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        "titulo" => "Substitui&#231;&#227;o do SCORE pelo SCORE2 nos cuidados de sa&#250;de prim&#225;rios em Portugal &#8211; &#171;not&#237;cias da frente&#187; da preven&#231;&#227;o cardiovascular"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;When trouble is sensed well in advance it can easily be remedied&#59; if you wait for it to show itself any medicine will be too late because the disease will have become incurable&#46;&#8221;</p></span><span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#8211; Niccol&#242; Machiavelli &#40;1469&#8211;1527&#41;</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the realm of preventive cardiovascular medicine&#44; scoring systems play a central role in gauging the likelihood of adverse events and the potential benefit of pharmacological therapy&#46; Despite their many limitations&#44; scoring systems are useful to provide clinicians with a snapshot of an individual&#39;s risk and are widely used in clinical practice&#46; In 2021&#44; the European Society of Cardiology &#40;ESC&#41;&#8217;s guidelines on cardiovascular disease prevention introduced the second version of their Systemic Coronary Risk Estimation &#40;SCORE2&#41;&#44; designed to estimate the risk of cardiovascular events in apparently healthy individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> Unlike its predecessor&#44; SCORE2 estimates the 10-year risk of both fatal and non-fatal cardiovascular events &#40;which means that SCORE and SCORE2 cannot be compared directly&#41;&#46; Another important difference is the classification of individuals into three risk categories according to age-specific thresholds&#58; low-to-moderate risk &#40;&#60;2&#46;5&#37; if &#60;50 years old or &#60;5&#46;0&#37; if aged 50&#8211;69 years&#41;&#44; high risk &#40;2&#46;5&#8211;7&#46;4&#37; if &#60;50 years or 5&#46;0&#8211;9&#46;9&#37; if 50&#8211;69 years&#41;&#44; and very high risk &#40;&#8805;7&#46;5&#37; if &#60;50 years or &#8805;10&#37; if 50&#8211;69 years&#41;&#46; Moreover&#44; a special version for older people &#40;SCORE2-OP&#41; was also introduced&#44; and European countries were divided into four risk strata&#44; with Portugal being placed in the moderate risk group&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">With these changes&#44; what should be expected from the introduction of this new scoring system into clinical practice in Portuguese primary care&#63; This was the seminal question that prompted Silva et al&#46; to perform their study that is published in the current issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Using data from the medical records of two Family Health Units&#44; they assessed 1642 individuals aged 40&#8211;65 years without previous cardiovascular disease&#44; diabetes or chronic renal failure&#46; They calculated both SCORE and SCORE2&#44; and categorized each patient&#39;s risk according to the respective thresholds&#46; Finally&#44; since individual low-density lipoprotein cholesterol &#40;LDL-C&#41; goals go hand-in-hand with risk classification&#44; the authors assessed the potential implications of using the new SCORE2 for the attainment of LDL-C targets&#46; Their findings can be summarized as follows&#58; &#40;1&#41; while SCORE classified 98&#37; of subjects as low or moderate risk&#44; only 55&#37; will remain in that category after using SCORE2&#59; &#40;2&#41; more than 40&#37; of the overall study population will be reclassified upwards &#40;from low&#47;moderate risk to high risk&#44; or from high risk to very high risk&#41;&#44; and hardly any individuals will be reclassified downward&#59; &#40;3&#41; most of the risk reclassification will occur in younger patients &#40;&#60;50 years old&#41;&#59; and &#40;4&#41; using SCORE2 instead of SCORE will decrease the proportion of those considered within the LDL-C target range from 39&#37; to 20&#37;&#44; implying that greater efforts for LDL-C control will be needed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given these staggering differences&#44; it is only natural that we ask ourselves whether the original SCORE really underestimated risk so much that a new&#44; more sensitive SCORE2 was needed&#46; The evidence shows that this was not the case at all&#46; In fact&#44; a direct comparison between the two scores shows similar discriminative power &#40;c-statistic of 0&#46;71 for SCORE and 0&#46;72 for SCORE2&#41;&#44; and SCORE2 appears to have comparable predictive power in Portuguese cohorts&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;4</span></a> The fundamental difference lies not in the scores themselves but in the age-specific thresholds for risk classification introduced along with SCORE2 in the 2021 ESC guidelines&#46; Two different individuals with the same SCORE2 result might be classified into different risk categories depending on their age&#46; This blurring of the distinction between absolute and relative risk serves two purposes&#58; to encourage the early initiation of treatment in younger patients whose absolute risk is not adequately depicted in scores&#59; and to soften the requirement for treatment in older people whose risk comes mostly from their age&#46; The early initiation of treatment in younger individuals &#40;&#8220;the earlier the better&#8221;&#41; is supported by recent evidence&#44; but also poses significant challenges&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Convincing asymptomatic young people to undertake sustained lifestyle modifications and&#44; in some cases&#44; initiate &#40;and adhere to&#41; pharmacological treatment will be no easy task&#44; as highlighted by the 80&#37; of individuals whose LDL-C is over target according to the new SCORE2 classification&#46; This shift in practice might also open new avenues for the refinement of risk stratification using cardiovascular imaging techniques such as coronary calcium scoring&#44; probably the best tool for &#8216;de-risking&#8217; individual patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6&#44;7</span></a> Ongoing studies will tell us whether some of these people might benefit from focused screening&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; the authors are to be congratulated for bringing these results to our attention and enriching current discussions with Portuguese results from the frontline of primary care&#46; In a country where local data are sometimes scarce&#44; this is a welcome addition to our knowledge of what is happening and what to expect in the coming years&#46; The integration of SCORE2 into electronic health records seems fundamental&#44; but so does improved reimbursement of lipid-lowering medication&#44; the inclusion of LDL-C control into healthcare performance metrics&#44; and access to innovative treatments&#46; Let us hope that Portuguese primary care physicians will receive all the tools they need to do their job well&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Replacing SCORE with SCORE2 in Portuguese primary care: News from the frontline of cardiovascular prevention
Substituição do SCORE pelo SCORE2 nos cuidados de saúde primários em Portugal – «notícias da frente» da prevenção cardiovascular
António Miguel Ferreiraa,b
a Cardiology Department, Hospital Santa Cruz – Unidade Local de Saúde de Lisboa Ocidental, Carnaxide, Portugal
b Advanced Cardiovascular Imaging Unit, Hospital da Luz, Lisboa, Portugal
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        "titulo" => "Substitui&#231;&#227;o do SCORE pelo SCORE2 nos cuidados de sa&#250;de prim&#225;rios em Portugal &#8211; &#171;not&#237;cias da frente&#187; da preven&#231;&#227;o cardiovascular"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;When trouble is sensed well in advance it can easily be remedied&#59; if you wait for it to show itself any medicine will be too late because the disease will have become incurable&#46;&#8221;</p></span><span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#8211; Niccol&#242; Machiavelli &#40;1469&#8211;1527&#41;</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the realm of preventive cardiovascular medicine&#44; scoring systems play a central role in gauging the likelihood of adverse events and the potential benefit of pharmacological therapy&#46; Despite their many limitations&#44; scoring systems are useful to provide clinicians with a snapshot of an individual&#39;s risk and are widely used in clinical practice&#46; In 2021&#44; the European Society of Cardiology &#40;ESC&#41;&#8217;s guidelines on cardiovascular disease prevention introduced the second version of their Systemic Coronary Risk Estimation &#40;SCORE2&#41;&#44; designed to estimate the risk of cardiovascular events in apparently healthy individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> Unlike its predecessor&#44; SCORE2 estimates the 10-year risk of both fatal and non-fatal cardiovascular events &#40;which means that SCORE and SCORE2 cannot be compared directly&#41;&#46; Another important difference is the classification of individuals into three risk categories according to age-specific thresholds&#58; low-to-moderate risk &#40;&#60;2&#46;5&#37; if &#60;50 years old or &#60;5&#46;0&#37; if aged 50&#8211;69 years&#41;&#44; high risk &#40;2&#46;5&#8211;7&#46;4&#37; if &#60;50 years or 5&#46;0&#8211;9&#46;9&#37; if 50&#8211;69 years&#41;&#44; and very high risk &#40;&#8805;7&#46;5&#37; if &#60;50 years or &#8805;10&#37; if 50&#8211;69 years&#41;&#46; Moreover&#44; a special version for older people &#40;SCORE2-OP&#41; was also introduced&#44; and European countries were divided into four risk strata&#44; with Portugal being placed in the moderate risk group&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">With these changes&#44; what should be expected from the introduction of this new scoring system into clinical practice in Portuguese primary care&#63; This was the seminal question that prompted Silva et al&#46; to perform their study that is published in the current issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Using data from the medical records of two Family Health Units&#44; they assessed 1642 individuals aged 40&#8211;65 years without previous cardiovascular disease&#44; diabetes or chronic renal failure&#46; They calculated both SCORE and SCORE2&#44; and categorized each patient&#39;s risk according to the respective thresholds&#46; Finally&#44; since individual low-density lipoprotein cholesterol &#40;LDL-C&#41; goals go hand-in-hand with risk classification&#44; the authors assessed the potential implications of using the new SCORE2 for the attainment of LDL-C targets&#46; Their findings can be summarized as follows&#58; &#40;1&#41; while SCORE classified 98&#37; of subjects as low or moderate risk&#44; only 55&#37; will remain in that category after using SCORE2&#59; &#40;2&#41; more than 40&#37; of the overall study population will be reclassified upwards &#40;from low&#47;moderate risk to high risk&#44; or from high risk to very high risk&#41;&#44; and hardly any individuals will be reclassified downward&#59; &#40;3&#41; most of the risk reclassification will occur in younger patients &#40;&#60;50 years old&#41;&#59; and &#40;4&#41; using SCORE2 instead of SCORE will decrease the proportion of those considered within the LDL-C target range from 39&#37; to 20&#37;&#44; implying that greater efforts for LDL-C control will be needed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given these staggering differences&#44; it is only natural that we ask ourselves whether the original SCORE really underestimated risk so much that a new&#44; more sensitive SCORE2 was needed&#46; The evidence shows that this was not the case at all&#46; In fact&#44; a direct comparison between the two scores shows similar discriminative power &#40;c-statistic of 0&#46;71 for SCORE and 0&#46;72 for SCORE2&#41;&#44; and SCORE2 appears to have comparable predictive power in Portuguese cohorts&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;4</span></a> The fundamental difference lies not in the scores themselves but in the age-specific thresholds for risk classification introduced along with SCORE2 in the 2021 ESC guidelines&#46; Two different individuals with the same SCORE2 result might be classified into different risk categories depending on their age&#46; This blurring of the distinction between absolute and relative risk serves two purposes&#58; to encourage the early initiation of treatment in younger patients whose absolute risk is not adequately depicted in scores&#59; and to soften the requirement for treatment in older people whose risk comes mostly from their age&#46; The early initiation of treatment in younger individuals &#40;&#8220;the earlier the better&#8221;&#41; is supported by recent evidence&#44; but also poses significant challenges&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Convincing asymptomatic young people to undertake sustained lifestyle modifications and&#44; in some cases&#44; initiate &#40;and adhere to&#41; pharmacological treatment will be no easy task&#44; as highlighted by the 80&#37; of individuals whose LDL-C is over target according to the new SCORE2 classification&#46; This shift in practice might also open new avenues for the refinement of risk stratification using cardiovascular imaging techniques such as coronary calcium scoring&#44; probably the best tool for &#8216;de-risking&#8217; individual patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6&#44;7</span></a> Ongoing studies will tell us whether some of these people might benefit from focused screening&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; the authors are to be congratulated for bringing these results to our attention and enriching current discussions with Portuguese results from the frontline of primary care&#46; In a country where local data are sometimes scarce&#44; this is a welcome addition to our knowledge of what is happening and what to expect in the coming years&#46; The integration of SCORE2 into electronic health records seems fundamental&#44; but so does improved reimbursement of lipid-lowering medication&#44; the inclusion of LDL-C control into healthcare performance metrics&#44; and access to innovative treatments&#46; Let us hope that Portuguese primary care physicians will receive all the tools they need to do their job well&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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