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When to remeasure cardiovascular risk in untreated people at low and intermediate risk: observational study

BMJ 2013; 346 doi: (Published 03 April 2013) Cite this as: BMJ 2013;346:f1895
  1. Katy J L Bell, assistant professor1,
  2. Andrew Hayen, associate professor in biostatistics2,
  3. Les Irwig, professor of epidemiology3,
  4. Osamu Takahashi, director4, vice chief5,
  5. Sachiko Ohde, researcher4,
  6. Paul Glasziou, director1
  1. 1Centre for Research in Evidence Based Practice, Bond University, QLD 4229, Australia
  2. 2School of Public Health and Community Medicine, University of New South Wales, NSW, Australia
  3. 3Screening and Test Evaluation Program, School of Public Health, University of Sydney, NSW, Australia
  4. 4Centre for Clinical Epidemiology, St Luke’s Life Science Institute, Tokyo, Japan
  5. 5Internal Medicine, St Luke’s International Hospital, Tokyo, Japan
  1. Correspondence to: K J L Bell katy.bell{at}
  • Accepted 8 March 2013


Objective To estimate the probability of becoming high risk for cardiovascular disease among people at low and intermediate risk and not being treated for high blood pressure or lipid levels.

Design Observational study.

Setting General communities in Japan and the United States.

Participants 13 757 participants of the Tokyo health check-up study and 3855 of the Framingham studies aged 30-74 years with complete data on risk equation covariates, not receiving blood pressure or cholesterol lowering treatment, and with an estimated risk of cardiovascular disease <20% within 10 years. We stratified participants on the basis of baseline risk: <5%, 5-<10%, 10-<15%, and15-<20%.We used follow-up measurements from the Tokyo study done annually over three years (2006-10) and follow-up visits in the Framingham study done between eight (1968-75) and 19 years (1990-1995) after baseline.

Main outcome measure Estimated 10 year risk of a cardiovascular event >20% using the Framingham equation.

Results At baseline most participants had <5% risk (60.6% of Tokyo cohort and 45.7% of Framingham cohort) or 5-<10% risk (24.0% and 28.0%, respectively) of a cardiovascular event within 10 years. There was <10% probability of crossing the treatment threshold at 19, 8, and 3 years for baseline risk groups <5%, 5-<10%, and 10-<15%, respectively, and >10% probability of crossing the treatment threshold at one year for the 15-<20% baseline risk group.

Conclusions Decisions on the frequency of remeasuring for cardiovascular risk should be made on the basis of baseline risk. Repeat risk estimation before 8-10 years is not warranted for most people initially not requiring treatment. However, remeasurement within a year seems warranted in those with an initial 15-<20% risk.


  • The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with the Framingham Heart Study and Framingham Offspring Study investigators. This manuscript was prepared using a limited access dataset obtained from the NHLBI and does not necessarily reflect the opinions or views of the Framingham studies or the NHLBI.

  • Contributors: KJLB conceived and designed the study, analysed and interpreted the data, and drafted and revised the manuscript. She is guarantor for the study. AH conceived and designed the study, analysed and interpreted the data, and revised the manuscript. LI, OT, and PG conceived and designed the study, interpreted the data, revised the manuscript, and obtained funding. SO analysed and interpreted the data and revised the manuscript. KJLB acquired a limited access dataset from the NHLBI and takes responsibility for the integrity of the data and the accuracy of the data analysis for the section of the paper pertaining to the Framingham Study.

  • Funding: This study received no specific funding. The authors have received funding from the Australian National Health and Medical Research Council (Program Grant No 633003, Early Career Fellowship No. APP1013390). The funders had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: KJLB, AH, LI, and PG have support from the Australian National Health and Medical Research Council (program grant No 633003, early career fellowship No APP1013390) for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the University of Sydney human research ethics committee (reference 05-2009/11855).

  • Data sharing: No additional data available.

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