Intended for healthcare professionals


Doctors no longer have to use Framingham equation to assessheart disease risk, NICE says

BMJ 2010; 340 doi: (Published 29 March 2010) Cite this as: BMJ 2010;340:c1774
  1. Susan Mayor
  1. 1London

    Healthcare professionals in the United Kingdom should use the cardiovascular risk assessment tool they consider most appropriate when assessing whether to prescribe lipid modifying therapy for the primary prevention of cardiovascular disease, an updated guideline from the National Institute for Health and Clinical Excellence (NICE) said this week.

    It downgrades the previous recommendation that the US derived Framingham risk equation should be used as the risk scoring tool of choice.

    The NICE guideline recommends that healthcare professionals use a systematic strategy for identifying people likely to be at high risk for cardiovascular disease who would benefit from lipid modifying therapy.

    The guideline recommends use of a risk equation to assess an individual’s risk, with healthcare professionals choosing the most appropriate of three options: QRISK, which was developed from data from UK general practice; ASSIGN, which was based on a Scottish cohort; or the Framingham risk equation.

    When NICE’s guideline development committee first developed its guideline on lipid modifying therapy in 2008 it recommended the Framingham risk equation as the tool of choice to assess risk of cardiovascular disease. This risk calculator is based on data drawn from the Framingham study, a landmark population study that explored cardiovascular risk.

    Fergus Macbeth, director of NICE’s Centre for Clinical Practice, explained why the Framingham risk equation was prioritised at the time: “When the original guideline was published, the guideline development group could not, on the basis of the evidence or expertise before them, make a decision that one risk assessment equation was clearly superior in the UK population.

    “As QRISK was at the time still a model in development, the group could not be confident that its introduction would bring significant benefits. They reasoned that Framingham, despite its known limitations, was currently in use and understood and that continuing to use Framingham in the short term would not compromise individual patient care.”

    The guideline committee recommended that further research be carried out on how best to assess cardiovascular disease risk. After reviewing new research published since 2008, including studies of QRISK, the committee decided that there is currently no clear evidence that any one method for assessing cardiovascular risk is better than another.

    “The decision acknowledges that both Framingham and QRISK have positive features to recommend them and that the field continues to evolve rapidly. Until, and if, the evidence shows a clear benefit of using one assessment tool over the other we have recommended that healthcare professionals use the tool that best suits their requirements,” said Dr Macbeth.

    The updated guideline notes that the Framingham risk equation overestimates risk by up to 50% in contemporary northern European populations, particularly in people living in more affluent areas, but underestimates risk in higher risk populations, such as the most socially deprived people. It also makes no allowance for family history of premature coronary heart disease and takes no account of ethnicity. QRISK and ASSIGN include social deprivation and family history.

    Further research to establish which scoring method is best should include adjusting Framingham for use in the UK population, validating QRISK in independent and clinical datasets, and assessing the use of ASSIGN outside Scotland, the guideline says.


    Cite this as: BMJ 2010;340:c1774


    • Cardiovascular Risk Assessment and the Modification of Blood Lipids for the Primary and Secondary Prevention of Cardiovascular Disease is at

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