Combined use of short-term and long-term cardiovascular risk scores in primary prevention: an assessment of clinical utility.
OBJECTIVE
To evaluate the clinical utility of cardiovascular disease (CVD) risk stratification based on a combined use of short-term and long-term risk scores in the primary prevention setting.


METHODS
CVD-free participants 40-65 years old initially to seven population-based cohorts enrolled in northern and central Italy were stratified as 'low' (ESC-SCORE ≤ 1%), 'intermediate' (SCORE 1-4%) and 'moderate/high' short-term CVD risk (SCORE ≥ 4% or diabetes). The long-term CVD risk was estimated using the CAMUNI-MATISS model, validated for the Italian population. Participants were followed up for a median time of 16 years to ascertain the first major CVD event, fatal or nonfatal. To compare the 'combined' (SCORE + CAMUNI-MATISS) with the 'current' (SCORE alone) stratification, we estimated the difference in Net Benefit between the two strategies.


RESULTS
Study sample included 3935 men (468 CVD events) and 4393 women (210 events). Under the 'current' stratification, 76% of men and 21% of women were at 'intermediate' risk and eligible to treatment. Only 40% of them had elevated predicted long-term risk and could have received indication to treatment under the 'combined' strategy. The latter would have saved 3 and 3.5 unnecessary treatments per every CVD case in men and women, respectively, and the Net Benefit significantly increased [men: 4.1, 95% confidence interval (CI): 2.7-5.6; women: 4.4, 95% CI: 1.7-6.9].Similarly, among the 74% of women not receiving indication for prevention because at 'low' short-term risk, the 'combined' stratification significantly increased the Net Benefit (1.4, 95% CI: 0.6-2.1) and reduced from 40 to 10% the proportion of events occurring among women not eligible to any preventive action.


CONCLUSIONS
In the Italian population, a combination of validated short-term and long-term CVD risk scores has the potential to select for prevention women whose risk is currently not fully addressed and to reduce unnecessary costly treatment.
aCentro Ricerche in Epidemiologia e Medicina Preventiva, Dipartimento di Medicina e Chirurgia, Università degli Studi dell'Insubria, Varese bDipartimento malattie cardiovascolari, dismetaboliche e dell'invecchiamento, Istituto Superiore di Sanità, Roma cAssociazione Nazionale Medici Cardiologi Ospedalieri, ANMCO, Firenze dDepartment of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli eClinica Medica, Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano fIRCCS Multimedica, Sesto San Giovanni, Milano gCentro Ricerche per la Sanità Pubblica, Università di Milano-Bicocca, Monza.
Giovanni
G
Veronesi
Simona
S
Giampaoli
Diego
D
Vanuzzo
Francesco
F
Gianfagna
Luigi
L
Palmieri
Guido
G
Grassi
Giancarlo
G
Cesana
Marco M
MM
Ferrario
D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D003661:Decision Support Techniques; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011322:Primary Prevention / Q000379:methods*; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors