Key result
Adding diet and physical activity to SCORE2-OP yields ~41% net reclassification in older adults.
Why the study?
The SCORE2 and SCORE2-OP models for estimating 10-year risk of first ASCVD do not include lifestyle factors, leaving uncertain whether adding self-reported physical activity and Mediterranean diet adherence improves risk prediction.
Does adding self-reported physical activity and Mediterranean diet adherence improve 10-year first incident ASCVD risk prediction beyond SCORE2/SCORE2-OP in the general population?
Cohort (n=2,587)
Does adding self-reported physical activity and Mediterranean diet adherence improve 10-year first incident ASCVD risk prediction beyond SCORE2/SCORE2-OP in the general population?
Adding self-reported physical activity and Mediterranean diet adherence to SCORE2-OP significantly improves ASCVD risk discrimination, calibration, and reclassification in adults aged 70 years or older, though it offers no predictive improvement over SCORE2 in younger adults.
Background The SCORE2/SCORE2-OP, recommended for estimating 10-year risk of first atherosclerotic cardiovascular disease (ASCVD), does not include lifestyle factors. We investigated whether adding self-reported physical activity and Mediterranean diet adherence improves prediction beyond SCORE2/SCORE2-OP. Methods We analyzed participants from the population-based cohort with data for the Physical Activity Frequency Questionnaire (PAFQ) and Mediterranean Diet Score (MedDietScore). Participants with history of cardiovascular disease, lipid-lowering therapy, diabetes, severe chronic kidney disease or LDL-cholesterol > 4.9 mmol/L were excluded from this analysis. Different Cox-based prediction models were tested: SCORE2 or SCORE2-OP depending on the participant age, alone or in addition to PAFQ, MedDietScore or both. Discrimination (Harrell’s C), calibration slope and net reclassification improvement (NRI) were calculated. The primary outcome was first incident ASCVD (myocardial infarction, ischemic stroke and cardiovascular death). Results A total of 2,587 participants (59% women; median age 55 years) were followed for a median duration of 9.0 years (IQR: 8.13-11.6), during which 145 ASCVD events occurred. Of these, 2,348 were younger than 70 years and evaluated using SCORE2, with 106 ASCVD events. The remaining 239 were aged 70 years or older and assessed with SCORE2-OP, with 39 ASCVD events. Adding physical activity or diet or both to SCORE2 did not improve discrimination (Harrell’s C: 0.74 for all models), calibration (slope: 1.06 for all), nor reclassification (continuous total NRI: -8.8 to 2.5%). In contrast, adding both lifestyle factors to SCORE2-OP improved discrimination (Harrell’s C: 0.63 to 0.66), calibration (slope: 1.34 to 1.16) and reclassification (continuous total NRI: 41% (95%CI 7–74%) with event (ASCVD) NRI of 28% and non-event (non-ASCVD) NRI of 13%). Conclusion The addition of self-reported physical activity and Mediterranean diet may be clinically useful to improve ASCVD risk prediction in older adults beyond the traditional SCORE2-OP.
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Artels et al. (2026) conducted a cohort in Atherosclerotic cardiovascular disease (ASCVD) risk in the general population (n=2,587). Addition of self-reported physical activity (PAFQ) and Mediterranean diet adherence (MedDietScore) to SCORE2/SCORE2-OP vs. SCORE2 or SCORE2-OP alone was evaluated on First incident ASCVD (myocardial infarction, ischemic stroke, and cardiovascular death) (Continuous total NRI 41% (in SCORE2-OP ≥70 years); Harrell's C 0.66 vs 0.63, 95% CI 7-74%). Adding physical activity and Mediterranean diet to SCORE2-OP in adults ≥70 years improved ASCVD prediction (Harrell's C 0.63 to 0.66; NRI 41%, 95% CI 7–74%), with no improvement for SCORE2 (<70 years).
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