Collins and colleagues compare the clinical effects of QRISK2-2011 and the NICE Framingham equation in predicting the risk of cardiovascular diseases (1). A limitation of the study recognized by the Authors is the large amounts of missing data for total serum cholesterol to high density lipoprotein ratio.

For this reason, we have several concerns.
First, estimation of total cardio-vascular disease (CVD) and coronary heart disease (CHD) event risk is useful in individuals at increased risk both for patient education and for deciding when to initiate preventative strategies such as aspirin and statins. In addition cardiovascular risk using multivariate risk profiling was strongly endorsed by an AHA/ACC Scientific Statement in 1999 (2).

Second, the appropriate application of risk score assessment to patient management includes the following considerations:
i) The ATP III recommendations for the treatment of hyperlipidemia are influenced by the coexistence of CHD and the number of cardiac risk factors (3) .
ii) The goal blood pressure in patients at high risk for the development of CVD is controversial, with some experts suggesting use of risk models and others not. It has been suggested that determination of a patient's calculated cardiovascular risk profile, and presentation of the results to the patient, may improve compliance with risk reduction measures (2) . However, no data are available to confirm this assertion.
iii) It has also been suggested that determination of a patient's risk profile should improve physician recognition and treatment of modifiable risk factors. Because under-recognition of hypertension, hyperlipidemia and other risk factors is a common problem, routine risk assessment may be an effective approach to improving their identification.

Third, multiple risk models have been developed and have been validated predominantly in populations similar to those from which they were derived. It includes all the variables in the Framingham risk scores as well as C-reactive protein (CRP) level and family history of myocardial infarction (MI) before age 60.

We suggest in our review (data unpublished) selecting a risk prediction model appropriate for the patient under consideration when possible. In addition we suggest that risk models which predict MI, cardiovascular death, and cerebrovascular events be used for the purpose of deciding on whether to start therapy with either aspirin or statins.

Finally we recommend:
i) an appropriate application of risk score assessment to patient management with ATP III recommendations for the treatment of hyperlipidemia,
ii) a goal blood pressure in patients at high risk for the development of CVD,
iii) to determine the patient's risk profile that should improve physician recognition and treatment of modifiable risk factors.

References
1.Collins GS, Altman DG. Predicting the 10 year risk of cardiovascular disease in the United Kingdom: independent and external validation of an updated version of QRISK2. BMJ 2012;344:e4181 doi: 10.1136/bmj.e4181

2.Grundy, SM, Pasternak, R, Greenland, P, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: A statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 1999; 100:1481.

3.Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143.

Competing interests: None declared