CARDIOVASCULAR MEDICINE

Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee, UK

Correspondence to:
Professor Hugh Tunstall-Pedoe
Cardiovascular Epidemiology Unit, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK; h.tunstallpedoe{at}dundee.ac.uk

Objective: To examine whether the efficiency and equity of cardiovascular risk scores that identify patients at high risk for preventive interventions are compromised by omitting social deprivation, which contributes to risk.

Design: Cohort study.

Setting: The SHHEC (Scottish heart health extended cohort) study of random sample risk factor surveys across 25 districts of Scotland in 1984–87 and North Glasgow in 1989, 1992, and 1995

Participants: 6419 men and 6618 women aged 30–74, free of cardiovascular disease at baseline, followed up with permission for mortality and morbidity to March 1997. Participants were allocated to population fifths of the Scottish index of multiple deprivation (SIMD) and their observed coronary risk was compared with that expected from the Framingham score for all coronary heart disease.

Results: The Framingham score overestimated risk overall and in each SIMD fifth. It seriously underestimated the variation in risk with deprivation. The relative risk of observed 10 year coronary risk (sexes combined) analysed across population fifths had a steep gradient, from least to most deprived, of 1.00, 1.81, 1.98, 2.22, and 2.57. Expected risk, calculated from baseline risk factor values and the Framingham score, had one quarter of that gradient, with relative risks of 1.00, 1.17, 1.19, 1.28, and 1.36.

Conclusion: Cardiovascular risk estimated by the Framingham and related scores is misleading in guiding treatment decisions among people at different levels of social deprivation. Such scores foster relative undertreatment of the socially deprived, exacerbating the social gradients in disease, which national policies seek to minimise. Debate and action are needed to correct this anomaly.

Keywords: prevention; cardiovascular disease; Framingham score; social status; MONICA project

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This article has been cited by other articles:

• Bhala, N., Zaman, M J. S (2009). Preventing premature mortality in chronic diseases for South Asians in the UK and beyond. JRSM 102: 459-463 [Full Text]  
• Collins, G. S, Altman, D. G (2009). An independent external validation and evaluation of QRISK cardiovascular risk prediction: a prospective open cohort study. BMJ 339: b2584-b2584 [Abstract] [Full Text]  
• Pagano, D, Freemantle, N, Bridgewater, B, Howell, N, Ray, D, Jackson, M, Fabri, B M, Au, J, Keenan, D, Kirkup, B, Keogh, B E, on behalf of the Quality and Outcomes Research Uni, (2009). Social deprivation and prognostic benefits of cardiac surgery: observational study of 44 902 patients from five hospitals over 10 years. BMJ 338: b902-b902 [Abstract] [Full Text]  
• Capewell, S. (2008). Will screening individuals at high risk of cardiovascular events deliver large benefits? No. BMJ 337: a1395-a1395 [Full Text]  
• Christiaens, T. (2008). Cardiovascular risk tables. BMJ 336: 1445-1446 [Full Text]  
• Harald, K, Koskinen, S, Jousilahti, P, Torppa, J, Vartiainen, E, Salomaa, V (2008). Changes in traditional risk factors no longer explain time trends in cardiovascular mortality and its socioeconomic differences. J. Epidemiol. Community Health 62: 251-257 [Abstract] [Full Text]  
• Macleod, J., Metcalfe, C., Smith, G. D., Hart, C. (2007). Does consideration of either psychological or material disadvantage improve coronary risk prediction? Prospective observational study of Scottish men. J. Epidemiol. Community Health 61: 833-837 [Abstract] [Full Text]  
• Hippisley-Cox, J., Coupland, C., Vinogradova, Y., Robson, J., May, M., Brindle, P. (2007). Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study. BMJ 335: 136-136 [Abstract] [Full Text]  
• Woodward, M., Brindle, P., Tunstall-Pedoe, H., for the SIGN group on risk estimation*, (2007). Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 93: 172-176 [Abstract] [Full Text]  
• Jurgensen, J S (2006). The value of risk scores. Heart 92: 1713-1714 [Abstract] [Full Text]