What's new in risk prediction guidelines?

Highlight: EPCCS satellite symposium held at WONCA meeting in September 2008 in Istanbul

Although traditional risk factors account for 90% of all CVD cases (Yusuf S. Lancet 2004) and several evidence-based treatment programs exist that reduce these risk factors, physicians often underestimate their patients’ CVD risk.(Backlund L et al. Prim Health Care Res Dev 2004).

It is generally accepted that subjects at high risk of CVD (existing CVD) are eligible for immediate reduction of overall disease (secondary prevention). In addition, the Framingham Heart Study showed the importance of detecting those at risk of CVD without pre-existing disease (primary prevention). The question that needs to be answered is how we should scale risk factors into treatment decisions.

For this reason, in 2003 the SCORE system was developed. The SCORE system consists of two charts, estimating the 10-years risk of fatal CVD, for high and low risk regions, male or female, based on age, smoking, systolic blood pressure and cholesterol levels.
Subjects with a risk over 10% are eligible for reduction of overall risk by titration of treatments aimed at traditional risk factors.
Inevitably, the SCORE system has several limitations, the most important one being that CVD risk scores are not easy to use in a busy practice In daily practice only 13% of physicians use these risk charts (Erhardt L. Int J Clin Pract 2002) and, although these risk charts seem to benefit the elderly, they may not adequately estimate the risk of CVD in younger adults. Cardiovascular risk scoring should be considered in the following situations: when a patient asks for it, when one risk factor is known to be raised, when the person is a middle-aged smoker, when there is a family history of premature CVD or of major risk factors such as hyperlipidemia, or in case of symptoms of suggestive CVD. Total risk should be assessed by medical history, physical examination, laboratory test, ECG and exercise ECG (if angina is suspected), or echocardiography (in young or severely hypertensive subjects). Measuring CRP, Lpa, fibrinogen and homocysteine can be considered on specialist referral.

There are several proposed alternatives to the currently used CVD risk calculation, such as CRP, BNP, aldosterone, homocysteine. However, these biomarkers seem to add little to the standard risk factors (Wang et al. N Engl J Med 2006).

CVD primary prevention has increased during the last years, but a large proportion of subjects still remains untreated. Moreover, the public does not seem to be well informed about the risks of CHD. They are unaware that CHD is the main cause of death and that cholesterol is an important risk factor for CHD. In conclusion, the current CVD risk score calculators are adequate but underutilized. Therefore, the current CVD guidelines should be simplified and unified.

Current guidelines advise the clinician to identify overall CVD risk on the basis of multiple risk factors. Furthermore, clinicians are advised to target all risk factors and to titrate treatments aimed at traditional risk factors. However, CVD risk scores are not easy to use in a busy practice.