Study protocol for a randomized controlled trial: the feasibility and impact of cardiovascular absolute risk assessment in Australian general practice. 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 The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review Cardiovascular disease risk reduction in rural China: a clustered randomized controlled trial in Zhejiang Sustaining cardiovascular absolute risk management in Australian general practice. Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Absolute Cardiovascular Disease Risk and Shared Decision Making in Primary Care: A Randomized Controlled Trial The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study: intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare A simple risk score using routine data for predicting cardiovascular disease in primary care. Randomized trial of a computerized coronary heart disease risk assessment tool in HIV-infected patients receiving combination antiretroviral therapy. 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 Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians Influence of cardiovascular absolute risk assessment on prescribing of antihypertensive and lipid-lowering medications: a cluster randomized controlled trial. Evaluation of a cardiovascular disease risk assessment tool for the promotion of healthier lifestyles Is a targeted and planned GP intervention effective in cardiovascular disease prevention? A randomized controlled trial Predictive accuracy of the 'Framingham's general CVD algorithm' in a Middle Eastern population: Tehran Lipid and Glucose Study. Lifestyle‐Based Prediction Model for the Prevention of CVD: The Healthy Heart Score
BACKGROUND Although cardiovascular absolute risk ( CVAR ) assessment has been recommended for use in Australian general practice for a number of years , there is continuing uncertainty about its implementation and impact . Our previous work has developed a multifaceted implementation model . This study aims to investigate both the feasibility of using this model and the impact of CVAR assessment and management on general practice clinical processes and patient care . STUDY DESIGN This cluster r and omized controlled trial will be conducted in general practice s in Sydney , involving general practitioners ( GPs ) , other practice staff , and patients aged 45 to 69 years without existing cardiovascular disease . METHODS A total of 32 practice s ( 40 GPs ) and 1,320 patients will be recruited . R and omization will be conducted at the practice level . The intervention group of GPs will be trained to use a CVAR implementation model , whereas the control group of GPs will continue usual care . Study outcomes include clinical processes , patient risk , use of lifestyle intervention , and prescription of antihypertensive and lipid-lowering medications .  Data will be collected and analyzed using mixed methods . Study outcomes before and after the intervention will be compared , and the 2 groups will also be compared after adjusting for baseline difference and clustering factors . DISCUSSION This trial will be the first study in Australian general practice and one of few international studies to evaluate the impact of implementing CVAR assessment and management . Results of this study will help improve the primary prevention of cardiovascular disease and inform guidelines for clinical practice and the implementation of other health initiatives 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 Objectives : The SCORE model predicts the ten-year risk of cardiovascular mortality but it is still unknown whether applying the SCORE in clinical practice subsequently improves cardiovascular disease ( CVD ) outcomes . The objective of this study is to assess the effect of total cardiovascular risk estimation using the SCORE in preventing serious cardiovascular events in European adults without prior CVD . Methods and results : Data sources : eight bibliographical data bases ( 2003 – August 2015 ) , other internet sources and reference lists of articles were checked . This was supplemented by contact with the board members of the European Society of Cardiology ( ESC ) and the authors of the SCORE model . Study eligibility criteria : all prospect i ve studies in any language investigating the effect of using the SCORE on the clinical outcome ( CVD death , major events and adverse outcomes ) in an adult population were examined . Two review ers assessed the studies independently ( titles , abstract s , full texts ) . After removal of duplicates , 5,256 records were screened and 14 full text papers considered . No eligible studies were identified . An extensive literature search revealed no r and omized control trial or other prospect i ve study comparing significant clinical outcomes between groups that used the SCORE and those who did not . Conclusions : The effect of using the SCORE ( with or without subsequent intervention ) on CVD death , all-cause mortality , major CVD events like myocardial infa rct ion and stroke , as well as adverse outcomes , is still unknown . A cluster r and omised controlled trial is warranted to evaluate the use of the SCORE on important outcomes Background Cardiovascular disease ( CVD ) is a major cause of death in China . Despite government efforts , the majority of hypertensive and diabetic patients in China do not receive proper treatment . Reducing CVD events requires long-term care that is proactive , patient-centred , community-based , and sustainable . We have design ed a package of interventions for patients at high risk of CVD to be implemented by family doctors based in township hospitals ( providers of primary care ) in rural Zhejiang , China . This trial aims to determine whether the systematic CVD risk reduction package results in reduced CVD events among patients at risk of CVD compared with usual care , and whether the package is cost-effective and suitable for routine implementation and scale-up . Methods / Design This is a prospect i ve , open-label , cluster r and omized controlled trial ( RCT ) with blinded data analysis . The trial will r and omize 67 township hospitals with 31,708 participants in three counties in Zhejiang Province . Participants will be identified from existing health records and will comprise adults aged 50 to 74 years , with a calculated 10-year CVD risk of 20 % or higher , or diabetes . In the intervention arm , participants will receive a package of interventions including : 1 ) healthy lifestyle counseling ( smoking cessation , and salt , oil , and alcohol reduction ) ; 2 ) prescription of a combination of drugs ( antihypertensives , aspirin , and statin ) ; and 3 ) adherence support for drug compliance and healthy lifestyle change . In the control arm , participants will receive usual care for hypertension and diabetes management at individual clinicians ’ discretion . The primary outcome is the incidence of severe CVD events over 24 months of follow-up . All CVD events will be defined according to the World Health Organization ( WHO ) monitoring of trends and determinants in cardiovascular disease ( MONICA ) definitions , diagnosed at the county hospital or higher level , and reported by the Zhejiang surveillance system . Secondary outcomes include : mean systolic and diastolic blood pressure , blood glucose , serum total cholesterol ( TC ) , and adherence to appointments , and drugs and lifestyle changes . Discussion This trial focuses on risk reduction of CVD rather than specific diseases . It is not design ed to compare therapeutic and healthy lifestyle interventions , but rather their combined effects in primary care setting s. Through the trial , we intend to underst and the effectiveness of the comprehensive CVD reduction package in routine practice . We also intend to underst and the barriers and facilitators to implementing the package , and thus to advise on policy and practice change . Trial registration Current Controlled Trials : IS RCT This study describes the attitudes and practice s of patients and GPs 12 months after participating in a trial of absolute cardiovascular risk assessment in general practice . It involved a qualitative design using semistructured interviews with 12 Sydney GPs from the intervention arm of a cluster r and omised controlled trial of cardiovascular absolute risk ( CVAR ) assessment and 15 of their moderate to high risk patients who participated in the assessment s. Most GPs had sustained CVAR assessment in their practice , using it primarily to motivate patients to change their behaviour and adhere to management rather than to make decisions about pharmacotherapy or referral . Time was a barrier to its use . Patients who sustained changes to their behaviour had internalised the benefits to their health and received support from family and friends . Those who relapsed attributed this to their own lack of motivation and extrinsic factors . CVAR assessment needs to be incorporated into practice information systems and long-term planned preventive care if it is to be sustained in general practice and have long-term impacts on patient behaviour 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 PURPOSE We wanted to determine the effect of promoting the effective communication of absolute cardiovascular disease ( CVD ) risk and shared decision making through disseminating a simple decision aid for use in family practice consultations . METHODS The study was based on a pragmatic , cluster r and omized controlled trial ( phase III ) with  continuing medical education ( CME ) groups of family physicians  as the unit of r and omization . In the intervention arm , 44 physicians ( 7 CME groups ) consecutively recruited 550 patients in whom cholesterol levels were measured . Forty-seven physicians in the control arm ( 7 CME groups ) similarly included 582 patients . Four hundred sixty patients ( 83.6 % ) of the intervention arm and 466 patients ( 80.1 % ) of the control arm were seen at follow-up . Physicians attended 2 interactive CME sessions and received a booklet , a paper-based risk calculator , and individual summary sheets for each patient . Control physicians attended 1 CME-session on an alternative topic . Main outcome measures were patient satisfaction and participation after the index consultation , change in CVD risk status , and decisional regret at 6 months ’ follow-up . RESULTS Intervention patients were significantly more satisfied with process and result ( Patient Participation Scale , difference 0.80 , P<.001 ) . Decisional regret was significantly lower at follow-up ( difference 3.39 , P = .02 ) . CVD risk decreased in both groups without a significant difference between study arms . CONCLUSION A simple transactional decision aid based on calculating absolute individual CVD risk and promoting shared decision making in CVD prevention can be disseminated through CME groups and may lead to higher patient satisfaction and involvement and less decisional regret , without negatively affecting global CVD risk Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease ( CVD ) risk management .  Electronic decision support ( EDS ) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia . We have developed HealthTracker , a multifaceted EDS and quality improvement intervention to improve the management of CVD risk . Methods / design It is hypothesised that the use of HealthTracker over a 12-month period will result in : ( 1 ) an increased proportion of patients receiving guideline -indicated measurements of CVD risk factors and ( 2 ) an increased proportion of patients at high risk will receive guideline -indicated prescriptions for lowering their CVD risk . Sixty health services ( 40 general practice s and 20 Aboriginal Community Controlled Health Services ( ACCHSs ) will be r and omised in a 1:1 allocation to receive either the intervention package or continue with usual care , stratified by service type , size and participation in existing quality improvement initiatives . The intervention consists of point-of-care decision support ; a risk communication interface ; a clinical audit tool to assess performance on CVD-related indicators ; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance .  The control arm will continue with usual care without access to these intervention components . Quantitative data will be derived from cross-sectional sample s at baseline and end of study via automated data extraction . Detailed process and economic evaluations will also be conducted . Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee ( HREC ) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC . Formal agreements with each of the participating sites have been signed . In addition to the usual scientific forums , results will be disseminated via newsletters , study websites , face-to-face feedback forums and workshops . Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910 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 BACKGROUND Exposure to combination antiretroviral therapy ( cART ) can lead to important metabolic changes and increased risk of coronary heart disease ( CHD ) . Computerized clinical decision support systems have been advocated to improve the management of patients at risk for CHD but it is unclear whether such systems reduce patients ' risk for CHD . METHODS We conducted a cluster trial within the Swiss HIV Cohort Study ( SHCS ) of HIV-infected patients , aged 18 years or older , not pregnant and receiving cART for > 3 months . We r and omized 165 physicians to either guidelines for CHD risk factor management alone or guidelines plus CHD risk profiles . Risk profiles included the Framingham risk score , CHD drug prescriptions and CHD events based on biannual assessment s , and were continuously up date d by the SHCS data centre and integrated into patient charts by study nurses . Outcome measures were total cholesterol , systolic and diastolic blood pressure and Framingham risk score . RESULTS A total of 3,266 patients ( 80 % of those eligible ) had a final assessment of the primary outcome at least 12 months after the start of the trial . Mean ( 95 % confidence interval ) patient differences where physicians received CHD risk profiles and guidelines , rather than guidelines alone , were total cholesterol -0.02 mmol/l ( -0.09 - 0.06 ) , systolic blood pressure -0.4 mmHg ( -1.6 - 0.8 ) , diastolic blood pressure -0.4 mmHg ( -1.5 - 0.7 ) and Framingham 10-year risk score -0.2 % ( -0.5 - 0.1 ) . CONCLUSIONS Systemic computerized routine provision of CHD risk profiles in addition to guidelines does not significantly improve risk factors for CHD in patients on cART 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 There is nonoptimal adherence of general practitioners ( GPs ) and patients to cardiovascular risk reducing interventions . GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk . In addition , communicating cardiovascular risk to patients has proved to be difficult . Aims Improving primary prevention of cardiovascular disease ( CVD ) in primary care by enhancing patient involvement in the use of a decision support tool . Design Cluster r and omized trial . Methods Thirty-four GPs included patients ( 40 - 75 years old ) without CVD . In an interactive , small group training session lasting 4h , the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool . The control group received educational material s about the guidelines on paper .  GPs ’ clinical performance and patients ’ risk perception and self-reported lifestyles were measured at baseline and after 6 months . Results Thirty-four GPs recorded 490 consultations , 276 in the intervention and 214 in the control group . After 6 months , no significant effect of the intervention on the GPs ’ performance or the patients ’ risk perception was found . There was only an effect on self-reported lifestyle , in that more men in the intervention group than in the control group increased their physical activity ( odds ratio 3.8 , 95 % confidence interval 1.7–8.7 ) . Conclusion The 4-h interactive , small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs ’ performance or correct patients ’ risk perception . The positive effect on physical activity justifies further research on patient involvement . Eur J Cardiovasc Prev Rehabil 14 : 44 - 50 © 2007 The European Society of BACKGROUND Guidelines for management of hypertension and lipids recommend using cardiovascular absolute risk ( CVAR ) to manage patients . This r and omized controlled trial investigated the impact of CVAR assessment in family practice on management of cardiovascular risk , including prescription of antihypertensive and lipid-lowering medication . METHODS A cluster r and omized controlled trial was conducted from 2008 to 2010 in Sydney , Australia . Family practice s were r and omized , and patients aged 45 to 69 years were invited to participate . Intervention  family physicians ( FP ) were trained in use of CVAR , provided with an electronic CVAR calculator , and assessed their patients ' absolute risk in a dedicated consultation . Control practice patients received a general health check . Primary outcome analyzed was the proportion of patients in each group on antihypertensive and /or lipid-lowering medication  at 12 months . Multilevel logistic regression was performed to explore variables influencing changes in pharmacologic therapy . RESULTS The study recruited 36 FPs from 34 practice s and 1,074 patients , of which 906 ( 84.4 % ) completed 12-month follow-up . At 12 months , there was no significant difference between the intervention and control groups in proportion of patients on antihypertensives ( 31.2 % vs 34.3 % , P = .31 ) , but control group patients were more likely to be on lipid-lowering medications ( 30.2 % vs 22.7 % , P = .01 ) . After multilevel analysis , this difference was not present . Intensification or reduction of pharmacologic therapy was associated with meeting treatment targets for blood pressure and lipids but not with the CVAR or intervention group . CONCLUSIONS Single-risk factor management remains a strong influence on FP prescribing practice s. Shifting to an approach based on CVAR will require more intensive intervention Background Although percentage risk formats are commonly used to convey cardiovascular disease ( CVD ) risk , people find it difficult to underst and these representations . Aims To compare the impact of providing a CVD risk message in either a traditional format ( % risk ) or using an analogy of risk ( Heart-Age ) on participants ' risk perceptions and intention to make lifestyle changes . Methods Four hundred and thirteen men and women were r and omly allocated to one of two conditions ;  CVD risk as a percentage or as a Heart-Age score ( a cardiovascular risk adjusted age ) . Results There was a grade d relationship between perceived and actual CVD risk only in those participants receiving a Heart-Age message ( P<0.05 ) . Heart-Age was more emotionally impactful in younger individuals at higher actual CVD risk ( P<0.01 ) . Self-reported emotional reactions further mediated the relationship between risk perception and intention to make lifestyle changes . Conclusion This study found that the Heart-Age message significantly differed from percentage CVD risk score in risk perceptions and was more emotionally impactful in those participants at higher actual CVD risk levels Background The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular ( CV ) risk still need to be established . The aim of this study was to evaluate the impact of general practitioner ’s ( GP ’s ) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors . Material / Methods This was a cluster-r and omized trial ( IS RCT N31857696 ) including 64 practice s and 3245 patients aged ≥40 . The participating GPs and their examinees were r and omized into an intervention or to a control group ( st and ard care ) . Intervention group practitioners followed up their examinees during 1 , 3 , 6 , 12 , and 18 months . The main outcome measures were change in proportion of patients with low , moderate , high , and very high CV risk , and change in individual CV risk factors from the first to the second registration . Results The proportion of patients with very high CV risk was lower in the intervention group , the same as of patients with high blood pressure , total and LDL cholesterol , and increased intake of alcohol . The mean systolic ( −1.49 mmHg ) and diastolic ( −1.57 mmHg ) blood pressure , triglycerides ( −0.18 mmol/L ) , body mass index ( −0.22 ) , and waist ( −0.4 cm ) and hip circumference ( −1.08 cm ) was reduced significantly in the intervention group . There was no additional impact in the intervention group of other tested CV risk factors . Conclusions Systematic and planned GP ’s intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits AIMS To examine the performance of ' the Framingham 's general CVD algorithm ' in estimating 5-year risk of cardiovascular disease ( CVD ) and coronary heart disease ( CHD )  in an adult Middle Eastern community . METHODS In a population -based prospect i ve cohort , the Tehran Lipid and Glucose Study ( TLGS ) , CVD risk estimates were calculated for 3838 individuals ( 2183 women ) free of CVD at baseline . RESULTS Over 8.6 years , there were 119 CVD ( 106 CHD ) events among women , and 164 ( 137 ) among men aged ≥ 30 years . St and ard risk factors [ age , systolic blood pressure ( SBP ) , antihypertensive treatment , total and high-density lipoprotein cholesterol , smoking and diabetes mellitus ] , measured at baseline , were significantly related to the incidence of CVD . The only exception , lack of significance for coefficients of SBP among women , was attributable to collinearity between age and SBP . For most risk factors , hazard ratios ( HRs ) for CVD were similar for the TLGS and the Framingham cohorts ' participants . Few exceptions were lower HR for SBP among TLGS ' women and lower HR for age among TLGS ' men . The Framingham equations quite correctly discriminated participants [ C statistic : CVD , 0.818 ( women ) and 0.774 ( men ) ; CHD : 0.822 ( women ) and 0.751 ( men ) ] with good calibration ( all calibration χ(2 ) values < 15 , ps > 0.1 ) . DISCUSSION AND CONCLUSIONS The Framingham 's CVD algorithm was effective at ranking individuals and could be used to quantify risk and to guide preventive care in Iranian adults . For regions without established cohort , recalibration using risk factors and CVD ( CHD ) rates may be an effective method to develop CVD ( CHD ) risk prediction algorithms for local practice Background Clinical practice focuses on the primary prevention of  cardiovascular ( CV ) disease ( CVD ) through the modification and pharmacological treatment of elevated risk factors . Prediction models based on established risk factors are available for use in the primary prevention setting . However , the prevention of risk factor development through healthy lifestyle behaviors , or primordial prevention , is of paramount importance to achieve optimal population ‐wide CV health and minimize long‐term CVD risk . Methods and Results We developed a  lifestyle‐based CVD prediction model among 61 025 women in the Nurses ’ Health Study and 34 478 men in the Health Professionals Follow‐up Study , who were free of chronic disease in 1986 and followed for ≤24 years .  Lifestyle factors  were assessed by question naires in 1986 . In the derivation step , we used the Bayes Information Criterion to create parsimonious 20‐year risk prediction models among a r and om two thirds of participants in each cohort separately . The scores were vali date d in the remaining one third of participants in each cohort . Over 24 years , there were 3775 cases of CVD in women and 3506 cases in men . The Healthy Heart Score included age , smoking , body mass index , exercise , alcohol , and a composite diet score . In the validation cohort , the risk score demonstrated good discrimination ( Harrell 's C‐index , 0.72 ; 95 % confidence interval [ CI ] , 0.71 , 0.74 [ women ] ; 0.77 ; 95 % CI , 0.76 , 0.79 [ men ] ) , fit , and calibration , particularly among individuals without baseline hypertension or hypercholesterolemia . Conclusions The Healthy Heart Score accurately identifies individuals at elevated risk for CVD and may serve as an important clinical and public health screening tool for the primordial prevention of CVD
There is uncertainty whether current strategies for providing CVD risk scores  affect CVD events .
Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm .
BACKGROUND The current paradigm for cardiovascular disease ( CVD ) emphasises absolute risk assessment to guide treatment decisions in primary prevention .
Although the derivation and validation of multivariable risk assessment tools , or CVD risk scores , have attracted considerable attention , their effect on clinical outcomes is uncertain .
OBJECTIVES To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes , risk factor levels , preventive medication prescribing , and health behaviours .