Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC)
- 1Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee, Scotland, UK
- 2Bristol Teaching Primary Care Trust and Department of Social Medicine, University of Bristol, Bristol, UK
- Correspondence to:
Professor Hugh Tunstall-Pedoe
Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, Scotland, UK;
- Accepted 26 October 2006
- Published Online First 7 November 2006
Objective: To improve equity in cardiovascular disease prevention by developing a cardiovascular risk score including social deprivation and family history.
Design: The ASSIGN score was derived from cardiovascular outcomes in the Scottish Heart Health Extended Cohort (SHHEC). It was tested against the Framingham cardiovascular risk score in the same database.
Setting: Random-sample, risk-factor population surveys across Scotland 1984–87 and North Glasgow 1989, 1992 and 1995.
Participants: 6540 men and 6757 women aged 30–74, initially free of cardiovascular disease, ranked for social deprivation by residence postcode using the Scottish Index of Multiple Deprivation (SIMD) and followed for cardiovascular mortality and morbidity through 2005.
Results: Classic risk factors, including cigarette dosage, plus deprivation and family history but not obesity, were significant factors in constructing ASSIGN scores for each sex. ASSIGN scores, lower on average, correlated closely with Framingham values for 10-year cardiovascular risk. Discrimination of risk in the SHHEC population was significantly, but marginally, improved overall by ASSIGN. However, the social gradient in cardiovascular event rates was inadequately reflected by the Framingham score, leaving a large social disparity in future victims not identified as high risk. ASSIGN classified more people with social deprivation and positive family history as high risk, anticipated more of their events, and abolished this gradient.
Conclusion: Conventional cardiovascular scores fail to target social gradients in disease. By including unattributed risk from deprivation, ASSIGN shifts preventive treatment towards the socially deprived. Family history is valuable not least as an approach to ethnic susceptibility. ASSIGN merits further evaluation for clinical use.
- cardiovascular disease
- Scottish Heart Health Extended Cohort
- socioeconomic status
Published Online First 7 November 2006
Funding: Scottish Executive Health Department for this analysis. The Cardiovascular Epidemiology Unit and its studies were funded by a British Heart Foundation Programme grant from 1995 to late 2005, and before that by the Chief Scientist Office of the Scottish Home and Health Department. The opinions expressed in this paper are those of the authors and not the funding bodies.
Competing interests: None declared.
MW planned the analysis of the database, developed the risk score and carried out its critical evaluation, contributing appropriately to the manuscript. PB contributed to the design concept and made critical contributions to the development of the score and the manuscript. HTP planned the study in consultation with the SIGN risk estimation group, obtained the funding, managed and updated the database with staff of the Dundee Unit, is guarantor of the data, assisted in planning the score and in its evaluation, and wrote the paper.
Members of the SIGN (Scottish Intercollegiate Guidelines Network, 28 Thistle Street, Edinburgh EH2 1EN) risk estimation group who helped to refine the study proposal and analyses were: Dr James Grant (chair, principal in general practice, Auchterarder), Dr Moray Nairn (secretary, SIGN Edinburgh), Dr Adrian Brady (consultant cardiologist, Glasgow), Dr Peter Brindle (research and development strategy lead and honorary research fellow, Bristol Teaching Primary Care Trust and Department of Social Medicine, University of Bristol), Mrs Joyce Craig (senior health economist, NHS Quality Improvement Scotland), Dr Alex McConnachie (statistician, Robertson Institute, Glasgow), Mr Adam Redpath (Programme Principal, Information Services, NHS National Services Scotland, Edinburgh), Mr Roger Stableford (patient representative, Falkirk), Professor Hugh Tunstall-Pedoe (cardiovascular epidemiologist, Dundee) and Professor Graham Watt (general practice, Glasgow).
Ethical approval was received from all relevant medical research ethics committees covering the individual populations involved.