Frequently Asked Questions

Welcome to the QRISK^®3-2018 risk calculator

Welcome to the QRISK^®3-2018 Web Calculator. The QRISK^®3 algorithm calculates a person's risk of developing a heart attack or stroke over the next 10 years. It presents the average risk of people with the same risk factors as those entered for that person.

The QRISK^®3 algorithm has been developed by doctors and academics working in the UK National Health Service and is based on routinely collected data from many thousands of GPs across the country who have freely contributed data to the QResearch database for medical research.

QRISK^®3 has been developed for the UK population, and is intended for use in the UK. All medical decisions need to be taken by a patient in consultation with their doctor. The authors and the sponsors accept no responsibility for clinical use or misuse of this score.

The science underpinning QRISK^®3 has been published in the BMJ -- see the publications tab for details.

What does this calculator do?

This cardiovascular risk calculator provides you with an interactive and individualized tool which provides an absolute estimate (%) of a person's chance of having a cardiovascular event over a specific period of time and an idea of the potential benefit of treatment. It is only valid for people who have never had a cardiovascular event.

This calculator was designed to dynamically show how the value of specific risk factors impact cardiovascular risk. Results are shown using a representation of 100 "happy faces" to help illustrate risk. This format seems to be one of the better ways to present risks visually. Risks are also provided as absolute numbers and rounded off to one decimal point even though any cardiovascular estimates likely are +/- 5-10% at best.

There are TWO different views for this calculator. An ENHANCED VIEW which displays all the different types of interventions including non-drug, drugs for cholesterol, drugs for statins, drugs for blood pressure, drugs for glucose. The BASIC VIEW displays only non-drug, statins and ASA as interventions and all patient variables need to be inserted before any numbers are presented. In addition, it only displays three different faces - those with no event, those with an event, and those for benefit. You can toggle back and forth between the two different views.

How do I use the Absolute CVD Risk/Benefit Calculator?

1) Enter the unmodifiable factors

These are the factors that really can't be changed - age, gender, ethnicity/race.

2) Enter the modifiable factors

These are factors that can mostly be modified with lifestyle changes or medications - smoking, blood pressure, cholesterol, diabetes.

3) Estimate benefit

Estimate of benefit - clicking on an intervention like Physical Activity, Mediterranean Diet vs Low Fat, Vitamin/Omega-3 supplements, (if SBP is >/= 140 mmHg) BP Meds, (regardless of cholesterol) Low-mod intensity statins, High intensity statins, Fibrates, Niacin, Ezetimibe, (if diabetic) Metformin, Sulfonylureas, Insulins, Glitazones, GLPs, DPP-4s, Meglitinides, SGLT2 and ASA will input a specific relative benefit and this will be applied to the absolute risk to calculate the % of people who could benefit from a therapy. Examples of relative benefits are taken from a synopsis of the best available evidence - see below for more details

ABSOLUTE NUMBERS - calculated risk and benefits

a) NO EVENT BLUE FACES - are the % of people who would NOT have an event over the time period

Information

What is the difference between QRISK^®3 and QRISK^®2?

QRISK^®3 includes more factors than QRISK^®2 to help enable doctors to identify those at most risk of heart disease and stroke.
These are

• Chronic kidney disease, which now includes stage 3 CKD
• Migraine
• Corticosteroids
• Systemic lupus erythematosus (SLE)
• atypical antipsychotics
• severe mental illness
• erectile dysfunction
• a measure of systolic blood pressure variability

Has QRISK^®3 been validated?

Yes. QRISK^®3 has been validated on a separate group of practices from that used to develop the score and the performance is very good. See the academic paper for more details.

Why change the name from QRISK^®2 to QRISK^®3?

It's the same science and team behind the score, and the way that we intend it to be used remains exactly the same. In many ways it is very similar to our usual annual updates -- however, we thought that as we are introducing several new parameters, we'd upgrade its major version number.

What will now happen to QRISK^®2?

QRISK^®2-2017 will be the last version of QRISK^®2 that we will produce. QRISK^®3 will be the standard version of QRISK^® shipped in our software development kits in 2018, so all implementations will become QRISK^®3 in due course.

The following information below, written for QRISK^®2, applies equally well to QRISK^®3 -- it is just that there are more parameters.

What is the QRISK^®2 CVD score?

• QRISK^®2 is a well-established cardiovascular disease (CVD) risk score, in use across the NHS since 2009, which is designed to identify people at high risk of developing CVD who need to be recalled and assessed in more detail to reduce their risk of developing CVD.
• The QRISK^®2 score estimates the risk of a person developing CVD over the next 10 years.
• QRISK^®2 has been specifically developed by doctors and academics for use in the UK.
• The original research underpinning QRISK^® was published in July 2007 in the British Medical Journal and in January 2008 in Heart journal. The original research underpinning version 2 of QRISK^® (QRISK^®2) has been published in the British Medical Journal in June 2008.
• The research was done using the QResearch anonymised medical research database which consists of the electronic health records of over 10 million patients registered with 550 general practices using the EMIS clinical computer system of whom 2 million contributed to the QResearch database.
• All medical decisions relating to the QRISK^®2 score need to be taken by a patient in consultation with their doctor. The authors, University of Nottingham, ClinRisk and EMIS accept no responsibility for clinical use or misuse of the score.

What is cardiovascular disease?

• Stroke
• Transient ischaemic attack
• Myocardial infarction or heart attacks
• Angina

What does 10 year risk of cardiovascular disease mean and why is it important?

• 10 year risk of cardiovascular disease means the risk of someone developing cardiovascular disease over the next ten years.
• If someone has a 10 year QRISK^®2 score of 20% then in a crowd of 100 people like them, on average 20 people would get cardiovascular disease over the next 10 years. Or put another way, they have a 'one in five' chance of getting cardiovascular disease over the next 10 years.

How can I work out my risk?

• You can use the QRISK^®2 web calculator to estimate your risk.
• Note though that this is just an estimate and that if you do not know some of the information needed for the calculator (like your blood pressure) then it will substitute population average values for someone of your age and sex so the result is just a guide.
• If you are concerned about estimated risk then you can see a doctor or nurse for a full risk assessment.
• Your doctor will have a way of identifying who needs to be assessed based on information already present in your electronic health record and may contact you if you need a review.

What is body mass index and how is it measured?

• Body mass index is a number calculated from your height and weight.
• It is the weight in kilograms divided by the height in metres squared.
• Conventionally a person is considered to be obese if they have a body mass index over 30 kg/m²

What does 'family history of premature coronary heart disease in a first degree relative' mean?

• You have a positive family history if you have a mother, father, brother or sister who has had a heart attack or 'angina' under the age of 60.
• If you have a positive family history it will give you an increased risk so it is even more important that you try to have a healthy lifestyle -- i.e. don't smoke or aren't overweight, do exercise etc.

Which people can have a QRISK^® cardiovascular score calculated?

• You can use QRISK^®2 if you are aged between 25 and 84 years unless you have had a heart attack, angina, stroke or transient ischaemic attack.

I live in the UK and I am from a black or ethnic group. Can I use the QRISK^®2 calculator?

• Yes you can use QRISK^®2 calculator which includes self-assigned ethnicity.

Why does the score need a postcode?

• Cardiovascular risk varies according to where people live and the score takes account of this for us. The postcode is used to calculate the score only. The information is not retained by the website.

I am over 84 years, why isn't QRISK^®2 suitable for someone of my age?

• Most people over the age of 84 years have a risk score of more than 20% and so the QRISK^®2 score isn't terribly useful at identifying high risk patients once they get to this age.

What things can I do myself to reduce my chances of getting heart disease?

• If you are concerned and want to discuss it or get some help to reduce your risk factors, then make an appointment to see your doctor.
• However, you can do things yourself to lower your risk.
• The biggest thing you can do is to stop smoking if you smoke (your doctor can help you with this).
• Take regular exercise (do take professional advice on this!).
• Try to lose weight if you are overweight (body mass index is > 25kg/m²).
• Your doctor might advise you to take medication to lower your blood pressure or lower your cholesterol levels.

I am on blood pressure treatment and I notice that my risk is higher than it would be had I not been taking blood pressure treatment. Why is this?

• Blood pressure treatment lowers your blood pressure and reduces your risk of heart disease and stroke.
• The fact that you are taking blood pressure treatment means that you have already been identified by your doctor as someone needing treatment which automatically puts you in a higher risk group.
• The treatment itself isn't increasing your risk but is acting as a marker for the fact that your underlying risk is higher.

I am already taking statins given to me by my doctor. Should I see what my QRISK^® score is?

• If you are already on statins then your doctor has already assessed your risk and decided to treat you so you don't need to do it again.
• You do need to keep your appointments with your GP and keep taking the treatment you have been given.

What is the difference between QRISK^®2 and the traditional Framingham score?

• Self-assigned ethnicity
• Family History of premature coronary heart disease in a first degree relative under the age of 60
• Deprivation (measured using the Townsend deprivation score)
• Blood Pressure Treatment
• Body Mass Index
• Rheumatoid Arthritis
• Chronic Kidney Disease
• Atrial Fibrillation

Why was a new CVD risk score needed for the UK when we already had Framingham?

• Estimates of CVD risk derived from equations are not an exact science but are better than clinical judgment alone for the estimation of CVD risk.
• A number of risk assessment equations are available that estimate cardiovascular risk in individual patients. They have been derived from studies of individuals who have been followed up often for substantial lengths of time.
• Risk assessment equations predict risk best in the type of population from which they were derived. The Framingham equations were derived from North American populations from the 1960s to the 1980s when coronary heart disease (CHD) was at its peak and they overestimate risk in contemporary European populations by around 100% in Southern European populations and by 50% or more in Northern European populations including the UK.
• Conversely, such equations may underestimate risk in populations such as people with diabetes, South Asian men or the most socially deprived who are at higher than average risk. Overall the Framingham risk equation is likely to overestimate risk in the current UK population.
• They may also underestimate risk in people with extreme risk factor levels or other clinical risks not included in the model.

Why was a measure of socio-economic deprivation included in the QRISK^®2 equation?

• Cardiovascular risk is closely associated with socio-economic status such that people from deprived areas have higher risks.
• Framingham equations do not include socio-economic status and underestimate risk in people who are relatively socially deprived.
• The use of equations that do not include a measure of socio-economic status may exacerbate inequalities in CVD, i.e. the difference between rich and poor.

What is the Townsend score, what does it measure and why was it used?

• The Townsend score is a measure of material deprivation based on where a person lives and obtained using their postcode and includes four variables obtained from census data: unemployment (lack of material resources and insecurity), overcrowding (material living conditions), lack of owner occupied accommodation (a proxy indicator of wealth) and lack of car ownership (a proxy indicator of income).
• This score is considered the best indicator of material deprivation currently available and has been widely used in medical research including a range of studies conducted on the QResearch database.

How has the QRISK^®2 score been validated?

• The original QRISK^®1 score and the QRISK^®2 score were both initially validated in a one third sample of the QResearch database by comparing its performance against the traditional Framingham score which was then in use in the UK. This research was published in the British Medical Journal in July 2007.
• A second validation study was performed using the THIN database (which is a similar UK research database consisting of the electronic records of patients using a different computer system). This was published in the Heart journal in January 2008.
• An editorial accompanying this study explains that the two main measures by which a risk prediction tool should be judged are calibration and discrimination. Calibration relates to how close the predicted risk is to the observed risk. Discrimination is the ability of the tool to differentiate between people who will have an event and those who will not, over a defined period of time (often five to ten years).
• On both measures and in both studies, the QRISK^® scores outperformed Framingham indicating that they are likely to be more accurate than Framingham at estimating cardiovascular risk.
• Further validation studies have now been completed. These studies were undertaken by an independent team of academics using an external data source which represents the gold standard for validating a risk score. The independent validation of QRISK^®1 was published in the BMJ in 2009 and the validation of QRISK^®2 published in the BMJ in 2010 and 2012.

Has QRISK^® been compared against any other cardiovascular risk scores apart from Framingham and what were the results?

• Yes, QRISK^®1 was compared against the Scottish ASSIGN score and the results published in our original BMJ paper. The results showed that QRISK^®1 was better calibrated to the UK population than ASSIGN and that QRISK^®1 had better discrimination. We have found similar results when comparing QRISK^®2 against the ASSIGN score in the QResearch^® database as shown in the table (higher scores represent better performance). Also, statisticians from the University of Oxford have independently validated QRISK^®1 and QRISK^®2 using an independent dataset and found comparable results which they have published in the BMJ.

Where patients are on antihypertensive treatment, should a pre-treatment blood pressure be used when calculating their risk?

• No. QRISK^®2 has been designed such that if a patient is taking antihypertensive medication then their current blood pressure on treatment can be used rather than a pre-treatment value.

What is the difference between an 'estimated' QRISK^®2 CVD score and an 'actual' QRISK^®2 CVD score?

• The actual QRISK^®2 CVD score can be calculated where all values needed to calculate the score are available in the patient's electronic health record or entered directly into www.qrisk.org.
• The estimated QRISK^®2 score is a CVD score which has been calculated using the data recorded in the patient's electronic health record but also using predicted values based on the patient's ethnicity, age and sex where some data are missing.
• For example, if a patient is a 55 year old Indian male and has all the data for calculating a QRISK^®2 score in his 'e' health record except a systolic blood pressure, then the system will select a default value for blood pressure for Indian males aged 55 years.

Why is it important to measure HDL cholesterol in order to get the best estimate of CVD risk?

• It is the ratio of total cholesterol to HDL cholesterol that is the best predictor of risk, better than either total cholesterol or HDL cholesterol alone.
• Someone with a total cholesterol of 7.5mmols/l and an HDL cholesterol of 1.8mmols/l has a ratio of 4.2 which is associated with a considerably lower risk than someone with a total cholesterol of 5.8mmols/l and an HDL of 0.8 (ratio 7.2)

What about other factors which may increase CVD risk but are either not included in the score or fully accounted for?

• There are other factors which can increase CVD risk which are not directly accounted for in the QRISK^®2 algorithm.
• These include, for example, alcohol excess, very heavy smoking, poor diet, lack of exercise and extreme obesity. These factors will all tend to increase risk of cardiovascular disease.
• There is a strong relationship between deprivation and CVD risk, and so the inclusion of deprivation in the QRISK^®2 algorithm will take account of this to some extent.

Has NICE now recommended QRISK^®2?

• Yes, NICE updated its lipid modification guidance in 2010 and in 2014 to include QRISK^®2 as the preferred algorithm for assessing cardiovascular risk.

Why is the QRISK^®2 algorithm updated and changed over time?

• QRISK^®2 is a dynamic risk factor score developed from live anonymised electronic health records recorded by thousands of family doctors in the UK. We know that the characteristics of the population change over time and this will affect the equation itself. For example, the incidence of heart disease itself has fallen over the last 30 years, blood pressure has fallen, obesity is rising, smoking patterns have changed.
• QRISK^®2 is therefore updated annually in order to reflect these population changes and also to take advantage of the continual improvements in the quality of electronic health records and the latest evidence regarding new or additional risk factors.

I am a GP. Is QRISK^® available in the clinical computer systems?

• Yes. QRISK^®2 is integrated into all four of the main GP computer systems -- EMIS, Vision, SystmOne and Microtest.
• In addition, there are third party software companies which have CVD prevention software. A list of approved suppliers which licence our professionally supported QRISK^®2 software development kit is available.

I am interested in using the QRISK^®2. Where can I find out more information?

• Please see the tab marked 'Software' above.

Annual updates

Information on the annual updates can be found at the following links:

• QRISK2 2010 Annual Update Information
• QRISK2 2011 Annual Update Information
• QRISK2 2012 Annual Update Information
• QRISK2 2013 Annual Update Information
• QRISK2 2014 Annual Update Information
• QRISK2 2015 Annual Update Information
• QRISK2 2016 Annual Update Information

Publications

QRISK^®3 includes more factors than QRISK^®2 to help enable doctors to identify those at most risk of heart disease and stroke.
Here's the latest paper:

• Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study, BMJ 2017;357:j2099

The other scientific papers which describe the development and validation of QRISK^® are available at the links below:

• Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2, BMJ 2008;336:1475-82
• Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study, BMJ July 2007;335;136
• Performance of the QRISK cardiovascular risk prediction algorithm in an independent UK sample of patients from general practice: a validation study, Heart 2008;94:34-39
• An independent external validation and evaluation of QRISK cardiovascular risk prediction: a prospective open cohort study, BMJ 2009;339:b2584
• An independent and external validation of QRISK2 cardiovascular disease risk score: a prospective open cohort study, BMJ 2010;340:c2442
• Collins, GS, Altman, DG, Predicting the 10 year risk of cardiovascular disease in the United Kingdom: independent and external validation of an updated version of QRISK2. BMJ 2012;344:e4181.

• Validation of QRISK2 (2014) in patients with diabetes, Hippisley-Cox J, Coupland CA, Brindle P.

QRISK^®2 and QRISK^®3 allow us to predict risk more accurately among people from different ethnic groups.

An external independent validation of QRISK^®2, which compares it with Framingham and the new US CVD score in a US population, and shows that QRISK^®2 performs best:

• Pike MM, Decker PA, Larson NB, et al. Improvement in Cardiovascular Risk Prediction with Electronic Health Records. Journal of Cardiovascular Translational Research 2016:1-9 doi: 10.1007/s12265-016-9687-z

• Crossan C, Lord J, Ryan R, Nherera L, Marshall T. Cost effectiveness of case-finding strategies for primary prevention of cardiovascular disease: a modelling study. British Journal of General Practice 2016 doi: 10.3399/bjgp16X687973

• Hippisley-Cox J, Coupland C, Brindle P. The performance of seven QPrediction risk scores in an independent external sample of patients from general practice: a validation study. BMJ Open 2014;4:e005809

About

This calculator uses

• the QRISK^®3 algorithm, version 2017
• the BMI predictor algorithm, version 2013.0
• the cholesterol ratio predictor algorithm, version 2013.0
• the SBP predictor algorithm, version 2013.0

Risk engine built by ClinRisk Ltd.

Modified by Ufuk Ali TURK, MD.