Assessment Tools
Framingham
The Framingham equation is the most commonly accepted method for estimating cardiovascular risk. It is based on a study of more than 10,000 residents of Framingham in Massachusetts, USA. Participants of the study were mainly white and any resident with previously diagnosed CVD was excluded. This limits the accuracy of the equation in certain patient groups. Framingham tends to overestimate risk in low risk populations whilst underestimating risk in the higher risk populations such as the socially deprived and Asian population.
The Framingham risk factor is calculated in three age bands:
- Under 50
- 50-59
- 60 or over
Patients will not reach the full risk factor indicated in the charts until they reach the age of 49, 59 or 69 respectively which means the charts can overestimate the risk for younger patients and underestimate risk for patients over 70.
The Framingham equation uses a patient's age, gender, systolic blood pressure, total cholesterol, HDL cholesterol, smoking status and the presence of diabetes to predict cardiovascular risk. Significant risk factors that are not included in the Framingham equation have emerged since the equation was formulated; these include family history, physical inactivity, metabolic syndrome, and BMI.
QRISK
QRISK is the first risk assessment tool to use electronic health records to produce a risk assessment algorithm. QRISK is a British risk assessment tool that was first introduced in 2008. The first version, QRISK1, used the following variables to assess risk: gender, age, smoking status, total cholesterol, HDL-C, systolic blood pressure, BMI, family history, social deprivation and anti-hypertensive medication.
QRISK2 was developed to incorporate additional variables including self-assigned ethnicity, rheumatoid arthritis, atrial fibrillation and chronic kidney disease.
QRISK2 is the algorithm that is considered to most closely reflect the current UK population. NICE now recommends that QRISK2 should be the assessment tool used.13
JBS3
The JBS3 calculator displays cardiovascular risk for both a ten year period and also a lifetime risk score. This risk calculator predicts when a patient is likely to experience their first cardiovascular event if their current risk profile is maintained.
The aim of this calculator is to encourage patients to take ownership and responsibility for their own cardiovascular health, and to take appropriate actions to minimise their risk.
ASSIGN
This is the risk assessment tool recommended by SIGN (Scottish Intercollegiate Guidelines Network). The variables included are similar to those used in the Framingham tool but also include family history and social deprivation.
Version 1.5 of the tool has been updated to include rheumatoid arthritis as a risk factor.
Inclusion of family history indirectly relates to ethnic susceptibility. ASSIGN has been shown to assess more patients who are socially deprived or have a positive family history as being at high risk of cardiovascular event.
ETHRISK
This is a web based tool that was adapted from the Framingham equation to estimate risk in seven black and minority ethnic groups. This tool was developed to avoid over or underestimation of cardiovascular risk in ethnic groups.
UKPDS
The United Kingdom Prospective Diabetes Study was developed as a reliable assessment tool for cardiovascular risk in diabetic patients. Framingham is not a reliable assessment tool for diabetic patients, largely due to the few numbers of diabetic patients included in the Framingham study and the lack of consideration for glycaemic control. UKPDS differs from other assessment tools as rather than simply including diabetes as "yes or no" risk factor it considers the age at diagnosis and HbA1c i.e. effective diabetic control.
Reynold's risk score
Reynold's risk assessment was designed to provide a more accurate assessment of cardiovascular risk for women than previously available assessment tools.14
A key difference between Reynold's and other risk assessment tools is the inclusion of C reactive protein levels to factor the increased cardiovascular risk associated with inflammatory diseases such as rheumatoid arthritis.
INDANA
Individual Data Analysis of Antihypertensive drug intervention is a risk assessment tool specially designed for use in patients with pre-existing hypertension. Often treatment of these patients will focus on controlling their hypertension rather than considering the overall risk of cardiovascular disease.
SCORE
The Systemic Coronary Risk Evaluation assessment tool is based on European epidemiological studies from 250,000 patients. It has the disadvantage that it only predicts fatal CVD and consequently underestimates the impact of the condition. High risk and low risk SCORE charts are available for differing regions within Europe.