ASSIGN Paul Ryan, Clinical Director, North Glasgow CHCP

Risk Scoring Risk scoring Likelihood of having an event in next 10 years Not exact - underestimates for some and over estimates for others In fact most cardiac events occur in lower risk groups

Risk Scoring Original studies (eg Framingham) measured Coronary Heart Risk - CHD Newer studies (JBS 2 and ASSIGN) measure Cardiovascular Risk - CVD CVD Risk is sum of cardiovascular and stroke risk 15% CHD = 20% CVD

Risk Scoring The risk is composite of several risk factors ( age, sex, systolic BP, smoking, cholesterol) and is expressed as probability (% chance) of that person developing event within next ten years Gives threshold for when drug therapy should be instigated but that threshold is assigned arbitrarily since risk is a continuously distributed variable – there is no one point where risk really “takes off”

Risk Scoring For primary prevention i.e. those who have not developed CVD already Aid to Clinical Management Not replace Clinical Judgement May still have to treat individual risk factors in isolation if they are substantial enough (see guidelines) BP consistently >180 and/or 110, familial hypercholesterolemia.

Framingham Based on old studies in USA Does not include family history Does not include deprivation Underreporting in certain socio economic groups Underreporting in older women Measured CHD risk

Risk Scoring Framingham scores significantly under predicted CHD risk in Scottish Male population ( Paisley and Renfrew) Also underestimated risk in lower socio economic groups (Paisley/Renfrew fairly deprived)

JBS 2 Based on Framingham Scores Gives Cardiovascular Risk Proxy for deprivation by adding 10 years ( JBS2 + 10) CVD risk includes risk of stroke and equals CHD risk x 4/3

ASSIGN ASsessing cardiovascular risk using Scottish Intercollegiate Guidelines Network guidelines to ASSIGN preventative treatment

ASSIGN Results tested on Scottish Heart Health Cohort Extended ( SHHEC) - 6,419 men - 6,618 women aged in 25 local government districts in Scotland between 1984 and 1995 i.e. local

ASSIGN Age Sex Smoking Family History Systolic BP Cholesterol HDL SIMD

ASSIGN New Features Family History SIMD (Scottish Index of Multiple Deprivation)

Family History Parents developed CVD before 60 Siblings developed CVD before 60 Grandparents, aunts, uncles, first cousins developed CVD before 60 (need 2)

SIMD Scottish Index of Multiple Deprivation Relative Indicator of Deprivation based on datazones 1 – 6,505 Based on 37 Indicators across 7 domains to provide weighted score SIMD scores range from 0.54 to 87.60

SIMD Domains Current Income 28% Employment 28% Health 14% Education 14% Geographic Access 9% Crime 5% Housing 2%

SIMD G22 5HD Allander St, Possilpark SIMD 73.4 G62 8PN Allander Road, Milngavie SIMD 9.81 (Range in Scotland 0.54 – 87.60)

ASSIGN Scores Male 50 smoker SBP150 Chol 6, HDL1,FH G22 5HD (Possil) 32% G62 8PN (Milngavie) 22% Fem 60, smoker SBP 140, Chol 6 HDL1,FH G22 5HN (Possil) 49% G62 8PN (Milngavie) 31%

Effect of ASSIGN CVD Risk FRAM 30 ASS30 ASS20 Affluent men 7% 3% 10% Deprived men 10% 9% 24% Affluent women 0% 0% 2% Deprived women 4% 7% 30%

ASSIGN ASSIGN 20 would commit 1 in 3 asymptomatic individuals aged 40 to drug treatment, with its attendant medical and social costs

ASSIGN Being Evaluated by Keep Well i.e. YOU This means we are looking at effect of using ASSIGN as against JBS2 and JBS2+10 How many and which patients move into and out of high risk groups (depending on where we decide “high risk” lies)

ASSIGN This means we are asking that you use all three scores where they are available We know many are missing and that makes evaluation difficult

Previous Guidelines Primary Prevention Cholesterol 30% CHD = 40% CVD BP 15% CHD = 20% CVD Antiplatelet 30% CHD = 40% CVD JBS2 20% CVD SIGN 97 20% CVD

New Guidelines UNIFIED TARGET TREAT at 30 % CVD RISK

NEW PATIENTS Calculate JBS2, JBS and ASSIGN Treat according to ASSIGN 30

TAKE HOME MESSAGES Use 30% CVD risk Record JBS2, JBS and ASSIGN for 1 st appointment 1st appointment ( new cases) use ASSIGN 30