1. We should continue treating on 10 year risk
Thierry Christiaens Ghent, Belgium

2. Name Thierry Christiaens Title Professor of family medicine
Disclosure of potential conflicts of interest

3. Framingham
1991 to 1998 Framingham Risk Score are developed as an innovative answer to the ‘mono-risk’ models: “don’t look at only one risk factor!”

4. FRAMINGHAM risk table: USA, Canada, Australia, NZ

5. SCORE vs Framingham
1991 to 1998 Framingham Risk Score, an innovative answer to the ‘mono-risk’ models: “don’t look at only one risk factor!”
But Framingham risk assessment over-estimates risks in European populations
Comparison of the Framingham risk function-based coronary chart with a risk function from an Italian population study. Eur Heart J 2000;21:
Framingham risk function overestimates risk of coronary heart disease in men and women from Germany—results from MONICA Augsburg and the PROCAM cohorts. Eur Heart J 2003;3:1-9.
Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study. BMJ 2003;327:1267-7

6. SCORE vs Framingham
Framingham risk assessment over-estimates risks in European populations
 in 2003 the SCORE Risk tables were developed for European populations
Regional and national SCORE, Q-risk… adapted to local reality

7. SCORE for Low Risk Countries and High Risk Countries

8. 8

9. Weaknesses of 10-years risk scores
The impact of “age” is too big:
young people with risk factors do not feel ‘at risk’
older people feel ‘anyway at high risk’
2007: Relative risk scales; usefull extra tool in ‘traditional’ 10 y risk scale

10. Relative risk usefull in ‘traditional’ 10 y risk scale
Relative Risk: compare with lowest risk for your gender
-young people with actual low risk see impact of risk factors
AND
-elder people with absolute high risk only because of their age, can compare with ‘lowest possible’ risk

11. SCORE vs Framingham vs Lifetime Risk
Whatever we chose:
It is not yet proven in RCT that using a tool (SCORE vs Framingham vs Lifetime Risk) gives more cardiovascular protection than usual care
(neither for polypill untill TIPS/HOPE in 2020?)

12. Back to real world practice and risk assessment tools
SO WHAT? how important is the instrument we use, once we know it has been validated?
More important is to decide which risk is considered as “too high”, and hence leads to starting treatment… for a not yet existing disease.
The real challenge for each GP in practice is not to know if the risk of that individual person is 6% or rather 8%, but to be able to identify these patients that need lifelong follow-up and drug treatment

13. Lowering cut-off values to start treatment, a never ending story?
Recent discussion in the USA on the implementation of the Jupiter-trial (N Engl J Med 2014; 370: ) :
“Among adults between the ages of 60 and 75 years without cardiovascular disease…, the percentage who would be eligible for statin therapy would increase from 30.4% to 87.4% among men …”.
If we continue to lower the cut-off to treat, a polypill for everybody probably becomes a more logic approach than any risk charts: why would we do so much effort to find the 12% NOT at need for drug treatment?

14. In conclusion The 10 years risk score is a validated tool
We needed years to refine it to locally applicable SCOREs and to add tools as the relative risk chart
We needed years to incorporate this in our softwares … and in our brain
No controled trials have proven extra gain by using risk scales over usual care
New tools are even less validated
The most important is not the tool, but how we implement this kind of tools in our patients