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Original research article
Prognostic validation of a non-laboratory and a laboratory based cardiovascular disease risk score in multiple regions of the world
  1. Philip Joseph1,
  2. Salim Yusuf1,
  3. Shun Fu Lee1,
  4. Quazi Ibrahim1,
  5. Koon Teo1,
  6. Sumathy Rangarajan1,
  7. Rajeev Gupta2,
  8. Annika Rosengren3,
  9. Scott A Lear4,
  10. Alvaro Avezum5,
  11. Patricio Lopez-Jaramillo6,
  12. Sadi Gulec7,
  13. Afzalhussein Yusufali8,
  14. Jephat Chifamba9,
  15. Fernando Lanas10,
  16. Rajesh Kumar11,
  17. Noushin Mohammadifard12,
  18. Viswanathan Mohan13,
  19. Prem Mony14,
  20. Annamarie Kruger15,
  21. Xu Liu16,
  22. Baoxia Guo17,
  23. Wenqi Zhao18,
  24. Youzhu Yang19,
  25. Rajamohanan Pillai20,
  26. Rafael Diaz21,
  27. Ambigga Krishnapillai22,
  28. Romaina Iqbal23,
  29. Rita Yusuf24,
  30. Andrzej Szuba25,
  31. Sonia S Anand1
  32. on behalf of the PURE INVESTIGATORS
  1. 1 Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
  2. 2 Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, and Fortis Escorts Hospital, Jaipur, India
  3. 3 Sahlgrenska University Hospital/Östra Hospital, Goteborg, Sweden
  4. 4 Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
  5. 5 Dante Pazzanese Institute of Cardiology and UNISA, São Paulo, Brazil
  6. 6 Fundacion Oftalmologica de Santander (FOSCAL) and Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia
  7. 7 School of Medicine, Ankara University, Ankara, Turkey
  8. 8 Hatta Hospital, Dubai Health Authority, and Dubai Medical University, Dubai, UAE
  9. 9 Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
  10. 10 Department of Internal Medicine, Universidad de La Frontera, Temuco, Chile
  11. 11 Department of Community Medicine & School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  12. 12 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  13. 13 Madras Diabetes Research Foundation, Chennai, India
  14. 14 St John’s Medical College & Research Institute, Bangalore, India
  15. 15 Faculty of Health Science, North-West University, Potchefstroom, South Africa
  16. 16 Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Fu Wai Hospital, Beijing, China
  17. 17 Shenyang Red Cross Hospital, Shenyang, China
  18. 18 Chinese Center for Disease Control and Prevention, Xi’ning, China
  19. 19 Huizu Hospital, Xi’ning, China
  20. 20 Health Action by People, and SMCSI Medical College Karakonam, Trivandrum, India
  21. 21 Estudios Clinicos Latinoamerica ECLA, Rosario, Argentina
  22. 22 Hospital Angkatan Tentera Tuanku Mizan, Kuala Lumpur, Malaysia
  23. 23 Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  24. 24 Independent University, Bangladesh (IUB), Dhaka, Bangladesh
  25. 25 Wroclaw Medical University, Wroclaw, Poland
  1. Correspondence to Dr Philip Joseph, Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada; philip.joseph{at}


Objective To evaluate the performance of the non-laboratory INTERHEART risk score (NL-IHRS) to predict incident cardiovascular disease (CVD) across seven major geographic regions of the world. The secondary objective was to evaluate the performance of the fasting cholesterol-based IHRS (FC-IHRS).

Methods Using measures of discrimination and calibration, we tested the performance of the NL-IHRS (n=100 475) and FC-IHRS (n=107 863) for predicting incident CVD in a community-based, prospective study across seven geographic regions: South Asia, China, Southeast Asia, Middle East, Europe/North America, South America and Africa. CVD was defined as the composite of cardiovascular death, myocardial infarction, stroke, heart failure or coronary revascularisation.

Results Mean age of the study population was 50.53 (SD 9.79) years and mean follow-up was 4.89 (SD 2.24) years. The NL-IHRS had moderate to good discrimination for incident CVD across geographic regions (concordance statistic (C-statistic) ranging from 0.64 to 0.74), although recalibration was necessary in all regions, which improved its performance in the overall cohort (increase in C-statistic from 0.69 to 0.72, p<0.001). Regional recalibration was also necessary for the FC-IHRS, which also improved its overall discrimination (increase in C-statistic from 0.71 to 0.74, p<0.001). In 85 078 participants with complete data for both scores, discrimination was only modestly better with the FC-IHRS compared with the NL-IHRS (0.74 vs 0.73, p<0.001).

Conclusions External validations of the NL-IHRS and FC-IHRS suggest that regionally recalibrated versions of both can be useful for estimating CVD risk across a diverse range of community-based populations. CVD prediction using a non-laboratory score can provide similar accuracy to laboratory-based methods.

  • cardiovascular disease
  • risk prediction
  • INTERHEART risk score

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors PJ, SY, SFL, QI, KT and SSA contributed to the conception and design of the paper; analysis and interpretation of the data; and drafting the article. SR, RG, AR, SL, AA, PL-J, SG, AY, JC, FL, RK, NM, VM, PM, AnK, XL, BG, WZ, YY, RP, RD, AmK, RI, RY and SSA contributed to the acquisition of data and critical revision of the article for intellection content. PJ, SFL and QI are responsible for the overall content of the article and data analysis.

  • Funding A full description of funding is provided in the supplementary appendix.

  • Competing interests None declared.

  • Ethics approval Hamilton Integrated Research Ethics Board, McMaster University.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Unpublished data related to this study are not available for public use as consent for this was not obtained by participants at the time of study enrolment.

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