SCORE2 & SCORE2-OP
What is new?
From SCORE to SCORE2 & SCORE2-OP
The Focused Update continues to endorse the concept supported in the 2019 Guidelines that a person’s estimated absolute risk of having an acute CV event should be used to guide the intensity of LDL-C lowering. It is also acknowledged that the CV risk reduction achievable by a similar magnitude of lowering atherogenic lipid levels appears to be greater at younger ages.
The Focused Update endorse the use of risk scores SCORE2 and SCORE2-OP for risk prediction. This has substantial implication for the type of events predicted and definition of risk categories.
- SCORE 2 algorithms predict both fatal and non-fatal events.
- Extended age range, encompassing ages 70-89.
- Risk thresholds have changed.
Due to the transition to SCORE2, thresholds for risk categories have changed. Broadly a multiplier by two has been applied to the thresholds in this update, as the risk of non-fatal cardiovascular disease is 2-3 time higher than for fatal cardiovascular disease.
Cardiovascular risk category
| Risk Factor | Very high (Any present) | High (Any present) | Moderate (Any present) | Low |
| SCORE2 or SCORE2-OP | ≥20% | 10%-<20% | 2%-<10% | <2% |
| Diabetes | Traget organ damage Three major risk factors Early onset and long duration Type 1 | Without target organ damage DM duration ≥10 years or additional risk factors | Type 1<35 years or Type 2<50 years, no other risk factors | |
| Familial Hypercholesterolemia | With ASCVD or major risk factor | Without other risk factors | ||
| Chronic Kidney Disease | eGFR <30 mL/min/1.73 m2 | eGFR 30-59 mL/min/1.73 m2 | ||
| ASCVD | Documented ASCVD, clinical or on imaging | |||
| Markedly elevated single risk factors | TC >8 mmol/L (>310 mg/dL) LDL-C >4.9 mmol/L (>190 mg/dl) BP ≥180/110 mmgHg |
Risk modifiers
The update recognises that risk is a continuum and thresholds may lead to misclassifications. Therefore it is recommended to consider potential risk modifiers in addition to risk category. Reliance on thresholds alone may lead to arbitrary classification of risk in patients.
A wide range of modifiers are relevant for estimation of cardiovascular risk, ranging from living conditions, biomarkers to clinical conditions. A complete clinical picture aids classification beyond algorithm alone.
Risk modifiers for consideration beyond the risk estimation based on the SCORE2 and SCORE2-OP algorithms:
| Demography | Lifestyle | Biomarkers | Clinical Conditions |
| Family history of premature CVD (men: <55 years; women: <60 years) | Stress symptoms and psychosocial stressors | Persistently elevated hs-CRP (>2 mg/L) | Obesity |
| High-risk (e.g. Southern Asian) ethnicity | Physical inactivity | Elevated Lp(a) (>50 mg/dL or approximately >105 nmol/L) | Chronic immune-mediated/inflammatory disorder |
| Social deprivation | Human immunodeficiency virus infection | ||
| History of premature menopause | |||
| Pre-eclampsia or other hypertensive disorders of pregnancy | |||
| Obstructive sleep apnoea syndrome | |||
| Major psychiatric disorders |
Recommendations
| Recommendations | Classa | Levelb |
| SCORE2 is recommended in apparently healthy people <70 years of age without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk.2c | I | B |
| SCORE2-OP is recommended in apparently healthy people ≥70 years of age without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk.3c | I | B |
| Presence of subclinical coronary atherosclerosis by imaging or increased CAC score by CT should be considered as risk modifiers in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification.24,27,28,36 d | IIa | B |
| Risk modifiers should be considered in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification.17,27,37 f | IIa | B |
| In primary prevention,g pharmacological LDL-C-lowering therapy is recommended in persons: – at very high risk and LDL-C ≥1.8 mmol/L (70 mg/dL), or – at high risk and LDL-C ≥2.6 mmol/L (100 mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk.1,13,38,39 | I | A |
| In primary prevention,g pharmacological LDL-C-lowering therapy should be considered in persons: – at very high risk and LDL-C ≥1.4 (55 mg/dL) but <1.8 mmol/L (70 mg/dL), or – at high risk and LDL-C ≥1.8 (70 mg/dL) but <2.6 mmol/L (100 mg/dL), or – at moderate risk and LDL-C ≥2.6 (100 mg/dL) but <4.9 mmol/L (190 mg/dL), or – at low risk and LDL-C ≥3.0 (116 mg/dL) but <4.9 mmol/L (190 mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk.1,13,38,39 | IIa | A |
ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CAC, coronary artery calcium; CKD, chronic kidney disease; CT, computed tomography; CVD, cardiovascular disease; DM, diabetes mellitus; LDL-C, low-density lipoprotein cholesterol; SCORE2, Systematic Coronary Risk Estimation 2; SCORE2-OP, Systematic Coronary Risk Estimation 2 for Older Patients.
a Class of recommendation.
b Level of evidence.
c Revised recommendation replacing the respective recommendation based on SCORE in the 2019 ESC/EAS Guidelines.
d Revised recommendation replacing the recommendation on CAC score for CV risk assessment in the 2019 ESC/EAS Guidelines.
e Listed in Box 1 in the Guidelines.
f New recommendation.
g Persons without known clinical atherosclerotic cardiovascular disease