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Cardiovascular Risk and Risk Scores: ASSIGN, Framingham, QRISK and others: how to choose
  1. Hugh Tunstall-Pedoe
  1. Correspondence to Prof Hugh Tunstall-Pedoe, Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, UK; h.tunstallpedoe{at}

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Coronary heart disease and stroke contribute significantly to premature mortality and morbidity. Largely preventable, they demand prevention. Emphases range from responsibilities of governments to individuals, and the clinic nurses or doctors advising and treating them. The risk of cardiovascular disease varies. To be efficient and effective, medical interventions must focus on those at highest risk.

The strongest marker of risk is existing cardiovascular disease (diabetes often included) demanding secondary prevention, now routine medical therapy. Next comes age, the criterion the polypill's promoters proposed for medicating the population.1 Age, sex and existing disease are major determinants of cardiovascular risk, but work begun 60 years ago in Framingham, USA,2 gave us risk factors—individual characteristics identifying increased risk. Combined as multifactorial risk they predict more than individual factors (see table 1). Since the Framingham classics (age, sex, smoking, blood pressure and lipids) other risk factors and scores have been proposed. The accompanying paper published in this issue of Heart examines some scores used currently in the UK (see page 491).3 How to choose?

View this table:
Table 1

Percentage of 10-year cardiovascular events occurring in high-risk category (top 20% for continuous variables) (Scottish Heart Health Extended Cohort). Sexes combined.

The first criterion is utility. If a score is user-friendly, motivates the clinic nurse or doctor and the patient to start and persist with preventive action, it is a good score. A sheathed sword cannot cut. Any score that gives positive weighting to age, smoking, blood pressure and lipids will largely agree with another. Debate should not encourage nihilism. Easy implementation matters: factors included should be available, or justify their addition.

Chauvinism is a questionable criterion, but motivates new scores. From the USA came Framingham and preventive (not …tative) cardiology.4 Framingham is often depreciated as based on outdated, middle-aged Americans. In 1991 specifications for developing …

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  • Linked article 203364.

  • Patient consent Obtained.

  • Sole contributor's statement of interest The sole contributor, Hugh Tunstall-Pedoe, developed the ASSIGN cardiovascular risk score jointly with Mark Woodward in 2006, in relation to the revised SIGN (Scottish Intercollegiate Guidelines Group) guideline 97 ‘Risk estimation and the prevention of cardiovascular disease’.10 11 It is adopted by SIGN and the Scottish Government Health Directorates as the current cardiovascular risk score of choice in Scotland.

  • Provenance and peer review Commissioned; not externally peer reviewed.

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