The Systematic Coronary Risk Assessment (SCORE) tool was developed to calculate cardiovascular (CV) risk for each individual, Initially, it was introduced in 2003 for the European population, it provides an estimate of the 10-year risk of a fatal CV event. The tool categorized different European regions into low- and high-risk levels; the calculated risk holds the same significance regardless of the patient's age.11 In Portugal, this tool has been integrated into SClínico™, the clinical records system used by general practitioners (GPs).

In 2021, a new CV risk calculation tool called SCORE2 was introduced. SCORE2 is a calibrated algorithm designed for more recent cohorts and is used to predict the 10-year risk of fatal or non-fatal CVD in a stratified European population across four risk levels. Its primary objective is to enhance the identification of individuals at a higher risk of developing CVD. SCORE2 serves as the foundation for personalized care and should be applied across various populations, ranging from apparently healthy individuals to those with known CV risk factors. The SCORE2 tool incorporates five variables: age, gender, smoking status, systolic blood pressure (SBP), and non-HDL cholesterol, with the latter being one of the primary differences compared to the previous SCORE.12

According to the new risk stratification using SCORE2, three risk categories have been established: low to moderate, high, and very high risk.12

Some patients are directly categorized into a specific risk category based on their past medical history. The presence of established atherosclerotic CVD, such as acute coronary syndrome, ischemic heart disease, cerebrovascular disease, or peripheral artery disease, indicates a very high risk. Depending on the presence of target organ damage, its severity, duration, and concomitant risk factors, individuals with type 2 DM can be classified into different risk categories. The same applies to patients with a history of chronic kidney disease (CKD), based on the severity of the condition. Patients with familial hypercholesterolemia are considered to have a high CV risk.12 For individuals who do not have any of the aforementioned conditions, their CV risk should be calculated using the SCORE2 tool if they are between 40 and 69 years of age, or the SCORE2-Older Persons tool if they are over 69 years of age.12

Age is the primary risk factor for CVD.12 Unlike the previous SCORE, in SCORE2, the same CVD risk at different ages carries a different meaning. If one takes the example of a person aged 55 with a 4% risk of developing a fatal or non-fatal CV event in 10 years, this individual falls into a higher risk category (high risk) compared to a person with a 4% risk at age 60 (low to moderate risk).

According to the latest guidelines on CVD prevention, the management of dyslipidemia should encompass two steps: initially, efforts should be made to lower LDL-C levels to below 100 mg/dL, and subsequently, the focus should be on achieving the intensified goals based on the assigned risk category.13

The International Classification of Primary Care, 2nd edition (ICPC-2), classifies the patient's reason for encounter, the problems/diagnosis managed, interventions, and the ordering of these data in the structure of care episodes in general/family practice and primary care.14

In primary care, patients with hypertension and/or diabetes are a vulnerable population requiring regular follow-up consultations, intended for the stabilization of existing diseases and preventive measures, particularly for the management of CV risk factors. Hypertension is codified as a problem/diagnosis according to ICPC-2: K86 – hypertension without complications and K87 – hypertension with complications.

As mentioned above the SCORE tool remains integrated into the medical record system SClínico™ as the CV risk calculator for patient stratification and management. This tool is currently outdated in view of the most recent guidelines.13 This could, therefore, have implications for routine clinical practice, particularly for therapeutic decision-making.

This observational cross-sectional study analyzed a population census of patients diagnosed with hypertension without complications (K86) according to ICPC-2 at the Nova Via Family Health Unit (n=3146). Sample recruitment was carried out through the MIM@UF™ platform, which is normally used in Portuguese primary care for data collection. The period under analysis ran from 1 January to 30 June 2022.

The patient selection steps can be found in the flowchart in Figure 1. First, we applied the only inclusion criteria – age between 40 and 69 years – and excluded 1401 patients. We applied our exclusion criteria in two steps. In the first one, 533 patients who had conditions leading to a direct CV risk category allocation were excluded automatically using, once again, the ICPC-2 classification codes for those conditions. Then, in a second step and after analyzing the patients’ electronic data using the SClínico™ software, we excluded 558 patients who met the following exclusion criteria: no in-person consultation in the period under analysis; no lipid profile entered into the system between one year prior to the consultation and June 30, 2022; no record of information regarding smoking, SBP and/or anti-dyslipidemia medication; CKD stage 3 or higher and also those who had coding errors in their clinical records. After applying the inclusion and exclusion criteria, the final sample size included 654 patients.

Figure 1.

Study design and patient selection according to the inclusion and exclusion criteria.

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The research protocol was approved by the Ethics Committee of the Northern Regional Health Administration (Administração Regional de Saúde do Norte).

The authors consulted the patients’ medical records, collecting data regarding age, date of consultation, lipid profile values, smoking habits, SBP, usual medication, the SCORE value calculated by the tool implemented in the SClínico™ program and the SCORE2 value recorded by the physician. When SCORE or SCORE2 values were not registered on the clinical record, the researchers calculated them as recommended by the 2012 European Society of Cardiology (ESC) guidelines15 or by using the online tool U-prevent™, respectively. LDL-C targets for each SCORE and SCORE2 risk categories were defined according to 2019 ESC/EAS guidelines for the management of dyslipidaemias16 and 2021 ESC guidelines on CVD prevention in clinical practice,13 respectively. Statins intensity was determined according to 2018 American Heart Association Guidelines on the Management of Blood Cholesterol.17

Data were stored in a Microsoft Office Excel™ program file database and were encrypted and password protected.

For statistical analysis of the data, Microsoft Office Excel™ and SPSS™ software were used. To compare the fulfillment of LDL-C targets using SCORE and SCORE2 a McNemar test was applied. Data obtained were summarized in tables and figures and described quantitatively.

This study included a total of 654 individuals, aged between 40 and 69 years, of whom 263 (40.21%) were men and 391 (59.79%) were women (Table 1). The mean age±standard deviation of all patients was 59±7 years (59±7 years for women and 58±7 years for men) with the larger group aged between 60 and 69 years (n=334, 51.07%). Most individuals were non-smokers (n=561, 85.78%). In the smokers’ group, 51 (54.84%) were men, with the highest percentage of smokers in the 50–59 age range. Based on SBP, the median (interquartile range) value was 134 (18.75) mmHg; lower median values were found in the women's group compared to the men's group.

When using the SCORE tool to assess CV risk, 188 of the 654 patients (28.75%) were classified as CV low risk and 448 (68.5%) as moderate risk. Finally, 17 patients (2.6%) were classified as high risk and only one male patient (0.15%) as very high risk (Figure 2). For further detail on gender distribution refer to supplementary material – Table 1.

Figure 2.

Distribution of cardiovascular risk categories according to SCORE and SCORE2.

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Upon switching to the SCORE2 tool, patients were redistributed into three categories instead of the four in SCORE. Specifically, 255 patients (38.99%) were classified as low to moderate risk with a predominance of female gender, 328 (50.15%) as high risk and 71 (10.86%) as very high risk, primarily consisting of males (Figure 2). For further details on gender distribution, please refer to the supplementary material – Table 2.

When comparing the two methods of assessing CV risk (Figure 3), the low risk group determined by the SCORE tool was recategorized using the SCORE2 algorithm: 149 individuals (79.26%) were categorized as low to moderate risk, 39 (20.74%) as high risk, and none as very high risk. Regarding the moderate risk category determined by SCORE, the transition to the SCORE2 calculator resulted in 106 patients (23.66%) remaining in the low to moderate risk category, while 288 (64.29%) were reclassified as high risk and 54 (12.05%) as very high risk. These discrepancies became even more pronounced when analyzing the high-risk category determined by SCORE: only one patient (5.88%) remained in the same category, while 16 (94.12%) were classified as very high risk.

Figure 3.

Redistribution of patients by SCORE categories using SCORE2 tool to estimate cardiovascular risk.

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The median (interquartile range) of total cholesterol, HDL-C and LDL-C, was 189 (48) mg/dL, 49 (16) mg/dL and 112.4 (36.7) mg/dL, respectively. These values were higher in the women's group compared to men (Table 2). Analyzing by SCORE risk category, LDL-C median values were higher in the high-risk category [115 (41.4) mg/dL], followed by the low [113.1 (36.85) mg/dL] and moderate [111.9 (37.25) mg/dL] risk categories. The only individual representing the very high-risk category had an LDL-C level of 141 mg/dL (supplementary material – Table 3). Considering SCORE2 risk categories, LDL-C median values were higher in the very high-risk category [114.6 (36.4) mg/dL], followed by the high and low to moderate risk categories, with minimal differences [113.3 (38.85) mg/dL and 111.4 (34.15) mg/dL, respectively] between them (supplementary material – Table 4).

A similar analysis was applied to lipid-lowering therapy (LLT). Concerning SCORE, in the low risk category, 43 patients (22.87%) were treated with a moderate intensity statin in monotherapy, while more than half (n=128, 68.09%) did not use any LLT. In the moderate risk category, the most commonly prescribed LLT was a moderate intensity statin (n=210, 46.88%), followed by a high intensity statin (n=34, 7.59%) and a low intensity statin (n=9, 2.01%), all of them in monotherapy; 171 individuals (38.17%) in this category were not medicated with LLT. In the high-risk group, 9 patients (52.94%) used a moderate intensity statin in monotherapy and eight patients (47.06%) did not use any LLT. The only individual in the very high-risk category was not treated with LLT. Addressing SCORE2 risk categories, the majority of patients in the low to moderate risk category were not using any LLT (n=153, 60%). Among those who were, a moderate intensity statin in monotherapy was the preferred LLT. In the high and very high-risk categories, most patients were treated with a moderate intensity statin in monotherapy, and approximately 40% in both groups did not take any LLT (126 and 29 patients, respectively). Detailed results are provided in Tables 3 and 4.

Patients were studied according to the fulfillment of LDL-C goals within each risk category of SCORE (Figure 4) and SCORE2 (Figure 5). According to SCORE and SCORE2, 408 patients (62.39%) and 550 patients (84.10%) did not meet the LDL-C target, respectively. There was a significant increase in individuals failing to meet the LDL-C target when using SCORE2, compared to the use of SCORE (p<0.001).

Figure 4.

Fulfillment of LDL-C targets according to SCORE.

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Figure 5.

Fulfillment of LDL-C targets according to SCORE2.

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When using the SCORE tool, among individuals categorized as low risk, 97 patients (51.60%) successfully met the LDL-C target (<115 mg/dL), while 149 patients (33.26%) in the moderate risk category achieved the target of <100 mg/dL. Nevertheless, none of the individuals classified as high risk or very high risk reached their respective targets of <70 mg/dL and <55 mg/dL, respectively. When restricting the analysis to the group of patients who met the LDL-C targets according to SCORE and switching the CV risk assessment tool to SCORE2, we observed that 49 patients (50.52%) in the low risk category and 93 patients (62.42%) in the moderate risk category failed to meet their new LDL-C target (Figure 6).

Figure 6.

Fulfillment of LDL-C targets according to SCORE2 considering the group of patients that met the SCORE LDL-C targets.

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