Using population-wide electronic health records for timely contemporary assessment of cardiovascular disease risk prediction model performance: COVID-19 impact on the SCORE2 models

Abstract

BACKGROUND AND AIMS: Risk estimation is key for primary prevention of cardiovascular diseases (CVD). The European Society of Cardiology recommends SCORE2, SCORE2-OP (Older Persons), and SCORE2-Diabetes (collectively, the SCORE2 family-of-models (FOMs)) for 10-year CVD-risk estimation. As the COVID-19 pandemic was associated with higher CVD incidences, we externally validated the SCORE2-FOMs using contemporary nationwide data and assessed the need for adaptation.

METHODS: Using population-wide electronic health records (EHRs) for England, we defined a cohort of 26.5 million individuals aged 40 to 89 years without prior CVD on 1st January 2022 followed-up until 31st December 2023. We calculated annual incidence rates of CVD events and non-CVD mortality by sex and one-year age-groups to estimate expected 10-year, competing-risk adjusted, CVD-risk using a life-table approach. We assessed SCORE2-FOMs calibration and discrimination, overall and by subgroups.

RESULTS: Within two years of follow-up, 239,815 incident CVD events occurred. For SCORE2, SCORE2-Diabetes, and SCORE2-OP the C-index values were 0.75 (95%CI: 0.75-0.76), 0.71 (0.71-0.71) and 0.65 (0.65-0.65), respectively. SCORE2-FOMs overpredicted CVD risks by 3% to 4% in males, and by 8% to 14% in females, with calibration variations by English region and ethnic group. Elevated CVD-risk associated with a recent COVID-19 hospitalisation led SCORE2 to underestimate risks by 2% in affected males aged 40-69 years.

CONCLUSION: The SCORE2-FOMs demonstrated good calibration and discrimination, suggesting that no adaptation is needed in response to the COVID-19 pandemic. Short-term EHRs provide a valuable resource for timely contemporary risk model validation and, if necessary, for adaptation according to shifts in CVD trends.

Rights

© The Author(s) 2026. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite as

Downloadable citations

Identifiers

DOI

https://doi.org/10.1093/eurjpc/zwag179