Cardiovascular Risk-Estimation Systems in Primary Prevention: Do They Differ? Do They Make a Difference? Can We See the Future?

In this review of cardiovascular risk estimation, we focus on 4 key aspects: (1) The rationale for estimating cardiovascular risk; (2) a comparison of current cardiovascular disease (CVD) risk-estimation systems; (3) an examination of whether there is any evidence that cardiovascular risk estimation improves patient outcomes; and (4) how CVD risk estimation may change in the future. Some of the material presented is derived from a recent general review of cardiovascular risk scores1 that we have used to underpin the present, more focused discussion. The atherosclerosis underlying most CVD is rarely the result of a single risk factor, such as familial hyperlipidemia, but more usually the end result of the combined effect of several risk factors. If one considers single risk factors, even if the evidence for intervention is based on randomized controlled trials, either overtreatment or undertreatment may result. Consider, for example, Table 1, taken from the current Joint European Guidelines on the prevention of CVD in clinical practice.2 Who should receive the statin? The 60-year-old woman with a blood cholesterol level of 8 mmol/L (309 mg/dL) and a 2% 10-year risk of fatal CVD or the man of the same age with a cholesterol level of 5 mmol/L (193 mg/dL) but a 10-fold higher risk because of multiple other risk factors? Current therapeutic trial data do not tell us, but logic would suggest the man, along with, of course, attention to all other factors. View this table: Table 1. Impact of Combinations of Risk Factors on Total CVD Risk These considerations have led the authors of all current guidelines to stress the need to consider the likely impact of all risk factors before making clinical management decisions and, in most cases, to recommend a system of evaluating combined risk factor effects.2–5 To be clinically useful, a CVD …