Intended for healthcare professionals

Clinical Review

Evaluating cardiovascular risk assessment for asymptomatic people

BMJ 2009; 338 doi: (Published 05 January 2009) Cite this as: BMJ 2009;338:a2844
  1. Ian A Scott, associate professor of medicine
  1. 1Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia
  1. Correspondence to: I A Scott ian_scott{at}
  • Accepted 8 November 2008

Summary points

  • Risk prediction tools based on the Framingham score are the most widely used for determining individuals’ absolute risk based on clinical risk factors, although newer tools are better calibrated

  • The clinical label metabolic syndrome and abnormalities on the resting electrocardiograph do not add prognostic information beyond that obtained by traditional risk factors

  • Exercise stress electrocardiography that generates a positive or negative result based on ST deviation alone is not predictive, although scores that integrate several electrocardiographic and clinical variables may be predictive in patients at intermediate risk

  • Laboratory biomarkers, even in the form of multimarker panels, are not helpful in refining clinical risk estimates

  • Imaging of subclinical atherosclerosis with computed coronary angiography can identify patients at significantly increased risk, but only a small proportion of patients screened fall into this group

  • No randomised evidence to date has shown that informing clinicians and patients of absolute risk of cardiovascular events leads to changes in care or improvement in outcomes

Clinician assessment of future risk of cardiovascular events in asymptomatic individuals is often inaccurate without formal risk prediction tools.1 Prediction tools that are easy to use and that integrate Framingham criteria of age, sex, serum cholesterol, blood pressure, smoking status, diabetes, and left ventricular hypertrophy into one global risk score have evolved to aid risk assessment.2 In recent decades, new putative risk factors have been described, including clinical risk factors such as chronic kidney disease and metabolic syndrome, as well as numerous laboratory markers of disease (box 1).3 4 5 Each new risk factor attracts studies evaluating whether a certain ancillary test shows an incrementally higher cardiovascular risk after adjusting for traditional risk factors.6 This review asks whether ancillary testing in asymptomatic adults improves the accuracy of predicting cardiovascular risk in individuals, and what effects it might have …

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