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Review
. 2006 May 15;22(7):606-13.
doi: 10.1016/s0828-282x(06)70283-5.

The role of global risk assessment in hypertension therapy

S A Grover  1 , Brenda Hemmelgarn, Lawrence Joseph, Alain Milot, Guy Tremblay
Affiliations
Review

The role of global risk assessment in hypertension therapy

S A Grover et al. Can J Cardiol. .

Abstract
in English, French

To maximize the benefits of preventive therapy, lipid and hypertension guidelines increasingly recommend that high-risk individuals be targeted for treatment. An individual's risk of developing cardiovascular disease depends on many risk factors, such as age, sex, blood pressure, blood lipid levels, body weight, physical fitness, smoking habits and familial predisposition. Multivariable statistical models have therefore been developed to better estimate the global risk of future coronary events and stroke. A Canadian model is not currently available because a prospective cohort of sufficient size has not been followed in Canada. Therefore, global risk assessment among Canadians can only be completed using models developed in the United States or Europe. In the present review, cardiovascular risk tools are identified that may be appropriate for Canadians, including those based on the Framingham model, the Cardiovascular Life Expectancy Model, the United Kingdom Prospective Diabetes Study (UKPDS) model and the Systematic COronary Risk Evaluation (SCORE) model. The accuracy of the Framingham model and the Cardiovascular Life Expectancy Model are also evaluated using data from a small, prospective Canadian cohort. Finally, a framework is proposed to assist health care professionals in choosing the global risk tool most appropriate for their patients.

Pour maximiser les bienfaits de la thérapie préventive, les lignes directrices sur la lipidémie et l’hypertension recommandent de plus en plus de cibler les personnes très vulnérables pour les traiter. Le risque personnel de souffrir d’une maladie cardiovasculaire dépend de nombreux facteurs de risque, tels que l’âge, le sexe, la tension artérielle, le taux de lipides sanguins, le poids, la condition physique, les habitudes reliées au tabagisme et les prédispositions familiales. Des modèles statistiques multivariables ont donc été mis au point pour mieux évaluer le risque global de futurs problèmes coronariens et accidents vasculaires cérébraux. Il n’existe pas de modèle canadien parce qu’aucune cohorte de taille suffisante n’a été suivie au Canada. Par conséquent, l’évaluation globale du risque chez les Canadiens ne peut être effectuée qu’à l’aide de modèles mis au point aux États-Unis ou en Europe. Dans la présente analyse, les outils de risque cardiovasculaire susceptibles de convenir aux Canadiens sont présentés, soit ceux qui se fondent sur le modèle de Framingham, le modèle d’espérance de vie cardiovasculaire, le modèle de l’étude prospective UKPDS sur le diabète au Royaume-Uni et le modèle SCORE d’évaluation systématique du risque coronarien. L’exactitude du modèle de Framingham et du modèle d’espérance de vie cardiovasculaire est évaluée à l’aide de données tirées d’une petite cohorte canadienne prospective. Enfin, une structure est proposée afin d’aider les professionnels de la santé à choisir l’outil de risque global qui convient le mieux à leur patient.

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Figures

Figure 1
Figure 1
A Risk prediction estimates in primary prevention among patients without cardiovascular disease or diabetes. CLEM(CHD) and CLEM(CVD) refer to the Cardiovascular Life Expectancy Model estimates of coronary death or cardiovascular death, respectively, based on the Lipid Research Clinics dataset (3). Framingham1 and Framingham2 refer to estimates for coronary death and all coronary events, respectively, based on the Framingham dataset (2). SCORE(CVD) refers to cardiovascular death estimates based on the Systematic COronary Risk Evaluation dataset (11). B Risk prediction estimates in primary prevention among diabetic patients without cardiovascular disease. CLEM refers to the Cardiovascular Life Expectancy Model estimates of coronary death based on the Lipid Research Clinics dataset. UKPDS refers to coronary events based on the United Kingdom Prospective Diabetes Study dataset (8). SCORE(CVD) refers to cardiovascular death estimates based on the SCORE dataset using a diabetes multiplier (2× for men, 4× for women). C Risk prediction estimates in secondary prevention among patients with cardiovascular disease. CLEM refers to the Cardiovascular Life Expectancy Model estimates of coronary death over 10 years based on the Lipid Research Clinics dataset. Framingham3 refers to estimates for all coronary events over four years based on the Framingham dataset
Figure 2
Figure 2
Receiver operating characteristic (ROC) curves demonstrating the discriminating ability of the Framingham model and the Cardiovascular Life Expectancy Model when forecasting coronary death among Canadians in the Lipid Research Clinics Follow-Up Cohort
Figure 3
Figure 3
Calibration of the Framingham model and the Cardiovascular Life Expectancy Model. Each model was used to estimate the risk of each Canadian subject in the Lipid Research Clinics Follow-Up Cohort, and all subjects were then rank-ordered from the lowest to highest risk. Dividing the cohort into risk quartiles, the mean risk estimated for each quartile was compared with the coronary death rate actually observed
See this image and copyright information in PMC

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