Original article
The ERICE-score: the New Native Cardiovascular Score for the Low-risk and Aged Mediterranean Population of SpainLa ecuación ERICE: la nueva ecuación autóctona de riesgo cardiovascular para una población mediterránea envejecida y de bajo riesgo en España

https://doi.org/10.1016/j.rec.2014.03.019Get rights and content

Abstract

Introduction and objectives

In Spain, data based on large population-based cohorts adequate to provide an accurate prediction of cardiovascular risk have been scarce. Thus, calibration of the EuroSCORE and Framingham scores has been proposed and done for our population. The aim was to develop a native risk prediction score to accurately estimate the individual cardiovascular risk in the Spanish population.

Methods

Seven Spanish population-based cohorts including middle-aged and elderly participants were assembled. There were 11 800 people (6387 women) representing 107 915 person-years of follow-up. A total of 1214 cardiovascular events were identified, of which 633 were fatal. Cox regression analyses were conducted to examine the contributions of the different variables to the 10-year total cardiovascular risk.

Results

Age was the strongest cardiovascular risk factor. High systolic blood pressure, diabetes mellitus and smoking were strong predictive factors. The contribution of serum total cholesterol was small. Antihypertensive treatment also had a significant impact on cardiovascular risk, greater in men than in women. The model showed a good discriminative power (C-statistic = 0.789 in men and C = 0.816 in women). Ten-year risk estimations are displayed graphically in risk charts separately for men and women.

Conclusions

The ERICE is a new native cardiovascular risk score for the Spanish population derived from the background and contemporaneous risk of several Spanish cohorts. The ERICE score offers the direct and reliable estimation of total cardiovascular risk, taking in consideration the effect of diabetes mellitus and cardiovascular risk factor management. The ERICE score is a practical and useful tool for clinicians to estimate the total individual cardiovascular risk in Spain.

Resumen

Introducción y objetivos

En España no existen unas cohortes poblacionales suficientemente grandes para hacer predicciones precisas del riesgo cardiovascular. Las ecuaciones de Framingham y EuroSCORE calibradas son las más utilizadas en España. El objetivo es desarrollar la primera ecuación de predicción autóctona para estimar con precisión el riesgo cardiovascular individual en España.

Métodos

Análisis conjunto de siete cohortes españolas de población de mediana edad y anciana. La población del estudio —11.800 personas (6.387 mujeres)— aportó un total de 107.915 personas-año de seguimiento y 1.214 eventos cardiovasculares (633 de ellos, mortales). Se efectuó un análisis de regresión de Cox para examinar la contribución de los diferentes factores al riesgo de cualquier evento cardiovascular (mortal y no mortal).

Resultados

La edad fue el principal factor de riesgo de eventos cardiovasculares. La presión arterial sistólica, la diabetes mellitus, el tabaquismo y el tratamiento antihipertensivo fueron factores predictivos fuertemente asociados con el riesgo cardiovascular. En cambio, la contribución del colesterol total sérico fue pequeña, especialmente en los mayores de 70 años. El modelo final de riesgo mostró un buen poder discriminatorio (estadístico C = 0,789 en varones y C = 0,816 en mujeres).

Conclusiones

ERICE es una nueva ecuación de riesgo cardiovascular genuinamente española obtenida a partir del riesgo concurrente individual de los participantes en varias cohortes. La ecuación ERICE ofrece una estimación directa y fiable del riesgo cardiovascular total teniendo en cuenta factores como la diabetes mellitus y el tratamiento farmacológico de los factores de riesgo cardiovascular, habitualmente no incluidos en otras ecuaciones.

Section snippets

INTRODUCTION

Current recommendations on the prevention of cardiovascular disease (CVD) in clinical practice encourage health workers to assess the individual's total CVD risk rather than focus on a specific CVD outcome alone.1

Several risk calculators are available in Europe and the United States2, 3, 4, 5 but most of them have been only validated in middle-aged populations or in areas with a relatively high coronary heart disease (CHD) risk and they do not account for the effect of medications used for risk

Data Sources

The ERICE (Ecuación de Riesgo Cardiovascular Española) project comprised seven population-based cohort studies in different geographical areas of Spain. The designs of the original studies have been detailed elsewhere.10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 A collaborative database was created with the individual data from all participants in these 7 cohorts (Table 1).

The studies had to meet the following criteria: single or multicenter surveys of general adult population of both sexes aged ≥

Characteristics of the Study Population

There were 11 800 participants (5413 men and 6387 women) representing 107 915 person-years of follow-up. The median follow-up for the entire study was 9.1 years. A complete follow-up was reported in 11 416 people (96.7% of the total population; 5235 men and 6181 women). We were able to assess the vital status of 100% of cohort participants (Table 1).

Table 2 shows the cardiovascular risk factors and events distribution by sex and study cohort. In total, 1214 CVD events occurred in the entire

DISCUSSION

The ERICE-score is unique in being based on a large cohort of 11 800 Spanish adults, covering a wide age range with uniform and harmonized baseline data. In contrast to previous scores such as the Framingham and EuroSCORE that were based on populations recruited before the 1990s, our estimates are based on more recent cohorts and offer different charts for individuals treated with antihypertensive drugs or not. The CVD incidence rates of this study stress the need of improving primary prevention

CONCLUSIONS

Age was the strongest risk factor for CVD in both sexes, as was well known. In our study, high SBP was the strongest modifiable risk factor of CVD in men, followed by DM and smoking. In women, DM played a crucial role, followed by high SBP and smoking. The contribution of TC to the CVD risk was small in the Spanish population, and in both sexes when considering all age groups in this study. The ERICE offers a new CVD risk estimation system for the Spanish population derived, from the local and

FUNDING

This research was funded by the Fondo de Investigación Sanitaria, Instituto de Salud Carlos III, grants G03/065 and PI05/1464; and by RECAVA (Red Temática de Investigación Cooperativa en Enfermedades Cardiovasculares), grant RD06/0014/0015.

CONFLICTS OF INTEREST

None declared.

Acknowledgments

To Rosario Madero from Unidad de Bioestadística, IdiPAZ (Instituto de Investigación Sanitaria del Hospital Universitario La Paz), Hospital Universitario La Paz, Madrid and to Nuria Soriano from Centre d’Atenció Primària Sardenya, Barcelona for statistical assistance; to Margarita Alonso Arroyo from IdiPAZ, Madrid and Teresa R. Pérez Castro from Instituto Universitario de Ciencias de la Salud, Universidad de A Coruña for data management. To Ana Isabel Ortega for editorial assistance.

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    See members of the ERICE study group in the Appendix of the supplementary material.

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