The use of assessment tools to decide

upon your risk of cardiovascular disease

(CVD) 

14/01/09: by Susan M Oliver RN MSc, Nurse Consultant Rheumatology, Chief Nurse Adviser for the National Rheumatoid Arthritis Society, Chair of the Royal College of Nursing Rheumatology Forum and Joint Chair of the Rheumatology Futures Project Group

Taken from NRAS magazine, Winter 2008

Background information

Reducing the risk of heart disease is an international problem as it not only shortens people’s lives but can have a powerful impact on quality of life and general health.

There are many reasons why you may have an increased risk of heart disease and these include factors such as age, sex, health and lifestyle factors as well as family history. So the assessments of your risk factors have routinely included:

• Your age (the risk of heart disease generally increases with age so screening programmes tend to target people over 40 years of age)
• Sex (there are differences between male and female risk factors especially in some populations) 
• Smoking history and current health status
• Blood pressure 
• Cholesterol levels

We have known that some populations can also have an increased risk of heart disease for example:

• Asian populations have a high risk of heart disease and this can vary between different Asian sub-groups and also between men and women. For example Bangladeshi men have a higher risk than Bangladeshi women of the same age
• People who have a condition that results in some form of on-going inflammation or auto-immune condition in the body such as diabetes or rheumatoid arthritis carry an added risk of cardiovascular disease

How do I know if I have been assessed for my risk of cardiovascular disease?

Your doctor may have undertaken an assessment of your risk with you by asking you about:

o Your smoking history

o Checking your blood pressure

o Taking a fasting blood test to measure your cholesterol

o Asking you about your family history

o Checking your diet and lifestyle

o Reviewing your medical history to see if you carry additional risks, for example if you’re diabetic

The Framingham Scoring System to assess the next 10 years' risk of CVD

Risk is calculated using an algorithm that considers all the different factors outlined above and is given as a percentage of risk of CVD over the next 10 years. The risk is colour-coded

< 10% risk - Green

10-20% risk - Orange

> 20% risk - Red

This algorithm is called the (modified) Framingham Score. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest that a formal risk assessment should be undertaken if your Framingham risk is calculated as >20%

OR if you already have:

• Coronary heart disease (history of previous heart attack) or major atherosclerosis
• A family tendency to have a high cholesterol level
• Kidney disease including problems with your kidneys related to diabetes
• Diabetes (type I or type II)

The scoring system should not be used to calculate your risks and you need your doctor to undertake an individual review of your risks

Other models to assess risk of CVD

Your doctor may have already assessed your specific risks and in discussion given you some choices about the next steps in your treatment or advised you on the best way to reduce your risks without medication. We know that having good control of your RA is one important way of reducing the risk of CVD. NICE has produced a patient information leaflet that you might find helpful (www.nice.org.uk – lipids modification/information for the public).

New tools to assess CVD

Recently a new tool called QRISK2 has been developed to assess people at high risk of CVD. It is early days but it appears to be an improved tool compared to the Framingham score because it includes in its calculations:

• Specific issues related to ethnicity that affect the 10 year risk of CVD
• Calculations based on other factors such as RA, renal disease and atrial fibrillation (a type of heart condition)
• Social issues that can increase an individual’s risks. For example, people who are socially deprived have a higher risk of CVD

If you would like to read a little more about the QRISK2 - you can go to www.qresearch.org/public/qriskINformationforPatients.aspx.

There is also a medical paper about the QRISK2 – Author: Hippisley-Cox J et al entitled: Predicting cardiovascular risk in England and Wales; prospective derivation and validation of QRISK2. It can be accessed online from: British Medical Journal; (2008)336.a 332. www.bmj.com

What should I do when I see my general practitioner?

It is important to ask whether your risk of cardiovascular disease has been assessed. If you have had your risk assessed you might want to know more about your score and what advice your doctor suggests you take to reduce this. You might also want to ask them about how your RA was taken into account in the assessment. Remember it is early days with the QRISK2 and it will take a while for it to be fully implemented and further researched …. but it may be a good point for discussion with your doctor.

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