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Education And Debate

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

BMJ 2000; 320 doi: (Published 11 March 2000) Cite this as: BMJ 2000;320:702

This article has a correction. Please see:

  1. John Robson, senior lecturer (,
  2. Kambiz Boomla, senior lecturera,
  3. Ben Hart, general practitionerb,
  4. Gene Feder, professora
  1. a Department of General Practice and Primary Care, St Bartholomew's and the Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, London E1 4NS
  2. b Chrisp Street Health Centre, London E14 6PG
  1. Correspondence to: J Robson

    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

    What do the Framingham risk equations predict?

    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 …

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