I read with great interest the study by Rogozik et al. [1], which demonstrated that cardiovascular risk assessed using SCORE2 was substantially higher than that estimated with Pol-SCORE in patients with hypercholesterolemia without established cardiovascular disease. Through risk reclassification and comparisons of treatment status between the two scoring systems, the authors further showed that many individuals classified as high or very high risk by SCORE2 were discharged without lipid-lowering therapy. This finding highlights a clinically relevant treatment gap in primary prevention.
A key explanation for this discrepancy lies in the different conceptual focus of the two models. Pol-SCORE estimates the 10-year risk of cardiovascular mortality, whereas SCORE2 was developed to predict the 10-year risk of both fatal and nonfatal cardiovascular events, including myocardial infarction and stroke [2, 3]. Over recent decades, advances in acute cardiovascular care and pharmacological therapy have reduced case fatality, while the overall burden of nonfatal cardiovascular events has remained substantial.
In this clinical context, mortality-centered risk models may underestimate cardiovascular risk despite ongoing disease activity. Accordingly, current European Society of Cardiology prevention guidelines recommend SCORE2 or SCORE2-OP as the preferred tools for cardiovascular risk estimation [2].
Contemporary cardiovascular risk is increasingly shaped not only by endpoint selection but also by the underlying structure of disease, particularly the clustering of obesity-related cardiometabolic conditions [4]. Obesity is not merely an isolated risk factor but a central driver of the coexistence of hypertension, atherogenic dyslipidemia, and insulin resistance, which together substantially increase the risk of nonfatal, including recurrent, cardiovascular events [5, 6]. Risk models focused predominantly on fatal outcomes may therefore fail to capture this evolving disease architecture.
From this perspective, the findings reported by Rogozik et al. [1] further support the clinical relevance of SCORE2 in reflecting the contemporary burden of cardiovascular disease and reinforce its importance in guiding primary prevention strategies.