Cardiovascular prevention in general practice: development and validation of an algorithm Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. A simple risk score using routine data for predicting cardiovascular disease in primary care. Electronic Health Record-Based Patient Identification and Individualized Mailed Outreach for Primary Cardiovascular Disease Prevention: A Cluster Randomized Trial An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. NHS health checks through general practice: randomised trial of population cardiovascular risk reduction An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial The impact of individualised cardiovascular disease (CVD) risk estimates and lifestyle advice on physical activity in individuals at high risk of CVD: a pilot 2 × 2 factorial understanding risk trial Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour Motivational interviewing and problem solving treatment to reduce type 2 diabetes and cardiovascular disease risk in real life: a randomized controlled trial Cognitive-behavioral treatment of women's body-image dissatisfaction. Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial. Physicians' perception, knowledge and awareness of cardiovascular risk factors and adherence to prevention guidelines: the PERCRO-DOC survey. Estimating the population impact of screening strategies for identifying and treating people at high risk of cardiovascular disease: modelling study Predicting the 30-Year Risk of Cardiovascular Disease: The Framingham Heart Study ESC Working Group on Valvular Heart Disease Position Paper: assessing the risk of interventions in patients with valvular heart disease. Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT
Objective — General practice visits are a unique opportunity to identify and treat individuals with a high cardiovascular ( CV ) risk . However , a case-finding strategy suited to the daily general practice is not provided in the CV prevention guidelines .We wanted to create , vali date and test an algorithm for global CV risk assessment and management . Methods — The algorithm was 1 ) developed based on evidence from epidemiological studies and clinical trials , 2 ) vali date d in a population -based cohort and 3 ) tested by r and omly selected general practitioners ( GPs ) who rated its usefulness and applicability . Results — 1 ) Screening for seven clinical risk factors ( RF ) allowed a quick classification of patients in four CV risk typologies : obvious high risk ( previous CV event and /or type 2 diabetes ) in 17 % , obvious low risk ( no RF ) in 14 % , smoking-related risk ( single RF ) in 6 % , or undetermined risk ( any other RF ) to further evaluate in 63 % patients . Inter-physician reproducibility for risk prediction was excellent . Overall , predicted risk was high , moderate and low in 25 , 17 and 58 % of the patients , respectively . 2 ) These risk predictions were vali date d in a cohort of 962 men followed over 10 years . 3 ) Most GPs reported that the algorithm was applicable and useful , while half of them started using it frequently in their daily practice . Conclusion — This algorithm is a new , pragmatic and evidence -based strategy for systematic and global CV risk management . It was vali date d at the population level , and shown to be applicable and useful in the daily general practice AIMS To estimate the potential effectiveness of different " high-risk " and " population " approaches to the primary prevention of  cardiovascular disease ( CVD ) in middle-aged British men , after correction for regression dilution bias . METHODS AND RESULTS We used a combination of cohort and r and omised controlled trial evidence to estimate the effectiveness of high-risk strategies , based on the identification of high-risk factors or high absolute risk , and strategies based on population -wide reductions in cholesterol and blood pressure . High-risk strategies were potentially effective but would need to be used widely to have a substantial effect on CVD in the population . Aggressive pharmacological treatment ( using statins , beta-blockers , ACE-inhibitors and aspirin ) in individuals with a 10-year Framingham event risk of > or=30 % ( 6 % of population ) would have reduced major CVD by at most 11 % . This figure increased to 34 % at a > or=20 % treatment threshold ( 26 % of population ) . In contrast , modest downwards shifts in the population distributions of serum total cholesterol and systolic blood pressure led to marked expected reductions in major CVD . Taking regression dilution bias into account , 10 % reductions in long-term mean blood cholesterol and blood pressure could have reduced major CVD by 45 % . CONCLUSIONS If high-risk strategies are to have a major impact on CVD in the population , they need to be more widely used than previously envisaged . Population -wide reduction of major risk factors is needed if CVD is to be substantially reduced BACKGROUND Population -based screening for cardiovascular disease ( CVD ) risk , incorporating blood tests , is proposed in several countries . AIM The aim of this study was to evaluate whether a simple approach to identifying individuals at high risk of CVD using routine data might be effective . DESIGN OF STUDY Prospect i ve cohort study ( EPIC-Norfolk ) . SETTING Norfolk area , UK . METHOD A total of 21 867 men and women aged 40 - 74 years , who were free from CVD and diabetes at baseline , participated in the study . The discrimination ( the area under the receiver operating characteristic curve [ aROC ] ) , calibration , sensitivity/specificity , and positive/negative predictive value were evaluated for different risk thresholds of the Framingham risk equations and the Cambridge diabetes risk score ( as an example of a simple risk score using routine data from electronic general practice records ) . RESULTS During 203 664 person-years of follow-up , 2213 participants developed a first CVD event ( 10.9 per 1000 person-years ) . The Cambridge diabetes risk score predicted CVD events reasonably well ( aROC 0.72 ; 95 % confidence interval [ CI ] = 0.71 to 0.73 ) , while the Framingham risk score had the best predictive ability ( aROC 0.77 ; 95 % CI = 0.76 to 0.78 ) . The Framingham risk score overestimated risk of developing CVD in this representative British population by 60 % . CONCLUSION A risk score incorporating routinely available data from GP records performed reasonably well at predicting CVD events . This suggests that it might be more efficient to use routine data as the first stage in a stepwise population screening programme to identify people at high risk of developing CVD before more time- and re source -consuming tests are used ABSTRACT BACKGROUND Many individuals at higher risk for cardiovascular disease ( CVD ) do not receive recommended treatments . Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness . OBJECTIVE AND DESIGN To perform a 9-month cluster-r and omized trial , comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care . PARTICIPANTS Patients of participating physicians with a Framingham Risk Score of at least 5 % , low-density lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment , and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis .INTERVENTION Patients of physicians r and omized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin ( and controlling hypertension or quitting smoking when relevant).MAIN MEASURES The primary outcome was occurrence of a LDL-cholesterol level , repeated in routine practice , that was at least 30 mg/dl lower than prior . A secondary outcome was lipid-lowering drug prescribing . Clinical trials.gov identifier : NCT01286311.KEY RESULTS Fourteen physicians with 218 patients were r and omized to intervention , and 15 physicians with 217 patients to control . The mean patient age was 60.7 years and 77 % were male . There was no difference in the primary outcome ( 11.0 % vs. 11.1 % , OR 0.99 , 95 % CI 0.56–1.74 , P = 0.96 ) , but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication ( 11.9 % , vs. 6.0 % , OR 2.13 , 95 % CI 1.05–4.32 , p = 0.038 ) . In post hoc analysis with extended follow-up to 18 months , the primary outcome occurred more often in the intervention group ( 22.5 % vs. 16.1 % , OR 1.59 , 95 % CI 1.05–2.41 , P = 0.029 ) . CONCLUSIONS In this effectiveness trial , individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions , but we observed no difference in proportions lowering LDL-cholesterol after 9 months . With longer follow-up , the intervention ’s effect on LDL-cholesterol levels was apparent BACKGROUND Accurate risk assessment of atherosclerotic cardiovascular disease ( ASCVD ) is essential to effectively balance the risks and benefits of therapy for primary prevention . OBJECTIVE To compare the calibration and discrimination of the new American Heart Association ( AHA ) and American College of Cardiology ( ACC ) ASCVD risk score with alternative risk scores and to explore preventive therapy as a cause of the reported risk overestimation using the AHA-ACC-ASCVD score . DESIGN Prospect i ve epidemiologic study of ASCVD . SETTING MESA ( Multi-Ethnic Study of Atherosclerosis ) , a community-based , sex-balanced , multiethnic cohort . PATIENTS 4227 MESA participants aged 50 to 74 years and without diabetes at baseline . MEASUREMENTS Observed and expected events for the AHA-ACC-ASCVD score were compared with 4 commonly used risk scores- and their respective end points-in MESA after a 10.2-year follow-up . RESULTS The new AHA-ACC-ASCVD and 3 older Framingham-based risk scores overestimated cardiovascular events by 37 % to 154 % in men and 8 % to 67 % in women . Overestimation was noted throughout the continuum of risk . In contrast , the Reynolds Risk Score overestimated risk by 9 % in men but underestimated risk by 21 % in women .  Aspirin , lipid-lowering or antihypertensive therapy  , and  interim revascularization  did not explain the overestimation . LIMITATION Comparability of MESA with target population s for primary prevention and possibility of missed events in MESA . CONCLUSION Of the 5 risk scores , 4 , including the new AHA-ACC-ASCVD score , showed overestimation of risk ( 25 % to 115 % ) in a modern , multiethnic cohort without baseline clinical ASCVD . If vali date d , overestimation of ASCVD risk may have substantial implication s for individual patients and the health care system . PRIMARY FUNDING SOURCE National Heart , Lung , and Blood Institute Background The global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century . The Department of Health in Engl and has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk . The aims of this study were to monitor population changes in cardiovascular disease ( CVD ) risk factors over the first year of the new service and to assess the value of tailored lifestyle support , including motivational interview with ongoing support and referral to other services . Methods R and omised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent , Engl and . Thirty eight general practice s and 601 ( 365 usual care , 236 additional lifestyle support ) patients were recruited and r and omised independently between September 2009 and February 2010 . Changes in population CVD risk between baseline and one year follow-up were compared , using intention-to-treat analysis . The primary outcome was the Framingham 10 year CVD risk score . Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories . Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for : weight management , physical activity , cook and eat and positive thinking . Results Average population CVD risk decreased from 32.9 % to 29.4 % ( p < 0.001 ) in the NHS Health Check only group and from 31.9 % to 29.2 % ( p < 0.001 ) in the NHS Health Check plus additional lifestyle support group . There was no significant difference between the two groups at either measurement point . Prevalence of high blood pressure , high cholesterol and smoking were reduced significantly ( p < 0.01 ) in both groups . Prevalence of central obesity was reduced significantly ( p < 0.01 ) in the group receiving additional lifestyle support but not in the NHS Health Check only group . Conclusions The NHS Health Check service in Stoke on Trent result ed in significant reduction in estimated population CVD risk . There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction Background Cardiovascular diseases ( CVD ) are responsible for significant morbidity , premature mortality , and economic burden . Despite established evidence that supports the use of preventive medications among patients at high CVD risk , treatment gaps remain . Building on prior evidence and a theoretical framework , a complex intervention has been design ed to address these gaps among high-risk , under-treated patients in the Australian primary care setting . This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities ; availability of a range of CVD polypills ( fixed-dose combinations of two blood pressure lowering agents , a statin ± aspirin ) for prescription when appropriate ; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification . Methods Following a systematic development process , the intervention will be evaluated in a pragmatic cluster r and omized controlled trial including 70 general practice s for a median period of 18 months . The 35 general practice s in the intervention group  will work with a nominated partner pharmacy , whereas those in the control group will provide usual care without access to the intervention tools . The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels at the study end . The outcomes will be analyzed using data from electronic medical records , utilizing a vali date d extraction tool . Detailed process and economic evaluations will also be performed . Discussion The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients , pharmacists , and general practitioners ( GPs ) for CVD prevention . Trial registration Australian New Zeal and Clinical Trials Registry Background There is currently much interest in encouraging individuals to increase physical activity in order to reduce CVD risk . This study has been design ed to determine if personalised CVD risk appreciation can increase physical activity in adults at high risk of CVD . Methods / Design In a 2 × 2 factorial design participants are allocated at r and om to a personalised 10-year CVD risk estimate or numerical CVD risk factor values ( systolic blood pressure , LDL cholesterol and fasting glucose ) and , simultaneously , to receive a brief lifestyle advice intervention targeting physical activity , diet and smoking cessation or not . We aim to recruit 200 participants from Oxfordshire primary care practice s. Eligibility criteria include adults age 40–70 years , estimated 10-year CVD risk ≥20 % , ability to read and write English , no known CVD and no physical disability or other condition reducing the ability to walk . Primary outcome is physical activity measured by ActiGraph accelerometer with biochemical , anthropometrical and psychological measures as additional outcomes . Primary analysis is between group physical activity differences at one month powered to detect a difference of 30,000 total counts per day of physical activity between the groups . Additional analyses will seek to further eluci date the relationship between the provision of risk information , and intention to change behaviour and to determine the impact of both interventions on clinical and anthropometrical measures including fasting and 2 hour plasma glucose , fructosamine , serum cotinine , plasma vitamin C , body fat percentage and blood pressure . Discussion This is a pilot trial seeking to demonstrate in a real world setting , proof of principal that provision of personalised risk information can contribute to behaviour changes aim ed at reducing CVD risk . This study will increase our underst and ing of the links between the provision of risk information and behaviour change and if successful , could be used in clinical practice with little or no modification Background Cardiovascular disease ( CVD ) remains the leading cause of death globally . Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions . An integral part of this approach is the use of CVD risk scores . Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies . We aim to evaluate short-term effects of providing different types of information about coronary heart disease ( CHD ) risk , alongside lifestyle advice , on health-related behaviours . Methods / Design In a parallel-group , open r and omised trial , we are allocating 932 male and female blood donors with no previous history of CVD aged 40–84 years in Engl and to either no intervention ( control group ) or to one of three active intervention groups : i ) lifestyle advice only ; ii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics ; and iii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics . The primary outcome is change in objective ly measured physical activity . Secondary outcomes include : objective ly measured dietary behaviours ; cardiovascular risk factors ; current medication and healthcare usage ; perceived risk ; cognitive evaluation of provision of CHD risk scores ; and psychological outcomes . The follow-up assessment takes place 12 weeks after r and omisation . The experiences , attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups . Discussion The INFORM study has been design ed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours . Trial registration Current Controlled Trials IS RCT N17721237 . Registered 12 January 2015 Background Intensive lifestyle interventions in well-controlled setting s are effective in lowering the risk of chronic diseases such as type 2 diabetes ( T2DM ) and cardiovascular diseases ( CVD ) , but there are still no effective lifestyle interventions for everyday practice . In the Hoorn Prevention Study we aim ed to assess the effectiveness of a primary care based lifestyle intervention to reduce the estimated risk of developing T2DM and for CVD mortality , and to motivate changes in lifestyle behaviors . Methods The Hoorn Prevention Study is a parallel group r and omized controlled trial , implemented in the region of West-Friesl and , the Netherl and s. 622 adults with ≥10 % estimated risk of T2DM and /or CVD mortality were r and omly assigned and monitored over a period of 12 months . The intervention group ( n=314 ) received a theory-based lifestyle intervention based on an innovative combination of motivational interviewing and problem solving treatment , provided by trained practice nurses in 12 general practice s. The control group ( n=308 ) received existing health brochures . Primary outcomes was the estimated diabetes risk according to the formula of the Atherosclerosis Risk In Communities ( ARIC ) Study , and the estimated risk for CVD mortality according to the Systematic COronary Risk Evaluation ( SCORE ) formula . Secondary outcomes included lifestyle behavior ( diet , physical activity and smoking ) . The research assistants , the principal investigator and the general practitioners were blinded to group assignment . Linear and logistic regression analysis was applied to examine the between-group differences in each outcome measure , adjusted for baseline values . Results 536 ( 86.2 % ) of the 622 participants ( age 43.5 years ) completed the 6-month follow-up , and 502 ( 81.2 % ) completed the 12-month follow-up . The mean baseline T2DM risk was 18.9 % ( SD 8.2 ) and the mean CVD mortality risk was 3.8 % ( SD 3.0 ) . The intervention group participated in a median of 2 sessions . Intention-to-treat analyses showed no significant differences in outcomes between the two groups at 6 or 12-months follow-up . Conclusions The lifestyle intervention was not more effective than health brochures in reducing risk scores for T2DM and CVD or improving lifestyle behavior in an at-risk population .Trial registration Current Controlled Trials : IS RCT Body-image dissatisfaction is a problem that affects a substantial minority ofwomen and cuts across various diagnostic groups . College women with a significant level ofbody-image dissatisfaction were r and omly assigned to either a cognitive-behavioral treatment ( CBT ) program  ( n = 15 ) or to a waiting-list control group  ( n = 16 ) . The CBT program consisted of six structured , individual sessions that applied cognitive-behavioral procedures to the problem of negative body image . At pretest , posttest , and 7-week foUow-up , multiple aspects of body image and other areas of psychosocial functioning were assessed . Relative to the control condition , the CBT program successfully improved affective body image , weakened maladaptive body-image cognitions , and enhanced social self-esteem and feelings about physical fitness and sexuality . Treatment effects were largely maintained at followup . After posttest , the control group received a 3-week treatment with immediate effects that generally replicated those obtained in the 6-wer program AIM The EUROACTION PLUS trial measured the effectiveness of a nurse-led preventive cardiology programme ( EUROACTION ) offering intensive smoking cessation PLUS optional varenicline for persistent high CVD risk smokers to reduce overall cardiovascular risk compared with usual care ( UC ) in general practice ( GP ) . METHODS AND RESULTS A parallel group r and omized controlled trial in 20 GP in Italy , Netherl and s , Spain , and UK . Six hundred and ninety-six current smokers , ( 137 vascular disease and 559 high total CVD risk ) , were r and omized 350 to EUROACTION PLUS ( EA+ ) and 346 to UC . Specially , trained nurses offered the EUROACTION preventive cardiology programme addressing smoking cessation , diet , physical activity , and risk factor management to reduce overall cardiovascular risk . The primary endpoint was 7 day point prevalence of self-reported abstinence ( vali date d breath carbon monoxide < 10 p.p.m . ) at 16 weeks . Secondary outcomes included dietary habits , physical activity , weight , blood pressure ( BP ) , lipid , and glucose management . One hundred and seventy-seven ( 51 % ) EA+ patients ( 91 % opted to use varenicline ) were abstinent vs. 63 ( 19 % ) in UC ; OR 4.52 ( 95 % CI : 3.20 - 6.39 ) . The Mediterranean diet score of ≥9 in 149 ( 52 % ) EA+ patients vs. 97 ( 37 % ) in UC ; OR 1.84 ( 95 % CI : 1.31 - 2.59 ) . Physical activity target achieved in 46 ( 16 % ) EA+ patients vs. 19 ( 7 % ) in UC ; OR 2.48 ( 95 % CI : 1.41 - 4.36 ) . Target BP ( < 140/90 mm Hg ) achieved in 150 ( 52 % ) EA+ patients vs. 112 ( 43 % ) in UC , OR 1.47 ( 95 % CI : 1.05 - 2.06 ) with no difference in antihypertensive drugs . There were no differences in management of cholesterol or glucose . CONCLUSIONS The EUROACTION preventive cardiology programme in high CVD risk smokers using optional varenicline substantially increased smoking abstinence over 16 weeks and also reduced overall cardiovascular risk compared with UC . REC reference : 09/H0402/85 ; EudraCT number : 2009 - 012451 - 18 ; http://www.controlled-trials.com/IS RCT N22073647 , 12 February 2014 , date last accessed BACKGROUND Cardiovascular diseases ( CVD ) are the major cause of premature death in the world . This study was design ed to examine the physicians ' knowledge and perception of CVD risk factors and perceived implementation of CVD prevention guidelines as well as barriers to their implementation . METHODS A question naire survey by face-to-face interviews was performed among 1382 r and omly selected physicians ( general practitioners/family medicine specialists , internists and cardiologists ) from different regions of Croatia . RESULTS Most physicians believe that guidelines are useful but only 56.9 % are really using some guidelines . 40.2 % favour Joint European guidelines . More primary care physicians use their own personal experience in prevention while internists and cardiologists tend more to use the guidelines . 80.6 % believe that they treat their patients with dyslipidemia well but only 53.3 % knew the LDL-cholesterol goal value for high-risk patients and only 56.2 % knew which HDL-cholesterol level is the marker of increased risk . Hypertension was perceived as the most important risk factor , particularly by primary care physicians , while cardiologists tend to favour diabetes . Although most physicians considered the lack of financial re sources as the main barrier in CVD prevention , at the same time most of them believe that it could primarily be improved by better patient education . CONCLUSIONS Although most physicians support the guidelines use , only half of them use them and in average their knowledge of guidelines is not satisfactory . This is , together with the lack of time and finances and perceived lack of patients ' awareness , probably one of the main causes why they do not manage risk factors better Objective To estimate the potential population impact of different screening strategies for identifying and treating people at high risk of cardiovascular disease , including strategies using routine data for cardiovascular risk stratification , in light of the UK government ’s recommended national strategy to screen all adults aged 40 - 74 for cardiovascular risk . Design Modelling study using data from a prospect i ve cohort , EPIC-Norfolk ( European Prospect i ve Investigation of Cancer-Norfolk ) . Setting An English county . Participants 16 970 men and women aged 40 - 74 and free from cardiovascular disease and diabetes at baseline . Main outcome measures The main outcomes were the population attributable fraction , the number needed to screen to prevent one new case of cardiovascular disease , the number needed to treat to prevent one new case of cardiovascular disease , and the number of new cardiovascular events that could be prevented . Relative risk reductions for estimated treatment effects were derived from meta-analyses of clinical trials or guidelines from the National Institute for Health and Clinical Excellence . Results 1362 cardiovascular events occurred over 183 586 person years of follow-up . Compared with the recommended government strategy , a stepwise screening approach using a simple risk score incorporating routine data could prevent a similar number ( lower to upper estimates ) of new cardiovascular events annually in the United Kingdom ( 26 789 , 20 778 to 36 239 ) and 25 134 ( 19 450 to 34 134 ) , respectively ) but requiring only 60 % of the population to be invited to attend a vascular risk assessment . A similar number of cardiovascular events ( 25 016 , 19 563 to 33 372 ) could also be prevented by inviting everyone aged 50 - 74 for a vascular assessment . Using a participant completed Finnish diabetes risk score question naire or anthropometric cut-off points for risk prestratification was less effective . Conclusions Compared with the UK government ’s recommended national strategy to screen all adults aged 40 - 74 for cardiovascular risk , an approach using routine data for cardiovascular risk stratification before inviting people at high risk for a vascular risk assessment may be similarly effective at preventing new cases of cardiovascular disease , with potential cost savings Background — Present cardiovascular disease ( CVD ) risk prediction algorithms were developed for a ≤10-year follow up period . Clustering of risk factors at younger ages and increasing life expectancy suggest the need for longer-term risk prediction tools . Methods and Results — We prospect ively followed 4506 participants ( 2333 women ) of the Framingham Offspring cohort aged 20 to 59 years and free of CVD and cancer at baseline examination in 1971–1974 for the development of “ hard ” CVD events ( coronary death , myocardial infa rct ion , stroke ) . We used a modified Cox model that allows adjustment for competing risk of noncardiovascular death to construct a prediction algorithm for 30-year risk of hard CVD . Cross-vali date d survival C statistic and calibration & khgr;2 were used to assess model performance . The 30-year hard CVD event rates adjusted for the competing risk of death were 7.6 % for women and 18.3 % for men . St and ard risk factors ( male sex , systolic blood pressure , antihypertensive treatment , total and high-density lipoprotein cholesterol , smoking , and diabetes mellitus ) , measured at baseline , were significantly related to the incidence of hard CVD and remained significant when up date d regularly on follow-up . Body mass index was associated positively with 30-year risk of hard CVD only in models that did not up date risk factors . Model performance was excellent as indicated by cross-vali date d discrimination C=0.803 and calibration & khgr;2=4.25 ( P=0.894 ) . In contrast , 30-year risk predictions based on different applications of 10-year functions proved inadequate . Conclusions — St and ard risk factors remain strong predictors of hard CVD over extended follow-up . Thirty-year risk prediction functions offer additional risk burden information that complements that of 10-year functions AIMS Risk scores provide an important contribution to clinical decision-making , but their validity has been question ed in patients with valvular heart disease ( VHD ) , since current scores have been mainly derived and vali date d in adults undergoing coronary bypass surgery . The Working Group on Valvular Heart Disease of the European Society of Cardiology review ed the performance of currently available scores when applied to VHD , in order to guide clinical practice and future development of new scores . METHODS AND RESULTS The most widely used risk scores ( EuroSCORE , STS , and Ambler score ) were review ed , analysing variables included and their predictive ability when applied to patients with VHD . These scores provide relatively good discrimination , i.e. a gross estimation of risk category , but can not be used to estimate the exact operative mortality in an individual patient because of unsatisfactory calibration . CONCLUSION Current risk scores do not provide a reliable estimate of exact operative mortality in an individual patient with VHD . They should therefore be interpreted with caution and only used as part of an integrated approach , which incorporates other patient characteristics , the clinical context , and local outcome data . Future risk scores should include additional variables , such as cognitive and functional capacity and be prospect ively vali date d in high-risk patients . Specific risk models should also be developed for newer interventions , such as transcatheter aortic valve implantation Background A pilot project cardiovascular prevention was implemented in S and well ( West Midl and s , UK ) . This used electronic primary care records to identify untreated patients at high risk of cardiovascular disease then invited these high risk patients for assessment by a nurse in their own general practice . Those found to be eligible for treatment were offered treatment . During the pilot a higher proportion of high risk patients were started on treatment in the intervention practice s than in control practice s. Following the apparent success of the prevention project , it was intended to extend the service to all practice s across the S and well area . However the pilot project was not a robust evaluation . There was a need for an efficient evaluation that would not disrupt the planned rollout of the project . Methods / design Project nurses will sequentially implement targeted cardiovascular case finding in a phased way across all general practice s , with the sequence of general practice s determined r and omly . This is a stepped wedge r and omised controlled trial design . The target population is patients aged 35 to 74 , without diabetes or cardiovascular disease whose ten-year cardiovascular risk , ( determined from data in their electronic records ) is ≥20 % . The primary outcome is the number of high risk patients started on treatment , because these data could be efficiently obtained from electronic primary care records . From this we can determine the effects of the case finding programme on the proportion of high risk patients started on treatment in practice s before and after implementation of targeted case finding . Cost-effectiveness will be modelled from the predicted effects of treatments on cardiovascular events and associated health service costs . Alongside the implementation it is intended to interview clinical staff and patients who participated in the programme in order to determine acceptability to patients and clinicians . Practical considerations meant that 26 practice s in S and well could be r and omised , including about 6,250 patients at high risk of cardiovascular disease . This gives sufficient power for evaluation . Discussion It is possible to design a stepped wedge r and omised controlled trial using routine data to determine the primary outcome to evaluate implementation of a cardiovascular prevention programme
Conclusions This review demonstrates the potential for multifactorial interventions aim ed at individuals selected by CVD risk scores for lowering CVD risk and mortality .
However , the majority of studies in this area do not provide an intensity of intervention which is sufficient in significantly reducing CVD mortality or vali date d CVD risk
Objectives The high prevalence of cardiovascular disease ( CVD ) and the increased cost of treatment have prompted strategies for the primary prevention of CVD in the UK to move towards the use of vali date d CVD risk scores to identify individuals at the highest risk .
There are no review s evaluating the effectiveness of this strategy as a means of reducing CVD risk or mortality .
This review summarizes current evidence for and against the use of vali date d CVD risk scores for the primary prevention of CVD .