Estimating cardiovascular risk for primary prevention: outstanding questions for primary care

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Abstract
Editorial by Jackson The recent joint British recommendations on the prevention of coronary heart disease, 1 the British Hypertension Society guidelines for the management of hypertension, 2 and comparable recommendations from the United States3 all conclude that the decision to start drug treatment in people at high risk but without cardiovascular disease should be based on their risk of coronary heart disease as estimated by the Framingham risk equations. We review some implications of their use in primary care. #### Summary points Prediction of coronary risk on the basis of multiple risk factors is more accurate than with any single factor alone People with a 30% or greater risk of a coronary heart disease event in 10 years should be considered for treatment with aspirin, antihypertensives, and statins Risk assessment for coronary heart disease should be routinely added to the existing screening programme for smoking and raised blood pressure The measurement of serum lipid concentrations in all adults is not necessary for the identification of people at high risk A national programme is required to support the identification and treatment of the 10% of the population who have coronary risks of 30% or more For 50 years the Framingham heart study has documented blood pressure, smoking, lipid concentrations, and other characteristics of 5300 white men and women, together with their causes of death and disease.4 These data have been used to predict death or major vascular events. It is important to be clear which outcome is being predicted and over what period. Expressed as risks at one, five, or 10 years the predicted outcomes include fatal and non-fatal coronary heart disease, 5 stroke, 6 and total cardiovascular disease including congestive cardiac failure and peripheral vascular disease.7 8 The risk of a coronary heart disease event in 10 years (myocardial infarction …