title: Use of exercise capacity to improve SCORE risk prediction model in asymptomatic adults.
abstract: The SCORE risk estimation system is used for cardiovascular risk stratification in apparently healthy adults and is based on known cardiovascular risk factors. The purpose of the current study was to evaluate whether exercise capacity can improve the accuracy of the SCORE overall survival risk estimation.
  
  
  
  We investigated 22 878 asymptomatic men and women who were annually screened in a tertiary medical centre. All subjects were free of known ischaemic heart disease, and had completed maximal exercise stress test according to the Bruce protocol. The SCORE risk estimation system was used to evaluate individual cardiovascular risk for all subjects. The primary endpoint was mortality, after exclusion of patients with metastatic cancer during follow-up. The incremental contribution of exercise capacity in predicting the risk of death was evaluated by net reclassification improvement (NRI) and area under the receiver operating curve (AUROC). Mean age of the study population was 47.4 ± 10.3, and 71.6% were men. There were 505 (2.21%) deaths during a mean follow-up of 9.2 ± 4.1 years. Kaplan-Meier survival analysis showed that both SCORE and low exercise capacity were associated with reduced survival. When added to the SCORE risk prediction, exercise capacity allowed more accurate risk stratification: NRI analysis showed an overall improvement of 56.8% in the accuracy of classification and the AUROC increased (0.782 vs. 0.766).
  
  
  
  Both SCORE and exercise capacity are strong independent predictors of all-cause mortality. The addition of exercise capacity to the SCORE risk model can improve the accuracy of the model.
authors.affiliation: Leviev Heart Centre, Chaim Sheba Medical Centre, Tel-Hashomer 52621, Israel Clalit Health Services, Jerusalem, Israel.
authors.forename: Ariel
authors.initials: A
authors.lastname: Israel
authors.affiliation: Department of Internal Medicine C, Chaim Sheba Medical Centre, Tel-Hashomer, Israel Pinchas Borenstein Talpiot Medical Leadership Program, Chaim Sheba Medical Centre, Tel-Hashomer, Israel Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Shaye
authors.initials: S
authors.lastname: Kivity
authors.affiliation: Department of Internal Medicine C, Chaim Sheba Medical Centre, Tel-Hashomer, Israel Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Yechezkel
authors.initials: Y
authors.lastname: Sidi
authors.affiliation: Institute for Medical Screening, Chaim Sheba Medical Centre, Tel-Hashomer, Israel.
authors.forename: Shlomo
authors.initials: S
authors.lastname: Segev
authors.affiliation: Leviev Heart Centre, Chaim Sheba Medical Centre, Tel-Hashomer 52621, Israel.
authors.forename: Anat
authors.initials: A
authors.lastname: Berkovitch
authors.affiliation: Leviev Heart Centre, Chaim Sheba Medical Centre, Tel-Hashomer 52621, Israel.
authors.forename: Robert
authors.initials: R
authors.lastname: Klempfner
authors.affiliation: Medical Center Management, Chaim Sheba Medical Centre, Tel-Hashomer, Israel.
authors.forename: Bruno
authors.initials: B
authors.lastname: Lavi
authors.affiliation: Leviev Heart Centre, Chaim Sheba Medical Centre, Tel-Hashomer 52621, Israel Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Ilan
authors.initials: I
authors.lastname: Goldenberg
authors.affiliation: Leviev Heart Centre, Chaim Sheba Medical Centre, Tel-Hashomer 52621, Israel Pinchas Borenstein Talpiot Medical Leadership Program, Chaim Sheba Medical Centre, Tel-Hashomer, Israel eladmaor@gmail.com elad.maor@sheba.health.gov.il.
authors.forename: Elad
authors.initials: E
authors.lastname: Maor
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases; D015444:Exercise; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors
keywords: Exercise capacity; Exercise stress test; Fitness; Prevention; Risk stratification