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Cardiovascular disease risk assessment and prevention

Description of condition.

Cardiovascular disease (CVD) is a term that describes a group of disorders of the heart and blood vessels caused by atherosclerosis and thrombosis, which includes coronary heart disease, stroke, peripheral arterial disease, and aortic disease.

The risk of CVD is greater in men, patients with a family history of CVD, and in certain ethnic backgrounds such as South Asians. CVD risk is also greater in patients aged over 50 years and increases with age; patients aged 85 years and over are at particularly high risk. CVD has several important and potentially modifiable risk factors such as hypertension, abnormal lipids, obesity, diabetes mellitus, and psychosocial factors such as depression, anxiety, and social isolation. Low physical activity, poor diet, smoking, and excessive alcohol intake are also modifiable risk factors.

Aims of treatment

The overall aim of treatment is to prevent the occurrence of a cardiovascular event by reducing modifiable risk factors through lifestyle changes and drug management.

Cardiovascular disease risk assessment

Recommendations on cardiovascular disease (CVD) risk assessment are from the NICE—Cardiovascular disease: risk assessment and reduction, including lipid modification guideline (CG181, 2016) , and SIGN—Risk estimation and the prevention of cardiovascular disease guideline (SIGN 149, 2017) . SIGN 149 uses risk assessment strategies outlined by the Joint British Society (JBS)—Joint British Societies' consensus recommendations for the prevention of cardiovascular disease (2014) . Recommendations where NICE and SIGN differ have been highlighted.

NICE (2016) recommends that for primary prevention of CVD in primary care, a systematic approach be used to identify those who are likely to be at high risk. Patients should be prioritised based on an estimate of their CVD risk using risk factors already recorded in their medical records, before a full formal risk assessment. Priority for a full formal risk assessment should be given to patients with an estimated 10-year risk of 10% or more. Patients aged over 40 years should have their estimate of CVD risk reviewed on an ongoing basis. SIGN (2017) instead recommends that CVD risk assessments are offered at least every 5 years to all patients aged 40 years and over with no history of CVD, familial hypercholesterolaemia, chronic kidney disease or diabetes and who are not receiving treatment to reduce blood pressure or lipids. As well as to patients with a first-degree relative who has premature atherosclerotic CVD or familial dyslipidaemia, regardless of their age. A Strength of recommendation: High

Risk assessment with a calculator is not required in patients who are at increased or high risk of CVD. This includes those with established CVD, chronic kidney disease stage 3 or higher (eGFR <60 mL/minute/1.73 m 2 ), albuminuria, or familial hypercholesterolaemia. In addition to these patients, NICE (2016) does not recommend the use of a risk calculator in patients with other hereditary disorders of lipid metabolism, or type 1 diabetes mellitus. Whereas SIGN (2017) does not recommend the use of a risk calculator in patients with diabetes mellitus aged 40 years and over, and in those aged under 40 years with diabetes mellitus who have either had it for more than 20 years, present with target organ damage (such as proteinuria, albuminuria, proliferative retinopathy, or autonomic neuropathy), or have other significantly elevated cardiovascular risk factors. A Strength of recommendation: High

Risk calculators

Cardiovascular risk assessment calculators are used to predict the approximate likelihood of a cardiovascular event occurring over a given period of time. Standard risk scores may be underestimated in patients with additional risk due to existing conditions or medications that can cause dyslipidaemia (e.g. antipsychotics, corticosteroids, or immunosuppressants). CVD risk may also be underestimated in patients who are already taking antihypertensives or lipid-regulating drugs, or who have recently stopped smoking. Interpretation of risk scores as well as the need for further management of risk factors in those who fall below the CVD risk threshold, should always reflect informed clinical judgement. A Strength of recommendation: High

QRISK ® 2 and JBS3

QRISK ® 2 and JBS3 risk calculators are used to assess CVD risk for patients in England and Wales. Both tools assess cardiovascular risk of coronary heart disease (angina and myocardial infarction), stroke, and transient ischaemic attack. This is based on lipid profile, systolic blood pressure, sex, age, ethnicity, smoking status, BMI, chronic kidney disease (stage 4 or above), diabetes mellitus, atrial fibrillation, treated hypertension, rheumatoid arthritis, social deprivation, or a family history of premature CVD.

The QRISK ® 2 risk calculator ( https://www.qrisk.org/ ) is recommended by NICE clinical guideline 181 , and the JBS3 risk calculator ( http://www.jbs3risk.com/pages/risk_calculator.htm ) is endorsed by the Joint British Society.

QRISK ® 3 is an updated version of the QRISK ® 2 risk calculator. It considers additional risk factors such as chronic kidney disease (stage 3 or above), migraine, corticosteroid use, systemic lupus erythematosus, atypical antipsychotics use, severe mental illness, erectile dysfunction, and a measure of systolic blood pressure variability.

The JBS3 calculator is not only able to estimate short term (10-year) risk, but also lifetime risk of CVD events. Patients with a 10-year risk of CVD of less than 10% may benefit from an assessment of their lifetime risk using the JBS3 tool, and a discussion on the impact of lifestyle interventions and, if necessary, drug therapy.

The ASSIGN cardiovascular risk assessment calculator is tailored to the Scottish population and uses factors such as age, sex, smoking, systolic blood pressure, lipid profile, family history of premature CVD, diabetes mellitus, rheumatoid arthritis, and social deprivation to estimate cardiovascular risk. Other risk factors not included in this CVD risk assessment calculator (such as ethnicity, BMI, atrial fibrillation, psychological wellbeing, and physical inactivity) should also be taken into account when assessing and managing the patient's overall CVD risk. A Strength of recommendation: High

SIGN (2017) recommends that asymptomatic patients without established CVD (or other conditions that are automatically associated with a high CVD risk) should be considered at high risk if they are assessed as having a 20% or more risk of a first cardiovascular event within 10 years. A Strength of recommendation: High

The online calculator tool can be found at http://www.assign-score.com/estimate-the-risk/ . Full details can be found in the SIGN 149 clinical guideline (see Useful resources ).

Cardiovascular disease prevention

Recommendations on cardiovascular disease (CVD) prevention are from the NICE—Cardiovascular disease: risk assessment and reduction, including lipid modification guideline (CG181, 2016) , and SIGN—Risk estimation and the prevention of cardiovascular disease guideline (SIGN 149, 2017) . SIGN 149 uses strategies outlined by the Joint British Society (JBS)—Joint British Societies' consensus recommendations for the prevention of cardiovascular disease (2014) . Recommendations where NICE and SIGN differ have been highlighted.

All patients at any risk of CVD should be advised to make lifestyle modifications that may include beneficial changes to diet (such as increasing fruit and vegetable consumption, reducing saturated fat and dietary salt intake), increasing physical exercise, weight management, reducing alcohol consumption, and Smoking cessation . An annual review should be considered to discuss lifestyle modification, medication adherence and risk factors. The frequency of review may be tailored to the individual. A Strength of recommendation: High

Further preventative measures with drug treatment should be taken in individuals with a high risk of developing CVD (primary prevention), and to prevent recurrence of events in those with established CVD (secondary prevention). A Strength of recommendation: High

Primary prevention

Antiplatelet therapy.

Aspirin is not recommended for primary prevention of CVD due to the limited benefit gained versus risk of side-effects such as bleeding. A Strength of recommendation: High

Antihypertensive therapy

Antihypertensive drug treatment should be offered to patients who are at high risk of CVD and have sustained elevated systolic blood pressure and/or diastolic blood pressure. For further guidance on prescribing antihypertensive drugs in patients without symptomatic CVD and for specific groups at high cardiovascular risk, see Hypertension . A Strength of recommendation: High

Lipid-lowering therapy

A statin is recommended as the lipid-lowering drug of choice for primary prevention of CVD. All modifiable risk factors, comorbidities and secondary causes of dyslipidaemia (e.g. uncontrolled diabetes mellitus, hepatic disease, nephrotic syndrome, excessive alcohol consumption, and hypothyroidism) should be managed before starting treatment with a statin. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy. A Strength of recommendation: High

NICE (2016) recommends low-dose atorvastatin for patients who have a 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator), and for patients with chronic kidney disease. Low-dose atorvastatin should be considered in all patients with type 1 diabetes mellitus, and be offered to patients with type 1 diabetes who are either aged over 40 years, have had diabetes for more than 10 years, have established nephropathy, or have other CVD risk factors. Patients aged 85 years and over may also benefit from low-dose atorvastatin to reduce their risk of non-fatal myocardial infarction. SIGN (2017) recommends low-dose atorvastatin for patients who are considered to be at high risk of CVD and not on dialysis. A Strength of recommendation: High

Patients taking statins should have an annual medication review to discuss medication adherence, lifestyle modification, CVD risk factors, and non-fasting, non-HDL cholesterol concentration (if testing deemed appropriate). Total cholesterol, HDL-cholesterol, and non-HDL-cholesterol concentrations should be checked 3 months after starting treatment with a high-intensity statin. For statin intensity categorisation, see Dyslipidaemias . A Strength of recommendation: High

Aiming for a reduction in non-HDL-cholesterol concentration of greater than 40% is recommended. If this is not achieved, adherence to drug treatment should be checked and lifestyle modifications optimised. In patients deemed to be at a higher risk due to comorbidities, risk score, or clinical judgement, an increase in the statin dose should be considered. NICE (2016) recommends that the use of higher doses in those with chronic kidney disease with an eGFR less than 30ml/minute/1.73 m2 should be discussed with a renal specialist. A Strength of recommendation: High

Specialist advice should be sought regarding treatment options in patients at high risk of CVD who are intolerant of three different statins. A Strength of recommendation: High

SIGN (2017) recommends that ezetimibe and bile acid sequestrants such as colestyramine and colestipol hydrochloride only be considered for primary prevention in patients with an elevated cardiovascular risk in whom statin therapy is contraindicated, and in patients with familial hypercholesterolaemia. However, NICE (2016) recommends that ezetimibe be considered for primary hypercholesterolaemia as monotherapy when statins are unsuitable or not tolerated, or in combination with a statin for patients in whom the maximum tolerated dose of initial statin therapy fails to adequately control total or non-HDL-cholesterol levels and an alternative statin is being considered. NICE (2016) does not recommend bile acid sequestrants for primary prevention of CVD. A Strength of recommendation: High

Although fibrates are not routinely recommended for primary prevention of CVD, SIGN (2017) recommends that they be considered in patients with a combination of high CVD risk, marked hypertriglyceridaemia and low HDL-cholesterol concentration. A Strength of recommendation: High

For other lipid-lowering therapy options, see SIGN guideline: Risk estimation and the prevention of cardiovascular disease and NICE guideline: Cardiovascular disease: risk assessment and reduction, including lipid modification (see Useful resources ).

Lipid-lowering therapy recommendations from Joint British Societies' consensus (2014), NICE Clinical guideline 181 (2016), and SIGN Clinical guideline 149 (2017) all differ in certain respects for prevention of CVD in patients with diabetes mellitus—see individual guidelines for further details.

For further information on lipid-lowering therapy and familial hypercholesterolaemia, see Dyslipidaemias .

Secondary prevention

Antiplatelet therapy with low-dose daily aspirin should be offered to patients with established atherosclerotic disease. Alternatively, clopidogrel can be considered in patients who are intolerant to aspirin or in whom it is contraindicated. A Strength of recommendation: High

For guidance on the use of antiplatelet drugs in patients with a history of stroke or transient ischaemic attack, see Stroke . For guidance on the use of antiplatelet drugs in patients with acute coronary syndrome, see Acute coronary syndromes .

Antihypertensive drug treatment is recommended in patients with established CVD and sustained elevated systolic blood pressure and/or diastolic blood pressure. For further guidance on prescribing antihypertensive drugs in patients with CVD, see Hypertension . A Strength of recommendation: High

A statin is recommended as the lipid-lowering drug of choice for secondary prevention of CVD. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy. A Strength of recommendation: High

Treatment with high-dose atorvastatin should be offered to patients with established atherosclerotic CVD. However, a lower dose can be used if the patient is at an increased risk of side-effects or drug interactions. NICE (2016) recommends that low-dose atorvastatin should be offered to patients with established CVD and chronic kidney disease. A Strength of recommendation: High

High-dose simvastatin is generally avoided due to the risk of myopathy, unless the patient has been stable on this regimen for at least one year. A Strength of recommendation: High Furthermore, the MHRA advises that high-dose simvastatin should only be considered for patients who have not achieved their treatment goals with lower doses and have severe hypercholesterolaemia and high risk of cardiovascular complications; benefits should outweigh risks.

Patients taking statins should have an annual medication review to discuss medication adherence, lifestyle modification, CVD risk factors, and non-fasting, non-HDL-cholesterol concentrations (if testing deemed appropriate). Total cholesterol, HDL-cholesterol, and non-HDL-cholesterol concentrations should be checked 3 months after starting treatment with a high-intensity statin. Patients who are stable on a low or medium-intensity statin should discuss the benefits and risks of switching to a high-intensity statin at their next medication review. For statin intensity categorisation, see Dyslipidaemias . A Strength of recommendation: High

Aiming for a reduction in non-HDL-cholesterol concentration of greater than 40% is recommended. A Strength of recommendation: High JBS3 instead recommends a target non-HDL-cholesterol concentration below 2.5 mmol/litre. This level is also recommended in patients with ischaemic stroke or transient ischaemic attack and evidence of artherosclerosis in SIGN and Royal College of Physicians' National Clinical Guideline for Stroke for the UK and Ireland (2023) . A Strength of recommendation: High

If these targets are not achieved, adherence to drug treatment should be checked and lifestyle modifications optimised. In patients judged to be at a higher risk because of comorbidities, risk score, or clinical judgement, an increase in the statin dose (if started on less than maximum atorvastatin dose) should be considered. NICE (2016) recommends that the use of higher doses in those with chronic kidney disease with an eGFR less than 30ml/minute/1.73 m 2 should be discussed with a renal specialist. A Strength of recommendation: High

Specialist advice should be sought regarding treatment options in patients with existing CVD who are intolerant of three different statins. A Strength of recommendation: High

SIGN (2017) recommends that ezetimibe and bile acid sequestrants such as colestyramine and colestipol hydrochloride , can be considered for use in combination with a statin at the maximum tolerated dose if LDL-cholesterol remains inadequately controlled. NICE (2016) recommends ezetimibe for primary hypercholesterolaemia as monotherapy when statins are unsuitable or not tolerated, or in combination with a statin for patients in whom the maximum tolerated dose of initial statin therapy fails to adequately control total or non-HDL-cholesterol levels and an alternative statin is being considered. NICE (2016) does not recommend bile acid sequestrants for the secondary prevention of CVD. A Strength of recommendation: High

Icosapent ethyl is recommended in combination with a statin for patients with established CVD who have a raised fasting triglyceride concentration of 1.7 mmol/litre or above, and a LDL-cholesterol concentration above 1.04 mmol/litre and below or equal to 2.6 mmol/litre. A Strength of recommendation: High

Although fibrates are not routinely recommended for secondary prevention of CVD, SIGN (2017) recommends that they be considered in patients with both marked hypertriglyceridaemia and low HDL-cholesterol concentrations. A Strength of recommendation: High

Psychological risk factors

Psychological treatment should be considered in patients with mood and anxiety disorders and comorbid CVD; complex patients may require referral to mental health services for assessment and delivery of high-intensity or specialist treatments. Selective serotonin re-uptake inhibitors (SSRIs) should be considered for treatment in patients with depression and coronary heart disease. A Strength of recommendation: High For guidance on prescribing of antidepressant drugs, see Antidepressant drugs .

Useful resources

Risk estimation and the prevention of cardiovascular disease. Scottish Intercollegiate Guidelines Network. Clinical guideline 149. June 2017. https://www.sign.ac.uk/our-guidelines/risk-estimation-and-the-prevention-of-cardiovascular-disease/

Cardiovascular disease: risk assessment and reduction, including lipid modification. National Institute for Health and Care Excellence. Clinical guideline CG181. July 2014 (updated September 2016). https://www.nice.org.uk/guidance/cg181

Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). April 2014. http://www.jbs3risk.com/pages/report.htm

Related drugs

  • Atorvastatin
  • Clopidogrel
  • Colestipol hydrochloride
  • Colestyramine
  • Icosapent ethyl
  • Simvastatin

Related treatment summaries

  • Acute coronary syndromes
  • Antidepressant drugs
  • Antiplatelet drugs
  • Diabetic complications
  • Dyslipidaemias
  • Hyperparathyroidism
  • Hypertension
  • Polycystic ovary syndrome
  • Smoking cessation
  • Stable angina
  • Type 2 diabetes

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  • Volume 97, Issue 6
  • Cardiovascular Risk and Risk Scores: ASSIGN, Framingham, QRISK and others: how to choose
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  • Hugh Tunstall-Pedoe
  • Correspondence to Prof Hugh Tunstall-Pedoe, Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, UK; h.tunstallpedoe{at}dundee.ac.uk

https://doi.org/10.1136/hrt.2010.214858

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  • Cardiovascular risk scores
  • epidemiology
  • general practice
  • primary prevention
  • public health
  • risk stratification

Coronary heart disease and stroke contribute significantly to premature mortality and morbidity. Largely preventable, they demand prevention. Emphases range from responsibilities of governments to individuals, and the clinic nurses or doctors advising and treating them. The risk of cardiovascular disease varies. To be efficient and effective, medical interventions must focus on those at highest risk.

The strongest marker of risk is existing cardiovascular disease (diabetes often included) demanding secondary prevention, now routine medical therapy. Next comes age, the criterion the polypill's promoters proposed for medicating the population. 1 Age, sex and existing disease are major determinants of cardiovascular risk, but work begun 60 years ago in Framingham, USA, 2 gave us risk factors—individual characteristics identifying increased risk. Combined as multifactorial risk they predict more than individual factors (see table 1 ). Since the Framingham classics (age, sex, smoking, blood pressure and lipids) other risk factors and scores have been proposed. The accompanying paper published in this issue of Heart examines some scores used currently in the UK ( see page 491 ). 3 How to choose?

  • View inline

Percentage of 10-year cardiovascular events occurring in high-risk category (top 20% for continuous variables) (Scottish Heart Health Extended Cohort). Sexes combined.

The first criterion is utility. If a score is user-friendly, motivates the clinic nurse or doctor and the patient to start and persist with preventive action, it is a good score. A sheathed sword cannot cut. Any score that gives positive weighting to age, smoking, blood pressure and lipids will largely agree with another. Debate should not encourage nihilism. Easy implementation matters: factors included should be available, or justify their addition.

Chauvinism is a questionable criterion, but motivates new scores. From the USA came Framingham and preventive (not …tative) cardiology. 4 Framingham is often depreciated as based on outdated, middle-aged Americans. In 1991 specifications for developing the Dundee coronary risk disk 5 stipulated a British population base, anticipating criticism that risk factors might not behave in the same way. Likewise for European development of SCORE. 6 Biological risk factors are now known to behave similarly across diverse populations—we are the same species. Although Framingham competes strongly with scores from elsewhere, there is still a prejudice that recent, local scores are more credible.

Complexity arises from ‘risk prediction’ and ‘validation’. We cannot accurately predict a future myocardial infarction as if it were an eclipse of the sun despite claims to ‘predict absolute risk’. Single measurements of fluctuating risk factors and the unpredictable distribution and behaviour of individual atherosclerotic plaques guarantee imprecision.

In deriving a score we record the experience of a cohort followed for some years in terms of their initial risk factor levels and subsequent cardiovascular morbidity and mortality; then project it onto new disease-free populations to anticipate the future. If cardiovascular risk were determined exclusively by classic risk factors incidence rates of disease would be predictable. Long ago American risk scores were shown to overpredict event rates in Parisians. 7 Similar recent observations, and the need for SCORE itself to be recalibrated for different European populations, are not surprising. It would be coincidence were a score from one population at one time to be exactly calibrated to another. There are other and unknown determinants. Calibration, a part only of validation, has been overemphasised. It is secondary.

Risk scores are not crystal balls for prophesying. They are for prioritising preventive treatment. Individuals have risk factor values entered into a multifactorial score and are ranked according to this estimated risk to assess whether they justify treatment. More important than calibration is the score's discrimination between future cases and non-cases, by concentrating future cases at the top end of the distribution, the crucial component of validation. Table 1 shows how different factors and two scores discriminate in terms of the percentage of subsequent 10-year cardiovascular events occurring in the top 20% of risk, calculated from baseline risk factors in the Scottish heart health extended cohort (SHHEC). The best result approaches 50%. Two scores concentrating 50% of future cases in the top 20% have similar discrimination even if they are calibrated differently—the cutpoint to pick out this top 20% may be different, as it was for individual risk factors. Which individuals are high risk also differs. Good scores discriminate better than poor ones. Sophisticated statistical tests explore this in different ways.

Picking up half (for simplicity) of future cases when designating one fifth of the population as high risk for treatment is the paradox of risk scoring. Is the glass half full or half empty? Treatment is 20% of that treating everybody. Numbers needed to treat, to anticipate one case, are 40%, saving resources and side effects. The top 20% has four times the risk of the remainder, but it contains many false positives. Half the future cases are false negatives, not categorised high risk, therefore untreated, unless assessment of borderline cases is repeated at intervals. We are far from ‘predicting’ future cases with certainty.

An attribute of scores newly questioned by us and others is equity or fairness, the antithesis of discrimination. If a score is to be nationally adopted for preventive action it should not neglect sections of the population at excess risk for reasons incompletely identified by classic risk factors. Application of a Framingham score 8 across populations with large social gradients in disease like the UK will result in relative under-treatment of the socially deprived, and over-treatment of the socially privileged, frustrating national policies for diminishing social gradients in disease. 9 Harmful effects of social deprivation are only partly mediated by smoking, blood pressure and lipids. We were the first to propose a solution in the ASSIGN cardiovascular risk score in Scotland based on SHHEC, 10 11 a carefully standardised study, by adding in social deprivation and also family history. This was emulated 7 months later by QRISK 12 based on QRESEARCH, a much larger, predominantly English general practice population but with much missing data. ASSIGN 3 10 is shown to compensate for the social bias from Framingham 9 but it is not clear how well QRISK does. 3 13 These feature in the accompanying paper. 3

One effect of adding social deprivation and family history, powerful risk factors (see table 1 ), to classic factors in the ASSIGN score was a statistically significant improvement in discrimination, but disappointingly modest. 10 Diminishing returns is a common finding on adding new factors to the Framingham dataset. 14 Improvement is not inevitable; more does not mean better. The present paper 3 independently confirms our own finding in SHHEC 10 that ASSIGN discriminated better than a Framingham score 9 but not by much; also shown, but not emphasised, in the original QRISK paper on the QRESEARCH population. 12

The problem of calibration is resolvable by moving cutpoints for high-risk treatment. It has been suggested that ASSIGN and Framingham may lead to over-treatment, 12 but the converse argument for QRISK is that it may be identifying too few, particular in younger age groups, in which the number of positives may be too small to justify its use. 13 Framingham scores come both sides of ASSIGN: the Framingham cardiovascular score scores higher on average, more results exceeding a score of 20 8 10 (see table 1 ), but the composite of coronary plus stroke scores, and also the Cox Framingham score, frequently score lower, 3 12 results differing by age and sex and subject. Thresholds for treatment are coming down. ‘Absolute risk’ rises rapidly with age. If the same cutpoint is used regardless of age, all scores will identify a useful minority of the population for treatment over only a limited range of middle age; below this hardly anyone qualifies, above almost everybody. The paradigm needs re-examining.

Current testing of ASSIGN 3 in the THIN, largely English general practice population, had problems experienced in the QRESEARCH studies that much, and for some variables most, data (notably lipids and family history) were missing. The social gradient in disease for QRISK, QRESEARCH and THIN appears implausibly shallow. Maybe the indexing of social deprivation was unsatisfactory. 3 13 Scotland has its own Scottish index of multiple deprivation based on the postcode (see http://www.scotland.gov.uk/Topics/Statistics/SIMD (accessed 6 Jan 2011)). It would be nice to think that better data, especially for variables additional to Framingham, would improve discrimination by ASSIGN further, but that would be supposition. Data held in general practice need to be improved and standardised to get the full benefit from any system of risk factor scoring.

We launched ASSIGN for use in Scotland on grounds of social equity, 9 11 an argument now being heard as prominently outside Scotland. It is here shown to discriminate as well, if not marginally better, than its rivals, Framingham and possibly QRISK, in an independent study. Marginally better or equivalent discrimination may not prove a strong argument in itself, so the major rationale for ASSIGN is that of social equity. Implementation in place of the Framingham score modifies the distribution of high-risk cases across the population—increasing the primary care workload in socially deprived neighbourhoods, a challenge for health service support. We are currently revising ASSIGN, 15 incorporating the 2009 update of the SIMD.

  • de la Iglesia B ,
  • Potter JF ,
  • Poulter NR ,
  • Tunstall-Pedoe H
  • Conroy RM ,
  • Pyörälä K ,
  • Fitzgerald AP ,
  • for the SCORE project group
  • Ducimetière P ,
  • Richard JL ,
  • Cambien F ,
  • Anderson KM ,
  • Wilson PW ,
  • Tunstall-Pedoe H ,
  • Woodward M ,
  • Brindle P ,
  • for the SIGN group on risk estimation
  • ↵ SIGN (Scottish Intercollegiate Guidelines Network) . Risk estimation and the prevention of cardiovascular disease. Guideline No 97 . ISBN 1899893997 . Edinburgh : SIGN , 2007 . http://www.sign.ac.uk/guidelines/fulltext/97/index.html (accessed 11 Nov 2010).
  • Hippisley-Cox J ,
  • Coupland C ,
  • Vinogradova Y ,
  • ↵ ASSIGN Score . http://www.assign-score.com (accessed 11 Nov 2010).

Linked article 203364 .

Patient consent Obtained.

Sole contributor's statement of interest The sole contributor, Hugh Tunstall-Pedoe, developed the ASSIGN cardiovascular risk score jointly with Mark Woodward in 2006, in relation to the revised SIGN (Scottish Intercollegiate Guidelines Group) guideline 97 ‘Risk estimation and the prevention of cardiovascular disease’. 10 11 It is adopted by SIGN and the Scottish Government Health Directorates as the current cardiovascular risk score of choice in Scotland.

Provenance and peer review Commissioned; not externally peer reviewed.

Linked Articles

  • Epidemiology Performance of the ASSIGN cardiovascular disease risk score on a UK cohort of patients from general practice Beatriz de la Iglesia John F Potter Neil R Poulter Margaret M Robins Jane Skinner Heart 2010; 97 491-499 Published Online First: 20 Nov 2010. doi: 10.1136/hrt.2010.203364

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ASSIGN Score – prioritising prevention of cardiovascular disease

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ASSIGN is a cardiovascular risk score. The score was developed to prioritise the prevention of cardiovascular disease in those currently free of it by identifying those at highest risk. The score is ostensibly the ten-year percentage risk of developing cardiovascular disease (any manifestation of coronary heart disease or cerebrovascular disease including transient ischaemic attacks) in those disease-free at recruitment. So it is a number between 0 and 100. Note that although the score is "ostensibly" the risk percent over the next ten years this is based on historical data. There are reasons, including overall trends in disease rates, why current risks are probably lower. It is therefore more sensible to quote the ASSIGN score as the ASSIGN score, and its relevance as being in relation to the definition of high risk (ASSIGN 20) than to interpret it in terms of percentage risk as if this was a definite prediction. In any case, the overall aim is to lower the risk, not to carve it in stone. While the calibration of the score can be questioned on theoretical grounds, what matters is its discrimination. In other words, while a score of 10 may not actually be a risk of 10%, it does mean a higher risk than 5 and a lower risk than 15. It is this ranking of risk within a population which is the main purpose of the score, so identifying who is at highest risk.

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ASSIGN, QRISK and validation of cardiovascular risk scores

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An independent external validation and evaluation of QRISK cardiovascular risk prediction: a prospective open cohort study

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INTRODUCTION

The conclusions of the recent "independent external validation" of the QRISK cardiovascular risk score, (1) and the accompanying editorial from New Zealand, (2) imply strange logic and understanding of the political geography of the United Kingdom. The BMJ articles concluded that QRISK is the score for the United Kingdom. But QRISK's precursor and inspiration, ASSIGN, (3) was adopted for use in Scotland before QRISK was published. The articles' conclusions raise parallel questions on the use of databases containing huge amounts of unstandardised and missing data from primary care, in preference to dedicated, though smaller, cohort studies with greater quality control and completeness. The authors of the validation paper, (1) stressed the necessity of independent validation, but stated they could not validate ASSIGN as it was incompatible with the THIN database they used. To measure social deprivation (socio-economic status) ASSIGN uses the Scottish Index of Multiple Deprivation (SIMD) (4) - there are Welsh and English equivalents - rather than the older Townsend score in QRISK and THIN. It uses cigarette consumption for smoking, rather than yes/no.(3) But two previous groups, including the authors of the original QRISK paper(5) had already tested ASSIGN in mainly English databases - one using the QRESEARCH, (5) the other the THIN database. (6) BMJ readers are entitled to the missing Scottish perspective on cardiovascular risk scoring which sheds light both on ASSIGN and QRISK.

DEVELOPMENT OF ASSIGN

When the Scottish Intercollegiate Guidelines Network (SIGN), decided to revise its guidelines for coronary disease prevention in 2004, its risk estimation subgroup worried that social deprivation was an independent risk factor determining cardiovascular risk but not incorporated in existing risk scores. In collaboration with that group we analysed data from the SHHEC study (Scottish heart health extended cohort of Scots, randomly recruited from the middle 1980s to middle 1990s, followed since then by record linkage for mortality and morbidity).(7) Our analyses suggested that social deprivation, however defined, was as powerful an independent risk factor as cholesterol. Consequently, preventive treatment based on identifying high risk of cardiovascular disease through the Framingham score, without including deprivation, would unwittingly result in relatively overtreating in relation to their observed ten-year risk the socially privileged, at the expense of the socially deprived. If applied generally it could exacerbate social gradients in disease, negating national policies.(8) The resulting paper was rejected for publication without refereeing by the BMJ in 2005 but found a home in Heart.(9) The dilemma for the SIGN subgroup was that it could not now recommend the gold -standard Framingham score without modification as that would be socially divisive. Should the Framingham score have an added fudge factor or did we need a new score? The group was persuaded to sanction development of a score from the SHHEC study, similar to Framingham, but incorporating social deprivation and family history, which could then be compared with alternatives. Funding was provided by the Scottish Government Health Directorates. The ASSIGN cardiovascular risk score, the first ever to incorporate social deprivation, was developed in 2006. The accompanying manuscript was rejected for publication by the BMJ after refereeing, and on appeal, but again found a home in Heart. The full description, comparison with the Framingham cardiovascular score, and listing of the formulae and coefficients was published electronically in November 2006 and in print in February 2007, to go with the revised SIGN guideline. (3, 10)

ASSIGN's discrimination of future cases and non-cases was significantly, but only marginally, better than Framingham. Through having a full ten-year follow-up of our cohort we could identify both for a theoretical high-risk group, comprising the 20% of top scorers at recruitment, and the remaining 80% non-high-risk, who did, and who did not develop cardiovascular endpoints. True and false positives and negatives were identified across the whole population, and by fifths of SIMD. The ASSIGN and Framingham cardiovascular scores in individuals were highly correlated - 76% of those in the top fifth of risk to one score were in the top fifth to the other. We confirmed the unintended social inequity of the Framingham score, and showed that ASSIGN had overcome it. Where the Framingham score left a significant social gradient in those with future events not classified as high risk, the ASSIGN score did not. (3) The price of identifying a higher proportion of future cases as high risk among the socially deprived at baseline was a substantial increase in the predicted preventive workload in that group. Although decreased among the socially advantaged, the primary care teams involved would not be the same, with implications for resources. Testing in other databases was desirable but not considered essential: ASSIGN did as well as the gold standard Framingham score in discrimination (even after adjustment for 'self-testing' bias), and vindicated its use in terms of social equity, the objective of its development. Calibration differed from the equivalent Framingham cardiovascular risk score (11). It identified fewer as high risk, (>/=20% projected 10 year risk of cardiovascular disease) in most population groups, but cutpoints can always be adjusted. Rather than seeking 'independent validation' ASSIGN is currently the subject of progressive implementation studies in Scotland. (12)

DEVELOPMENT OF QRISK

Two future authors of QRISK, advisers to NICE, attended the launch of the revised SIGN guideline incorporating ASSIGN in February 2007. (10) They asked if funding was available from Scotland to test it in England. We said not, and learnt later that they obtained funding to develop their own score, incorporating social deprivation and family history, as we had in ASSIGN, but using a large general practice database, QRESEARCH. On hearing this, we suggested a collaborative head-to-head comparison of their planned QRISK score with ASSIGN. The offer was not taken up - indeed when QRISK was published in the summer of 2007(5) its formula and coefficients were unavailable to us and others. In rushing out their new score the QRISK authors failed to find that lipids were a significant risk factor, but rapidly changed the secret coefficients after a chorus of criticism (13); and they have been changed again since, with another version, QRISK2.(14) The authors plan to update them frequently, an added problem for those wondering how to make comparisons, but apparently approved by the BMJ leader writers. (2)

Without our involvement there was included in this QRISK paper a comparison with ASSIGN and also a Framingham score. It was not an independent validation, as it was partisan. It did show, despite problems of compatibility of definition of risk factors with the QRESEARCH database (we do not know how they were resolved), that ASSIGN again discriminated slightly better than Framingham in this different population. (5)

Last year the NICE committee put out to consultation recommendations that QRISK be adopted in England and Wales. (15) We replied with experience of ASSIGN in Scotland, and difficulty in comparing QRISK because of the failure to publish coefficients. We learnt that a decision was subsequently deferred for two years. Unknown to us, but revealed by PULSE magazine under the freedom of information act earlier this year, was the provisional unpublished result of a study submitted to NICE from East Anglia, which had used the THIN database. (6) It compared Framingham and QRISK but also ASSIGN, with some findings in the latter's favour. We are now told that this study was incorrect. (1) Failure to include ASSIGN in the current 'correct' comparison (1) leaves an intriguing question unanswered for us and the rest of the UK.

PROBLEMS WITH QRISK COMPARISONS WITH ASSIGN

The published comparison (1) shows that QRISK1.1 underestimates risk in the THIN population for reasons unknown. Previous data show ASSIGN identifying more people as high-risk (at a conventional score cutpoint of 20) than QRISK does, particularly below age 55 where it is questionable whether QRISK identifies enough to justify its use. We have not seen an analysis similar to ours (3) of the impact of QRISK in redressing potential inequity, despite several lengthy publications (1, 5, 14, 16) Perhaps this is because of the incomplete ten-year follow-up to date in the QRESEARCH and THIN databases. QRISK authors seem most concerned with what they call 'overtreatment' but this can be overemphasised. Unless a substantial minority of the population receive preventive treatment QRISK will achieve little change in the overall cardiovascular disease burden or in lessening social disparities, and will not justify its use.

MISSING AND QUESTIONABLE DATA

The problem of missing data (70% on lipids in QRESEARCH and THIN) is illustrated by an eight to one ratio of recorded prevalence, despite similar definitions, of a positive family history of cardiovascular disease . In the SHHEC cohort, with almost complete information men 26.4%, women 32.6%; QRESEARCH 9.2%, 12.4%.; THIN 3.5%, 4.2%. The QRESEARCH and THIN databases used are very similar. They both have incomplete 10-year follow-up with around half the person years of observation needed for full 10 year follow-up, despite referring to 'observed' ten-year event rates. The recent validation paper (1) states among the results for THIN that 36 483 patients were followed for at least 10 years out of 1 072 800 at the start or only 3.4%. The summary refers to 274 practices in England and Wales and the results to 288 practices. (1) Curiously, it was reported from QRESEARCH that patients with recorded lipid values had lower risk than where they were missing (4.9% versus 10.9% in men and 4.0% versus 7.9% in women) (5); from THIN the apparent opposite - complete risk factor data gave a risk of 19.9% for men and 12.8% in women, whereas one or more factor missing gave 5.0% for men and 3.4% for women. (1) There are other anomalies in the QRISK papers. Most relevant perhaps is that the social gradient in risk appears unduly flat compared with what we observe in SHHEC and this results in a smaller gradient when identifying high risk than we observed. (5, 3, 9) Our own data are more consistent with the social gradient in coronary disease mortality from routine statistics in both Scotland (using SIMD) and England (Carstairs score [not Townsend score, as posted]).(17) Given the known social gradient in smoking and other classic risk factors it is puzzling that the percentage high risk (score 20 and over) to Framingham in the QRESEARCH population in men is stated to be 20.5 in the first (least deprived) Townsend fifth and 19.5 in the fifth (most deprived).(5, Table 6). This is at odds with our own findings which show a significant positive gradient across all fifths. (3,9) The disparity cannot be explained by the relative under-representation of the most deprived fifth of the population in QRESEARCH and its overrepresentation in SHHEC.

CONCLUSIONS

QRISK derived from the QRESEARCH population with a very considerable amount of missing data has been independently validated using another very similar population, THIN with similar amounts missing. QRISK has not been formally tested in a population with more complete data and follow-up. We offered to collaborate in a head-to-head comparison of ASSIGN and QRISK before the latter was published, and again when it was, (13) and the offer is still open. Collaboration using agreed databases and a debate would be preferable to acting as devil's advocates. No score is perfect and the two scores may serve different priorities with different advantages.

If either score is to be used in different national environments there needs to be translation of indices of deprivation. Metaphysical arguments about validity are only relevant to whether cardiovascular risk scores help deliver preventive care effectively, efficiently, safely, equitably and affordably to those in greatest need. Problems in delivering and sustaining the follow-through are probably more important. There are problems common to all scores - how to handle extremes of age in particular. Cutpoints can and almost certainly will be modified over time as they have been in the past.

It is evident that the content, quality and completeness of items in general practice databases need to be greatly improved.

Meanwhile ASSIGN is being progressively adopted in Scotland. Further information on ASSIGN is available on its website ASSIGN-SCORE.COM.

1. Collins GS, Altman DG. An independent external validation and evaluation of QRISK cardiovascular risk prediction: a prospective open cohort study. BMJ 2009;339:b2584 doi:10.1136/bmj.b2584.

2. Jackson R. Marshall R, Kerr A, Riddell T, Wells S. QRISK or Framingham for predicting cardiovascular risk? BMJ 2009; 339:b2673.

3. Woodward M, Brindle P, Tunstall-Pedoe H, for the SIGN group on risk estimation. Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 2007;93:172-6.

4. Scottish Index of Multiple Deprivation www.scotland.gov.uk/Topics/Statistics/SIMD

5. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study. BMJ 2007;335:136.

6. Robins M, Potter J, Poulter N, Skinner J, de la Iglesia B. Response to Section 4,3 of the Guideline on Cardiovascular Risk Assessment. 2008. (See reference 15)

7. Tunstall-Pedoe H, Woodward M, Tavendale R, Brook RA, McCluskey MK. Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish Heart Health Study: cohort study. BMJ 1997;315:722-9.

8. Equally Well: Report by the Ministerial Task Force on Health Inequalities. ISBN 978-0-7559-5760-6. Edinburgh: Scottish Government, 2008. www.scotland.gov.uk/Resource/Doc/229649/0062206.pdf

9. Tunstall-Pedoe H, Woodward M, for the SIGN group on risk estimation. By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease. Heart 2006;92:307-10.

10. SIGN (Scottish Intercollegiate Guidelines Network). Risk estimation and the prevention of cardiovascular disease. Guideline No 97. ISBN 1899893997. Edinburgh: SIGN, February 2007. www.sign.ac.uk/guidelines/fulltext/97/index.html

11. Anderson KM, Odell PM, Wilson PWF, Kannel WB. Cardiovascular disease risk profiles. Am Heart J 1991;121(1 pt 2):293-8.

12. www.keepwellscotland.com .

13. Rapid responses to: Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study. www.bmj.com/cgi/eletters/335/7611/136

14. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 2008;336:a332.

15. National Institute for Health and Clinical Excellence. Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. London: NICE, 2008.

16. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Brindle P. Performance of the QRISK cardiovascular risk prediction algorithm in an independent UK sample of patients from general practice: a validation study. Heart 2008;94:34-9.

17. Scarborough P, Allender S, Peto V, Rayner M. Regional and social differences in coronary heart disease. London: British Heart Foundation, 2008. Table 1.5. www.heartstats.org/ .

Competing interests: No competing interests

assign score 20

ASSIGN Score - Risk Score

Professional guidelines, recent clinical studies, clinical prediction guides, recent systematic reviews.

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CVD risk assessment and management: Scenario: Management of people with an estimated risk of 10% or more

Last revised in May 2023

Covers the management of people with a CVD risk score of 10% or more.

Scenario: Management of people with an estimated risk of 10% or more

From age 18 years onwards.

How should I manage people with a CVD risk of 10% or more?

  • Use the clinical findings, lipid profile and family history to judge the likelihood of a familial lipid disorder — for more information on diagnosing or excluding familial hypercholesterolaemia as a cause of dyslipidaemia, see the CKS topic on  Hypercholesterolaemia - familial . 
  • Exclude possible secondary causes of dyslipidaemia (such as excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome).
  • Offer the opportunity to reassess CVD risk again after they have tried to change their lifestyle. 
  • Recognise that some people may need support to change their lifestyle — to help, refer them to programmes such as exercise referral schemes or smoking cessation services.
  • Discuss the benefits and risks of taking a lipid modification therapy, taking into account additional factors such as comorbidities, potential benefits from lifestyle interventions, the person's preferences, polypharmacy, general frailty and life expectancy.
  • Offer atorvastatin 20 mg daily if the person decides to take this and there are no contraindications — for more information on starting statin treatment, see the CKS topic on  Lipid modification - CVD prevention . 

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline  Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease  [ NICE, 2016 ], and the Public Health England (PHE) guide  NHS  Health check: best practice guidance [ PHE, 2017 ]. 

Cardiovascular disease (CVD) risk threshold

  • NICE has determined that the treatment threshold for primary prevention of CVD is a CVD risk of 10% as assessed using QRISK [ NICE, 2016 ].  
  • SIGN states that while the NICE approach identifies the proportion of the population which is cost effective to treat, it is less clear how the additional workload was accounted for within primary care to implement the policy, and the societal ramifications of the threshold effectively (placing almost all people in England and Wales above 65 years of age at high risk of CVD) were not explored.
  • In Scotland, almost 95% of individuals are at 10% or greater risk of a cardiovascular event within 10 years by the age of 60–64. Implementing this threshold in Scotland would increase the total number of people eligible for preventive treatment by around 70% to over 1.3 million.

What lifestyle advice should I give to help reduce the risk of CVD?

  • Lifestyle advice for people with a cardiovascular disease (CVD) risk of 10% or more is the same as for people with a CVD risk of less than 10%. See the section on lifestyle advice  in the  Scenario: Management of people with an estimated CVD risk less than 10% .

How should I manage comorbidities which are associated with increased risk of CVD?

  • Similar to people with a cardiovascular disease (CVD) risk of 10% or less, treatment other medical conditions which are associated with an increased risk of CVD should be optimized where possible, to reduce their effect on CVD risk. For more information, see the section on  Managing comorbidities in the Scenario: Management of people with an estimated CVD risk less than 10% . 

What drug treatments should I offer for the primary prevention of CVD?

  • Decide whether to start statin therapy after an informed discussion with the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle changes, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy.
  • Offer atorvastatin 20 mg a day (unless contraindicated) for the primary prevention of cardiovascular disease (CVD) to people (including those with type 2 diabetes) with an estimated CVD risk of 10% or more calculated using the QRISK3 assessment tool. 
  • Aged 85 years or older (beyond the QRISK range for inclusion) — consider offering atorvastatin 20 mg, which may be of benefit in reducing the risk of non-fatal myocardial infarction. But, take into account factors that may make treatment inappropriate such as comorbidities, polypharmacy, general frailty, and life expectancy.
  • With chronic kidney disease — for information on how to estimate and manage CVD risk, see the CKS topic on Chronic kidney disease . 
  • Offer atorvastatin 20 mg to adults aged over 40 years, or who have had diabetes for more than 10 years, or who have established nephropathy, or have other CVD risk factors.
  • With hypercholesterolaemia — for more information, see the CKS topic on  Hypercholesterolaemia - familial . 
  • For more information on when antihypertensive drug treatment is appropriate, see the CKS topics on Hypertension , and Diabetes - type 2 .
  • Do not routinely offer aspirin for the primary prevention of CVD.

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline  Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease  [ NICE, 2016 ], the European Society of Cardiology (ESC)  2016 European guidelines on cardiovascular disease prevention in clinical practice  [ ESC, 2016 ], an ESC position paper  Aspirin therapy in primary cardiovascular disease prevention  [ Halvorsen, 2014 ], the British and Irish Hypertension Society (BIHS)  Statement on the use of aspirin   [ BIHS, 2017 ], and the Scottish Intercollegiate Guidelines Network (SIGN) guideline  Risk estimation and the prevention of cardiovascular disease  [ SIGN, 2017 ]. 

Offering statins to people with a CVD risk of 10% or more

  • NICE based its recommendation on 34 studies on statin treatments.
  • CKS acknowledges that the threshold for offering statin treatment (a 10% or more 10 year risk of cardiovascular disease [CVD]) is controversial. Previous guidelines had used a 20% threshold, but the cost-benefit analysis performed for the current NICE guideline showed that this threshold should be lowered to 10% if a person wishes to take a statin after an informed discussion.
  • Much debate in the medical and lay press ensued from this recommendation. For example, see the  open letter  written to NICE from a group of leading doctors raising concerns about the guidance on statins and a  BMJ leader  in 2014 which also highlights some of the concerns. See also the  response from NICE  about the criticisms. Further to this, see an  open letter  sent from a group of leading doctors to the Health Select Committee of the House of Commons in October 2014, and the  response to this letter  from Professor Haslam, Chair of NICE.

Aspirin for primary prevention of CVD

  • Aspirin is not recommended for primary prevention of cardiovascular disease [ SIGN, 2017 ]. 
  • Aspirin may be considered beneficial for primary prevention if an individual’s future risk of stroke or heart attack is higher than average.
  • An accurate quantitative assessment of CVD risk is essential before prescribing aspirin for individuals in the primary prevention of CVD, where the evidence for benefit versus harm is very limited.
  • In a systematic review of six trials (n = 95,000), which compared the long-term use of aspirin vs control in people without overt CV or cerebrovascular disease, a risk reduction from 0.57% per year to 0.51% per year of serious vascular events was found, and major gastrointestinal (GI) and extracranial bleeds increased by 0.03% per year. The risk of vascular mortality was not changed by treatment with aspirin.
  • In a Japanese study (n = 14,464), people aged 60–85 years with hypertension, dyslipidaemia or diabetes mellitus were randomized to treatment with 100 mg aspirin or placebo. The 5-year cumulative primary outcome event rate (death from CV causes) was not significantly different between the groups, but treatment with aspirin significantly increased the risk of extracranial haemorrhage requiring transfusion or hospitalization (P = 0.004).
  • In the absence of such conditions, people with a 10-year risk of major CV of more than 20% should be given low-dose aspirin, and people with a risk 10–20% should be considered potentially eligible.

Statin use in the elderly

  • One meta-analysis of 8 trials including 24,674 patients aged 65 years or over (average age 73) without established CVD concluded that statins reduce the incidence of MI (RR 0.61, 95% CI 0.43 to 0.85) and stroke (RR 0.76, 95% CI 0.63 to 0.93) but do not significantly prolong survival. Similarly, an individual patient data analysis of major statin trials has confirmed reductions in first major cardiovascular events of 22% in those aged 66–75 and 16% in those aged over 75 per 1 mmol/l reduction in LDL cholesterol.
  • However, one RCT investigating the safety and benefit of stopping statins in people aged on average 74.1 years, with advanced, life-limiting illness, found that stopping statins is safe and may be associated with benefits including improved quality of life. The proportion of participants in the discontinuation versus continuation groups who died within 60 days was not significantly different (23.8% v 20.3%, 90% CI 3.5% to 10.5%) and did not meet the non-inferiority end point. Total quality of life (QoL) was better for the group discontinuing statin therapy (mean McGill QoL score 7.11 v 6.85, p=0.04). Few participants experienced cardiovascular events (13 in the discontinuation group, 11 in the continuation group).
  • There is no evidence of decreasing effectiveness of statins in patients aged over 75 years, and evidence supporting effectiveness in people aged over 80 years of age is very limited [ ESC, 2016 ]. 
  • In the elderly, the decision to start statin therapy should be based on 10-year CVD risk estimation, life expectancy, and QoL. Age alone is not a contraindication to drug therapy [ SIGN, 2017 ]. 

The content on the NICE Clinical Knowledge Summaries site (CKS) is the copyright of Clarity Informatics Limited (trading as Agilio Software Primary Care) . By using CKS, you agree to the licence set out in the CKS End User Licence Agreement .

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What Does a Safeassign Percentage Mean?

  • by Judy Jeni
  • January 16, 2024

a good percentage score

After you submit your work, it’s processed, and an originality report is generated. The report shows the Safeassign percentage, which highlights any unoriginal content. However, when your teacher creates an assignment on Safeassign, he determines whether you will view the results or not.

The report highlights all the matching text. In the light of the score, both the student and teachers should use the report as an opportunity to learn how to give attributions and not just paraphrase.

The originality report gives a list of sources copied from, highlighting each source with a different color. Meaning, if there are 20 different sources, they will highlight in 20 different colors.   

What Is a Safeassign Percentage?

A Safeassign percentage in the originality report is the overall Safeassign score for your paper. This means the percentage translates to the amount of matching content of your work to material that is already existing.

a safeassign report

When a Safeassign report has been processed, it is accessed on the Grade Assignment page. A Grade assignment page is accessed either from the Needs Grading page or from the Grade Center.

A Safeassign section is viewed in the grading sidebar on the Grade assignment page.  Similarly, a percentage pops up on the grading sidebar when the report is ready to view.

The originality report is accessed when paper processing is finished. It shows the percentage of text in the submitted work that matches existing sources.

It shows potential sources for the individual text of the submitted paper that shows a match.

The faculty can remove the rhyming sources from the paper and rerun it. This is an essential step to know whether the paper is a continuation of a previously submitted assignment by the same student.

In addition, when a student’s work is deleted from a course, its content remains in the database. This means it can be used to look for any matching by other students in future submissions.

Meaning of Safeassign Percentage

A percentage is used by the faculty to determine if a student copied. A teacher should be keen to read the entire student’s work to identify whether the matching text was adequately attributed since the report shows the matching text taken from other sources.

A SafeAssign percentage means the level of similarity between the scanned text and the source. It is a percentage score that shows the matching level of the two texts. In simple terms, it represents the degree of similarity of the copied text, and the original text that one copied from.

The overall score means the percentage of a submitted paper matches with existing sources.

showing low-risk score

 For example, a score of 95 means that there is a 95 percent probability that these two passages are the same.

While a score of 15 shows that there is a 15 percent chance that the highlighted text matches with an already existing material. The score highlights content from the existing source, whether it’s well attributed or not.

The Safeassign score is solely a warning indicator, and it’s the faculty’s responsibility to ascertain whether the student’s work is appropriately cited or not.

Low Safeassign scores below 15 percent : this means the paper has a few common quotes and phrases that match other documents. Such submissions don’t require further analysis.

A medium score between 15 and 40 percent : this means the papers are plagiarized. They have extensively quoted and paraphrased content. However, the teacher should check further to see whether it is attributed correctly.

High Safeassign score of 40 and above : this implies the content is plagiarized highly. Meaning a student copied the text extensively from another source.

Difference Between Safeassign Percentage and Safeassign Score

There is no difference between a Safeassign score and a Safeassign percentage; they represent the same. A Safeassign score means the percentage by which a document matches with other existing documents.

Sentence matching score gives the probability by which any two phrases have the same meaning. The score number depicts the reciprocal to the probability that these two passages are similar in chance.

Reading a Report from Multiple Attachments and Attempts on Safeassign

multiple attachments

Safeassign does not check a student’s current submission against his previous content submissions.

Uniquely, it can identify multiple attempts for a particular assignment submitted by the same student for the same.

Similarly, if the submission has more than one attachment, each is listed in the report.

What is a Good Safeassign Percentage?

A good Safeassign percentage is any score that is below 15 %.  A that is lower than 15% means a few instances of matching text in your submitted work. Usually, you have used commonly used phrases and quotes.

It is seen as a good similarity score since it lies within the low plagiarism levels of between 0-15, depicting your work as original. Safeassign looks for borrowed content in your work that overlaps with other existing materials.

100 % match on Safeassign

If the report indicates a 100% match, it shows a student copied the highlighted item word for word from an existing source. Usually, this happens when you use quotes by other people: copying and pasting directly. This is not a problem when the cited text matches 100 percent.

However, one can still copy but not get detected with plagiarism. Check out some of the ways to write essays without plagiarizing and see how to have essays that get good scores.

Judy Jeni

Franchise tag primer: Chris Jones again headlines tender decisions

The window for NFL teams to assign the franchise and transition tags begins Feb. 20 and ends at 4 p.m. ET on March 5. Teams can use only one tag per offseason.

The franchise tag restricts a player's rights in free agency while offering them a one-year contract. The tender's cost is determined by 120% of the player's cap number from the previous season or the average of the top five salaries at their respective position, whichever is greater. The player can sign the tag anytime and has until July 15 to negotiate a multi-year extension. Meanwhile, the transition tag allows a player to test free agency while giving his incumbent team the right to match any offer. The transition tag is presented as a one-year deal worth the average of the top 10 salaries at the player's position.

Keep in mind that some high-profile free agents aren't considered candidates here, including Minnesota Vikings quarterback Kirk Cousins and defensive end Danielle Hunter, whose contracts are void after the tag designation window closes. In cases like Tampa Bay Buccaneers receiver Mike Evans, using the tag may not make sense given how much it would cost ($28 million). Here are the top candidates for a tender in 2024, barring extensions:

(Salary projections courtesy: Over The Cap )

Candidates to get 2nd straight tag

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Chris Jones, DL, Chiefs Projected franchise tag salary: $32.1M

Losing Jones to free agency would be massive for Kansas City, but placing the franchise tag on him for a second straight year would significantly hurt the team's ability to address other needs. A non-quarterback has never received a tag worth north of $30 million. Jones had a lengthy holdout last year while negotiating a new deal with the Chiefs. There's mutual interest again, but it won't be easy for the sides to ink a new pact if the $32-million tag number is the star lineman's starting point this offseason. One of the best defensive linemen of his generation, Jones is in a position to demand a lot of money. A tag-and-trade scenario could be in play if K.C. decides not to reward Jones ahead of his age-30 season.

Saquon Barkley, RB, Giants Projected franchise tag salary: $12M

The Giants could tag Barkley for a second straight year. He received the 2023 tag and later agreed to a revised one-year contract. New York will keep negotiating, and given the state of the running back market, Barkley might not get what he wants from the team again. That's why buying time could be important for both sides. The 27-year-old recently said he'd be OK getting the designation as long as it happens early in the franchise-tag window. Despite his injury history, keeping Barkley, their best offensive player, should be a priority for the Giants.

No-brainers

Tee Higgins, WR, Bengals Projected franchise tag salary: $21.6M

The Bengals couldn't extend Higgins in 2023 and now have a big decision to make regarding his future. The 25-year-old is Cincy's No. 2 receiver, but other teams would certainly pay him as a No. 1 guy if he hits the open market. Cincinnati can't let that happen and presumably needs time to negotiate, so placing the tag on the two-time 1,000-yard receiver makes sense. Ja'Marr Chase is also eligible for an extension. It'll be interesting to see how that potentially affects Higgins' deal.

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Josh Allen, LB, Jaguars Projected franchise tag salary: $21.9M

The Jaguars plan to keep Allen, but it's unclear if the sides will agree on a long-term contract. Jacksonville using the tag on the two-time Pro Bowler seems inevitable since it sounds like negotiations will take time. Allen is a cornerstone of the team's defense and is coming off the best campaign of his career. The 26-year-old set a Jaguars single-season record with 17.5 sacks in 2023.

Brian Burns, LB, Panthers Projected franchise tag salary: $21.9M

All signs point to the Panthers and Burns needing extra time to negotiate a lucrative long-term contract. The 2019 first-round pick is Carolina's best pass-rusher, posting 95 quarterback hits and 46 sacks in five seasons. He's only 25 and wants to become one of the league's highest-paid players at a position topped by Nick Bosa with a $34-million average annual salary. By rejecting massive trade offers for Burns in recent years, the Panthers showed that they hope to keep the star defender. Finding the right number could be hard.

Michael Pittman Jr., WR, Colts Projected franchise tag salary: $21.6M

Letting Pittman - their No. 1 receiver - test free agency would be a disaster for the Colts, who have to continue to build around quarterback Anthony Richardson. But Indianapolis isn't expected to let Pittman hit the open market and has enough cap space to use the franchise tag if needed. The 26-year-old set a career high with 109 catches for 1,152 yards and four touchdowns in 2023.

Likely to be tagged

Jaylon Johnson, CB, Bears Projected franchise tag salary: $18.4M

Johnson and the Bears had ups and downs recently as they unsuccessfully negotiated a new contract. The 24-year-old reportedly requested a trade in October, but Chicago didn't move him. Johnson then said he hopes to remain with the team, though he added he's looking to become the NFL's highest-paid corner. The Bears have cap space to keep Johnson but will likely need time to negotiate. He amassed 10 pass breakups and four interceptions (one pick-6) in 2023 to earn his first All-Pro berth.

assign score 20

Antoine Winfield Jr., S, Buccaneers Projected franchise tag salary: $17.2M

The Bucs have several unrestricted 2024 free agents, but Winfield should be one of their main priorities. A first-team All-Pro, he finished last season with 122 tackles, 12 pass breakups, six sacks, six forced fumbles, and three interceptions. Winfield isn't going anywhere. Tampa Bay might be able to sign the star defensive back to a long-term deal by March. If not, the franchise tag will be in play.

Christian Wilkins, DT, Dolphins Projected franchise tag salary: $19.7M

Miami shouldn't let Wilkins leave in free agency. And after they failed to sign a long-term deal in 2023, we expect negotiations to take time in 2024. The market for interior linemen was reset in the past 12 months, and the 28-year-old Wilkins set career highs with 23 QB hits and nine sacks. However, the Dolphins are $52 million over the projected salary cap.

Justin Madubuike, DT, Ravens Projected franchise tag salary: $19.7M

The Ravens don't have much cap space but need to do everything they can to keep Madubuike after his spectacular breakout campaign. Buying some time using the franchise tag makes sense as Baltimore continues negotiating a lucrative long-term pact with the 26-year-old. The former third-round pick was one of football's best interior defensive linemen in 2023, recording 33 QB hits and 13 sacks to earn a second-team All-Pro nod.

Could be tagged

L'Jarius Sneed, CB, Chiefs Projected franchise tag salary: $18.4M

A main priority for the Chiefs is re-signing Jones and Sneed. If K.C. signs a new deal with Jones soon or lets him test free agency, the reigning Super Bowl champions could use the tag on Sneed instead. The former fourth-round pick is a major part of the Chiefs' secondary and forms arguably the NFL's best duo of corners along with Trent McDuffie.

Baker Mayfield, QB, Buccaneers Projected franchise tag salary: $35.9M

Winfield is the most likely Bucs player to receive the tag if Tampa Bay uses it, but Mayfield could also become a candidate depending on how negotiations unfold. Granted, that would cost a lot. However, what Mayfield's next contract will look like is one of this offseason's greatest mysteries. Are the Bucs sold on his career resurgence after last year? While playing on a cheap one-year contract, the former No. 1 pick set career highs with 4,044 yards and 28 touchdowns to help the club claim the NFC South and win a playoff game.

assign score 20

Kamren Curl, S, Commanders Projected franchise tag salary: $17.2M

Curl will likely be the target if Washington uses the tag. The 24-year-old has been a nice surprise since being drafted in the seventh round in 2020, appearing in 60 career games. However, Curl hasn't recorded an interception since his three-INT rookie campaign. With a new general manager and head coach in town, the Commanders may not use the 2024 tag. They have a lot of cap space and could explore free agency to reshape the roster.

Kyle Dugger, S, Patriots Projected franchise tag salary: $17.2M

The Patriots have multiple tag candidates between Dugger, offensive lineman Michael Onwenu, and tight end Hunter Henry. But they're not locks, and their futures could depend on new head coach Jerod Mayo's approach to free agency. Dugger played 98% of New England's defensive snaps and tied a team-high two interceptions in 2023. He also ranked third in tackles (109) and second in pass breakups (seven). There's speculation the 27-year-old would like to hit the open market, but Mayo and Co. could use the tag to get more negotiation time if they see him as a top priority. A multi-year deal worth between $12 million and $15 million is more fitting for the versatile defender.

Xavier McKinney, S, Giants Projected franchise tag salary: $17.2M

The Giants will try to keep McKinney, a team captain coming off a strong season and boasting solid coverage skills and tackling ability. But here's why the 24-year-old receiving the tag is far from a lock: the tender may be too expensive for a defender who's missed 17 games due to injury in four seasons. Plus, the Giants might have to place their tag on Barkley instead.

assign score 20

Bryce Huff, DE, Jets Projected transition tag salary: $20.1M

It's unlikely that Huff gets tagged, but the 25-year-old did break out in 2023. Despite appearing in only 42% of New York's defensive snaps, Huff recorded 21 QB hits and 10 sacks, likely playing his way out of the team's price range. Given his number of snaps, it would be surprising if the Jets placed the franchise tag (projected at $23.3 million for a defensive end) on him. However, New York could potentially use its transition tag. In that case, the club would get no compensation if Huff joins another team, but it'd have the right of first refusal. It's expensive, but Huff's ceiling is very high.

Jonathan Greenard, DE, Texans Projected franchise tag salary: $23.3M

Houston would love to keep Greenard after the 26-year-old posted a breakout season with 12.5 sacks in 15 games last year. But the former third-round pick battled injuries and has yet to play a full NFL campaign. Placing a tag worth more than $20 million on Greenard is unlikely, even for a Texans team with enough cap space.

Marquise Brown, WR, Cardinals Projected franchise tag salary: $21.6M

The Cardinals have wide receiver issues and don't roster another high-profile free agent, so Brown has been rumored as a tag candidate for Arizona, which traded a first-round pick for him in 2022. But the 26-year-old struggled to stay healthy and caught only 1,283 yards and seven touchdowns in two seasons with the NFC West team.

Leonard Williams, DT, Seahawks Projected franchise tag salary: $36M

As much as Seattle would like to retain Williams after trading two picks for him midseason, using the tag isn't a great option. It would cost a lot more than the projected tender for defensive tackles ($19.7 million) since Williams received the tag from the Giants in 2020 and 2021. Not only are the Seahawks tight on salary cap space, but general manager John Schneider has been reluctant to use the tag in the past.

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  1. Home

    'High risk' (score 20 or more) implies risk-lowering medication and/or other medical help. ASSIGN is the cardiovascular risk score chosen for use by SIGN (Scottish Intercollegiate Guidelines Network) and Scottish Government Health Directorates. ASSIGN can be adapted for use outside Scotland.

  2. Estimate the risk

    Thus a 20% risk (the conventional cut-point for intervention) means that one fifth will develop cardiovascular disease and 50% means one in two. Note that this is not the relative risk (or risk multiple) but the actual or 'absolute' risk. However, it is an estimate and not a guarantee.

  3. Cardiovascular disease risk assessment and prevention

    The ASSIGN cardiovascular risk assessment calculator is tailored to the Scottish population and uses factors such as age, sex, smoking, systolic blood pressure, lipid profile, family history of premature CVD, diabetes mellitus, rheumatoid arthritis, and social deprivation to estimate cardiovascular risk.

  4. About

    By convention (following Framingham scoring, and expert recommendations) the presumption is that anyone whose ASSIGN cardiovascular risk score is 20 or more is 'high risk' and a candidate for preventive treatment, and anyone with a score below that does not normally qualify.

  5. Cardiovascular Risk and Risk Scores: ASSIGN, Framingham, QRISK ...

    Table 1 Percentage of 10-year cardiovascular events occurring in high-risk category (top 20% for continuous variables) (Scottish Heart Health Extended Cohort). Sexes combined. The first criterion is utility.

  6. Prediction of Cardiovascular Risk Using Framingham, ASSIGN and QRISK2

    The Framingham, ASSIGN and QRISK2 risk scores have been validated by comparing observed to predicted risks in the overall population . There is no consensus about what risk score to use for CVD risk assessment and guidelines for primary CVD prevention propose to use any risk score [10] .

  7. About

    For Beginners For Professionals Introduction Development Funding & Sponsorship SHHEC SIGN Introduction ASSIGN is a cardiovascular risk score. The score was developed to prioritise the prevention of cardiovascular disease in those currently free of it by identifying those at highest risk.

  8. ASSIGN, QRISK and validation of cardiovascular risk scores

    puzzling that the percentage high risk (score 20 and over) to Framingham in the QRESEARCH population in men is stated to be 20.5 in the first (least deprived) Townsend fifth and 19.5 in the fifth (most deprived).(5, ... All three of us are instigators of the ASSIGN score and involved in its implementation. The ASSIGN score definition and ...

  9. Adding social deprivation and family history to cardiovascular risk

    The ASSIGN score was derived from cardiovascular outcomes in the Scottish Heart Health Extended Cohort (SHHEC). It was tested against the Framingham cardiovascular risk score in the same database. Setting Random‐sample, risk‐factor population surveys across Scotland 1984-87 and North Glasgow 1989, 1992 and 1995. Participants

  10. Beyond 10-Year Risk: A Cost-Effectiveness Analysis of Statins for the

    Results: Compared with an ASSIGN score ≥20%, reducing the risk threshold for statin initiation to 10% expanded eligibility from 804 000 (32% of adults ≥40 years of age without CVD) to 1 445 500 individuals (58%). This policy would be cost-effective (incremental cost-effectiveness ratio, £12 300/QALY [95% CI, £7690/QALY-£26 500/QALY]).

  11. Cardiovascular Risk Prediction Models and Scores in the Era of

    According to this score, patients with a score higher than 20% are considered to be at high risk [48,49,50]. The Assign score has been validated in comparison to Framingham and QRISK, and slightly outperformed the former [51,52]. Even though the Assign risk score might be useful in subjects living in Scotland, it has not been externally ...

  12. ASSIGN Score

    Definition ASSIGN Cardiovascular Disease 10-Year Risk Score (ASSIGN Score) Risk score. [from NCI] Professional guidelines PubMed Socioeconomic Deprivation: An Important, Largely Unrecognized Risk Factor in Primary Prevention of Cardiovascular Disease.

  13. Scenario: CVD risk assessment

    This means that you have a 20 in 100 chance (2 in 10 chance) of developing a cardiovascular disease CVD (CVD) within 10 years (angina, myocardial infarction, transient ischaemic attack, stroke or peripheral arterial disease.) In other words, in this example, 2 in 10 people with the same risk factors will develop a CVD within the next 10 years.

  14. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction

    Specifically, when there was evidence of nonobstructive (10 to 70% cross-sectional luminal stenosis) or obstructive coronary artery disease on the CTA, or when a patient had an ASSIGN score of 20 ...

  15. Freaking out... high safe assign score! : r/AskAcademia

    Whenever I see a Safe Assign score higher than 25%, I check it out. 99% of the time, it's students doing exactly what you did, using legit references that have been used in other sources. Take a deep breath, and know that your professor probably does what we all do, and checks out a high flag score to see if it is legit or not. Nobody trusts ...

  16. PDF 3 Guidance for Successful Evaluations

    may prefer to assign scores based on a standard unit of measure (e.g., time, dollars), a complex function, or another function type. By convention, in MAU analysis, any scoring function should be normalized so that the scores fall in the range from 0 to 1.

  17. Scenario: CVD risk 10% or more

    The proportion of participants in the discontinuation versus continuation groups who died within 60 days was not significantly different (23.8% v 20.3%, 90% CI 3.5% to 10.5%) and did not meet the non-inferiority end point. Total quality of life (QoL) was better for the group discontinuing statin therapy (mean McGill QoL score 7.11 v 6.85, p=0.04).

  18. SafeAssign Score: Interpret Good Scores and Reduce Bad ones

    1. Low SafeAssign Plagiarism Score It is a type of score that occurs below 15%. If your paper has few common phrases or quotes, it is likely to land in this category. As such, it indicates that your documents have a few matches against other works. Most times, such a paper may not need further analysis.

  19. What Does a Safeassign Percentage Mean?

    A SafeAssign percentage means the level of similarity between the scanned text and the source. It is a percentage score that shows the matching level of the two texts. In simple terms, it represents the degree of similarity of the copied text, and the original text that one copied from.

  20. java

    1 1 1 1 1 Clearly you can't assign scores until you've read all scores, because a later score could change the value of best. You need at least two loops, not one as you have now. - Erwin Bolwidt May 12, 2019 at 22:58 Add a comment 4 Answers Sorted by:

  21. Franchise tag primer: Chris Jones again headlines tender decisions

    The window for NFL teams to assign the franchise and transition tags begins Feb. 20 and ends at 4 p.m. ET on March 5. Teams can use only one tag per offseason.The franchise tag restricts a player ...