PLOS ONE Medicine&Health

Comparison of laboratory-based and non-laboratory-based WHO and GLOBORISK CVD risk scores: A cross-sectional analysis of the APCAPS cohort

by Hemant Mahajan, Poppy Alice Carson Mallinson, Judith Lieber, Santhi Bhogadi, Santosh Kumar Banjara, Anoop Shah, Vipin Gupta, Gagandeep Kaur Walia, Bharati Kulkarni, Sanjay Kinra

Cardiovascular diseases (CVDs) represent a growing public-health challenge in India, where nearly one in four deaths is CVD-related. Accurate risk stratification underpins targeted prevention, yet laboratory-dependent tools are often impractical in resource-limited settings. The World Health Organization (WHO) and GLOBORISK initiatives both offer non-laboratory-based 10-year CVD risk algorithms alongside their laboratory-based counterparts. We aimed to compare laboratory- and non-laboratory-based WHO and GLOBORISK CVD risk scores, assess their concordance, and examine relationships with sub-clinical atherosclerosis in a rural Indian cohort.

We conducted a cross-sectional analysis of 2,465 adults (1,184 men, 1,281 women) aged 40−74 years from the third wave (2010−12) of the Andhra Pradesh Children and Parents Study (APCAPS). Participants with prior CVD were excluded. Ten-year CVD risk was calculated using sex-specific WHO (South Asia) and India-calibrated GLOBORISK models, both laboratory-based (age, sex, smoking, systolic blood pressure, diabetes, total cholesterol) and non-laboratory-based (age, sex, smoking, systolic blood pressure, BMI) algorithms. Categorical agreement was quantified via percentage agreement and quadratic weighted kappa (κ); continuous agreement by Bland-Altman analysis. We also evaluated linear associations between each risk score (categorical and continuous) and three sub-clinical atherosclerosis markers: carotid intima-media thickness (CIMT), pulse-wave velocity (PWV), and augmentation index (AIx), through sex-stratified multi-level linear regression with random intercept at the household level, adjusting for multiple testing (p  Results

Median WHO-CVD-risk was 6.0% (IQR 4% − 9%) in men and 3.0% (2% − 4%) in women for both lab and non-lab models; median GLOBORISK-CVD-risk was 12.0% (9% − 16%) for lab-model vs. 15.0% (10% − 16%) for non-lab-model in men and 5.0% (3% − 9%) for lab-model vs. 5.0% (3% − 9%) for non-lab-model in women. Categorical agreement was substantial to almost perfect: WHO κ = 0.82 (overall), GLOBORISK κ = 0.72. Bland-Altman analyses demonstrated mean differences Conclusion

Non-laboratory-based WHO and GLOBORISK CVD risk scores exhibit high overall agreement with laboratory-based models and correlate strongly with subclinical atherosclerosis in rural India. However, modest underestimation in high-risk subgroups (diabetics, hypercholesterolemia) warrants cautious interpretation. These findings support the feasibility of non-lab risk assessment in resource-constrained settings, while underscoring the need for prospective validation against hard cardiovascular outcomes prior to large-scale implementation.