QRISK3 Calculator

QRISK3 is the 2017 updated version of the QRISK cardiovascular risk prediction algorithm, recommended by NICE in the UK. It estimates 10-year risk of CVD (MI, stroke, coronary death) and includes ethnicity, social deprivation (Townsend score), BMI, CKD, migraine, RA, SLE, severe mental illness, and erectile dysfunction.

QRISK3 adds CKD (stage 3–5), migraine, RA, SLE, severe mental illness, erectile dysfunction, and a more detailed ethnicity classification. It uses updated incidence rates from UK primary care data (QResearch).

NICE guideline recommends statin therapy for primary prevention when 10-year QRISK score is ≥ 10%. This is a lower threshold than the ACC/AHA 7.5% ASCVD threshold. Shared decision-making is emphasized.

Categories include White, Indian, Pakistani, Bangladeshi, Other Asian, Black Caribbean, Black African, Chinese, and Other. Bangladeshi ethnicity carries the highest risk (RR 1.87 vs White), while Chinese has the lowest (RR 0.82).

BMI is included as a continuous variable. Higher BMI increases risk, especially when combined with metabolic syndrome. The relationship is J-shaped, with very low BMI also associated with increased risk (confounding by smoking or chronic illness).

The Townsend deprivation score is included. Higher deprivation (unemployment, poor housing, lack of car access) increases CVD risk. This is a unique feature of QRISK not found in ASCVD or Framingham.

The Townsend index uses four variables: unemployment percentage, non-car ownership, non-home ownership, and household overcrowding. Higher scores mean greater deprivation. It is measured at the postcode level.

CKD (stage 3–5, eGFR < 60) increases CVD risk approximately 1.5–2 fold. QRISK3 is the first version to include CKD. CKD patients have higher risk at given risk factor levels and benefit from statin therapy (SHARP trial).

Migraine, especially with aura, increases risk of ischemic stroke and CVD 1.5–2 fold, particularly in women. Mechanism may involve endothelial dysfunction and vasospasm. QRISK3 is the first to include migraine.

Rheumatoid arthritis is associated with accelerated atherosclerosis due to chronic systemic inflammation. CVD risk is approximately 1.5–2 fold higher. ACC/AHA also considers RA a risk enhancer.

QRISK is UK-based from QResearch with 4+ million patients; includes ethnicity, deprivation, CKD, migraine, RA, SLE. ASCVD is US-based; includes race (Black/White); uses fewer risk factors. QRISK has better calibration in UK populations.

The healthy lifestyle QRISK estimates risk with optimal factors: non-smoker, BMI < 25, healthy diet, regular physical activity, moderate alcohol. The difference between actual and healthy risk is a powerful motivational tool.

Smoking cessation alone reduces risk 30–50% over 5–10 years. Weight loss (10%) reduces risk 15–20%. Regular exercise reduces risk 20–30%. Mediterranean diet reduces risk 30%. Combined reduction can exceed 50%.

The NHS Health Check is a free program for adults 40–74 in England assessing CVD risk via QRISK. It includes BP, cholesterol, BMI, and lifestyle review. Patients with QRISK ≥ 10% are offered statin and lifestyle intervention.

Every 5 years for low-risk adults unless new risk factors develop. Every 1–3 years for intermediate or high-risk patients. After statin initiation, reassess within 3–6 months for lipids and adherence.

QRISK3 is validated for adults aged 25–84. Ages 25–39 have low absolute risk but significant lifetime risk. Above 84, the algorithm has limited validation and clinical judgment is recommended.

Type 1 and type 2 diabetes are strong risk factors. Duration and glycemic control (HbA1c) matter. In type 1, CVD risk is especially high with nephropathy. QRISK3 does not explicitly include HbA1c but diabetes status captures much risk.

Family history of premature CVD (first-degree relative < 60) is not directly in QRISK but is a risk enhancer. It approximately doubles risk if present. NICE recommends considering it in shared decision-making.

Atrial fibrillation increases stroke risk 4–5 fold. It is not in QRISK3 (which estimates total CVD). Patients with AF need CHA2DS2-VASc for stroke risk and anticoagulation if score ≥ 2.

QRISK3 uses a Cox proportional hazards model with fractional polynomial terms and interactions. Full coefficients are published in BMJ 2017. Our tool approximates the algorithm for educational purposes with key risk factors.

QResearch is a large UK primary care database of anonymized records from 1,500+ general practices. It has been used to develop QRISK, QFracture, QDiabetes, and other prediction models with comprehensive ethnicity and deprivation data.

Systemic lupus erythematosus (SLE) increases CVD risk, especially in young women. QRISK3 includes SLE (RR ~1.5). Mechanism involves chronic inflammation, immune dysregulation, and corticosteroid effects on vasculature.

Variables: age, sex, ethnicity, Townsend score, BMI, systolic BP, BP treatment, smoking, diabetes (type 1/2), TC/HDL ratio, family history, CKD, migraine, RA, SLE, severe mental illness, erectile dysfunction, and atrial fibrillation.

QRISK3 includes ethnicity-specific coefficients. South Asian groups (Indian, Pakistani, Bangladeshi) have higher risk at same factor levels. Chinese have lower risk. This improves calibration in diverse UK populations.

NICE recommends statins when QRISK ≥ 10%. Atorvastatin 20 mg is the usual starting dose. Higher baseline risk = greater absolute risk reduction. Typical LDL reduction is 35–50%.

For QRISK 10%, absolute risk reduction with moderate statin is 1.5–2% over 10 years (NNT 50–70). For QRISK 20%, NNT ~25–35. This is considered cost-effective by NICE.

Preeclampsia, gestational diabetes, preterm delivery, and PCOS are associated with increased long-term CVD risk. These are not directly in QRISK but are risk enhancers that clinicians should consider.

HbA1c is not directly in QRISK3 but higher levels correlate with diabetes severity and CVD risk. For patients with diabetes, HbA1c > 7% indicates poorer glycemic control and likely higher risk than captured by diabetes status alone.

Heavy alcohol use (> 14 units/week) increases BP and CVD risk. Moderate consumption (1–2 units/day) may be protective but this is controversial. Alcohol is not directly in QRISK3 but affects BP, BMI, and diabetes.

NICE updated its guideline in 2017 to recommend QRISK3. UK general practices phased in QRISK3 between 2017–2019. The updated algorithm provides better risk discrimination, especially for ethnic minorities and those with CKD or autoimmune diseases.

Calculate QRISK at NHS Health Check or when CVD risk factors present. Discuss result with patient using heart age or risk visualization. If ≥ 10%, offer atorvastatin 20 mg and lifestyle advice. Repeat QRISK after 1–5 years depending on risk level.