Keywords: SCORE, Risk factor, Risk management, Risk assessment, Additional risk factors

Background:

The SCORE system for cardiovascular risk assessment (CVR) has been implemented in the primary care across Europe. However, its use in general practice is often limited by the absence of structured follow-up. Additionally, a number of countries, including Bulgaria use locally adapted versions of the system.

Research questions:

To compare cardiovascular risk assessment, using three different methodologies: SCORE ESC (2016), SCORE from the National Framework Contract (NFC) in Bulgaria, and SCORE ESC (2019), and to propose an improved model for cardiovascular risk management in general practice for the Bulgarian population.

Method:

This was a prospective cohort study with retrospective data collection. We included 4,551 patients from a general practice in Pavlikeni, Bulgaria, over a period of one calendar year. Each patient’s CVR was assessed using all three methodologies. Additional risk factors were considered. The analysis included descriptive statistics, non-parametric tests, and a relative risk calculation, using 95% confidence intervals and a significance level of α = 0.05.

Results:

SCORE ESC (2019) showed the highest diagnostic performance, with superior sensitivity, specificity, and predictive validity. These results were supported by the gold standard comparisons and morbidity-to-mortality index analysis. The relative risk of cardiovascular events was calculated, assessed and compared between two groups (exposed and unexposed individuals) based on the three SCORE methodologies. Furthermore, the addition of three risk factors -BMI > 30, blood glucose > 6.1 mmol/L, and treated but poorly controlled hypertension - led to notable patient reclassification, particularly from moderate to higher-risk categories. A modified risk model was developed to enhance the accuracy and clinical relevance of cardiovascular risk assessment in general practice.

Conclusions:

SCORE ESC (2019) outperformed other methods in risk prediction. The proposed model, integrating three additional risk factors, improves classification accuracy and supports more effective CVR management in primary care.

Points for discussion:

What is the experience with SCORE adaptation and use in other countries?