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By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease
  1. H Tunstall-Pedoe,
  2. M Woodward,
  3. for the SIGN group on risk estimation
  1. Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee, UK
  1. Correspondence to:
    Professor Hugh Tunstall-Pedoe
    Cardiovascular Epidemiology Unit, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK; h.tunstallpedoe{at}


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.

  • MONICA, monitoring trends and determinants in cardiovascular disease
  • SHHEC, Scottish heart health extended cohort
  • SIMD, Scottish index of multiple deprivation
  • prevention
  • cardiovascular disease
  • Framingham score
  • social status
  • MONICA project

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  • Published Online First 15 September 2005

  • The Scottish Executive Health Department funded this analysis. The Cardiovascular Epidemiology Unit and its studies have been funded by a British Heart Foundation Programme grant since 1996, now ending, and before that by the Chief Scientist Office of the Scottish Home and Health Department. Opinions expressed in this paper are those of the authors and not of the funding bodies

  • Competing interests: none declared.

  • Ethical approval was obtained from all relevant medical research ethics committees covering the individual populations involved

    HTP planned the study in consultation with the SIGN risk estimation group, obtained the funding, coded the end points, and prepared the database with staff of the Dundee Unit, is guarantor of the data, and drafted the paper. MW conducted the statistical analyses and is authoring a more comprehensive technical report.