将被QRISK 2重新归类为低风险。在这些重新分类的患者中观察到的10年风险为16.6%（95%置信区间16.1%-17.0%）-即低于20%的治疗阈值。在QRISK 2分类为高风险的78024例患者中，11962例（15.3%）将通过改良的Fragrance评分重新分类为低风险。这些患者的10年观察风险为23.3%（22.2%-24.4%）-即高于20%的阈值。在验证队列中，QRISK 2评分≥ 20%的人群中，女性心血管事件的年发生率为30.6/1000人年（29.8 - 31.5），男性为32.5/1000人年（31.9 - 33.1）。修改后的弗雷明汉方程的相应数字为女性每1000人年25.7人（25.0至26.3），男性每1000人年26.4人（26.0至26.8）。在20%的阈值，由QRISK 2确定的人口是在更高的风险的CV事件比人口确定的Fracket score.Conclusions种族，剥夺，和其他临床条件到QRISK 2算法的心血管疾病的风险，提高了准确性的识别那些在全国具有代表性的人群中的高风险。在20%的阈值下，QRISK 2可能是心血管疾病一级预防治疗决策的更有效和更公平的工具。由于验证是在与算法所源自的人群相似的人群中进行的，因此它可能具有“主场优势”。“因此，建议在其他人群中进行进一步验证。
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 personyears) 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, 11595 black African, 10402 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, >= 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, 11962 (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 >= 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.