CVD RISK PREDICTION: 

PAST, PRESENT & FUTURE
Ramesh Singh Veriah
Cardiology Unit
University Malaya Medical Centre (UMMC)
 AIMS
• History
• What is risk?
• How does risk relate to the management of 
cardiovascular disease (CVD)?
• Calculating CVD risk.
• How can we communicate risk to patients?
 Introduction
• CVD initially thought of as a natural 
consequence of aging.
• With time life‐style factors and biochemical as 
well as genetic factors were identified. 
 Seven Countries Study
• 1958 – 1970, men ages 40‐59 from 7 countries
• Clearly demonstrated that CVD rates varied 
around the world and is influenced by 
environmental factors.
• Migration factors appeared to have a strong 
influence.
 Framingham Heart Study 1961
• Earliest landmark study.
• Showed that hypertension, high cholesterol 
and smoking increased CV risk.
• Development of CVD involves a number of risk 
factors.
 Cardiovascular Disease is a Common
Complex Disease

Elevated Blood Adverse Lipid

Pressure Profile

Diabetes
Family
History
Cardiovascular
Disease

Sedentary
Obesity
Lifestyle

Smoking Nutrition
 "At least hundreds of genes are
involved in cardiovascular disease”

- Lusis AJ, 2000

“You can only predict things after 
they have happened”

Eugéne Ionesco 1912‐1994
 What is risk?
Risk is the likelihood of being harmed in some way
How we define and understand risk depends on 
– emotional factors rather than hard facts
– our instinctive bias
– if we understand the difference between risks and hazards
– based on evidence
– common sense

Harm is not often due to a single cause so it becomes 
harder to define what a risk is
When we try to avoid a risk, we can change some part 
of the situation that potentially results in exposure to 
a different risk
 Risk Factor Assessment
• Rarely occur in isolation.
• Rather CVD is a convergence of a number of risk 
factors thus global assessment is needed.
• Combine risk factors with disease markers can 
prove to be beneficial
• Important to identify the modifiable risk factors 
as it is a potential target for intervention.
• Which risk factor is an important predictor,  
assess it at minimal cost and easiest way.
 CV Risk Prediction:
Application
• Population
‐ planning for public health messages/forums
• Individual
‐ target more intensive programs that are also 
personalized to maximize the prevention of 
disease
 A ‘Perfect’ Risk Factor
• Prevalent in the population
• Can be easily and safely measured
• Good predictive value
• Inexpensive to measure
 Risk Scoring
• Many risk factors are correlated with one another.
• When conducting an initial screen only a handful of 
easily measured risk factors are needed to measure 
the individuals overall cardiac risk.
• Low risk or high risk (clearly scored) individuals will not 
need any further evaluation of additional risk factors as 
this will only add to cost and not yield further 
information.
• It is the intermediate risk individuals that will warrant 
further stratification. 
• Allows cost‐effective targeting of interventions.
 CRUDE ASSESSMENT
Risk of a Second Vascular Event
Increased risk vs general population (%)

Original event Myocardial infarction Stroke

Myocardial infarction 5–7 x greater risk1 3–4 x greater risk2

(includes death) (includes TIA)

Stroke 2–3 x greater risk2 9 x greater risk3

(includes angina and
sudden death*)
Peripheral arterial disease 4 x greater risk4 2–3 x greater risk3
(includes only fatal MI (includes TIA)
and other CHD death†)

*Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD)
†
Includes only fatal MI and other CHD death; does not include non-fatal MI

1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9.
3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63. 4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.
 High Risk Group
• Diabetics
• Chronic renal failure
• These groups warrant aggressive preventive 
interventions.
 Risk Prediction Scores
• Simple and reliable way.
• Low cost.
• Framingham Risk Scoring
• HeartScore (ESC)
• PROCAM Algorithm
• New Zealand Risk Scoring
 Improving Risk Scoring
• Calcium scoring
• Multi‐slice CT
• Echocardiography
• Cardiac catheterization
• C‐reactive protein (CRP)
 Women’s Health Study
• Addition of family history, HBA1c if diabetic 
and CRP can further reclassify women at 
intermediate risk to either low or high risk.
 LOWERING RISK
• 3 complementary approaches
‐ therapeutic interventions for secondary 
prevention in patients with known CVD
‐ identification and targeting of high‐risk 
individuals for primary prevention through 
mass screening or case finding
‐ general recommendations disseminated 
throughout the population 
 Framingham Data

Individuals who can reduce and 
minimize risk factor burden before 
age of 50 will substantially lower 
their life‐time risk of developing CVD
 Communicating risk
to patients

• It is difficult to communicate risk and uncertainty
• When  discussing  cardiovascular  disease  (CVD)  risk 
with people,  show  them  the  risk  prediction  charts 
(and  calculator)  to  help  them  understand  their 
estimated  risk  of  experiencing  a  cardiovascular 
event within the next 10 years 
• It  is  usually  more  helpful  to  discuss  total  CVD  risk 
rather than individual risks for CHD, stroke or other 
events
• Individuals  may  have  differing  thresholds of  risk 
before considering drug treatment to lower risk and 
this may be associated with social class
 Communicating risk to patients

• If  people  want  to  know  the  benefits  and  risks  of 
investigations  and  treatments  then  we  have  to  be 
able to communicate them effectively
• The  way  in  which  health  professionals 
communicate  risk  affects  patients’ perception  of 
that risk
• Patients  should  be  provided  with  a  balanced  and 
fair assessment of the pros and cons of the various 
options, based on well‐founded data
• Use  of  simple  visual  aids  and  everyday  analogies 
can help to increase understanding and ensure that 
consent is properly informed