WHAT ARE THE TARGETS?
European WHY IS CVD PREVENTION NEEDED?
SCORE Memocard
(Systematic COronary Risk Evaluation)
Think total cardiovascular risk
& act for better CVD prevention
EACPR
European Association for
Cardiovascular Prevention
and Rehabilitation
A Registered Branch of the ESC
www.escardio.org/EACPR
• Atherosclerotic CVD, especially CHD, remains the leading cause of premature
Smoking
death worldwide. No exposure to tobacco in any form
• CVD affects both men and women; of all deaths that occur before the age of Healthy diet- low in saturated fat with a focus on wholegrain
Diet
75 years in Europe, 43% are due to CVD in women and 36% in men. products, vegetables, fruit and fish*
• CVD mortality is changing, with declining age-standardized rates in most 2.5 to 5 hours moderately vigorous physical activity per week
Physical Activity
European countries, but it remains high in Eastern Europe or 30-60 minutes most days
• Prevention works: over 50% of the reductions seen in CHD mortality relate to BMI 20-25. Waist circumference <94 cm (men)
Body weight
changes in risk factors, and 40% to improved treatments. or <80 cm (women)
• Preventive efforts should be life-long, from birth (if not before) to old age. Blood pressure BP <140/90
• Population and high-risk preventive strategies should be complementary; an
approach limited to high-risk persons will be less effective; population Very high risk: LDL <1.8 mmol/L or >50% reduction
education programmes are still needed. High risk: LDL <2.5 mmol/L
• Despite gaps in our understanding, there is ample evidence to justify intensive Low to moderate risk: LDL <3 mmol/L
public health and individual preventive efforts. Lipids HDL cholesterol: No target but >1.0 mmol/L in men
and >1.2 mmol/L in women indicates lower risk
• There is still substantial room for improvement in risk factor control, even in
Triglycerides: No target but <1.7 mmol/L indicates lower risk
individuals at very high risk. and higher levels indicate a need to look for other risk factors
Diabetes HbA1C <7%, BP <140/80
WHAT ARE THE PRIORITIES?
* A healthy diet has the following characteristics:
Very high Risk: Subjects with any of the following:
• CVD • Saturated fatty acids to account for <10% of total energy intake, through
• Type 2 diabetes, or type 1 diabetes & target organ damage replacement by polyunsaturated fatty acids.
• Patients with moderate to severe CKD (GFR <60mL/min/1.73m2) • Trans unsaturated fatty acids: as little as possible, preferably no intake from
• SCORE ≥10% processed food, and <1% of total energy intake from natural origin
• <5 g of salt per day.
High Risk: Subjects with:
• 30–45 g of fibre per day, from wholegrain products, fruits and vegetables.
• Markedly elevated single risk factors such as:
- Familial dyslipidaemias
• 200 g of fruit per day (2-3 servings).
- Severe hypertension. • 200 g of vegetables per day (2-3 servings).
• SCORE ≥ 5% and <10% • Fish at least twice a week, one of which to be oily fish.
• Consumption of alcoholic beverages should be limited to 2 glasses per day
Moderate Risk: SCORE is ≥1 and <5% at 10 years, further modulated by: (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol)
• family history of premature CAD • HDL-C for women.
• abdominal obesity • TG
• physical activity pattern • hsCRP
• social class
Low Risk: SCORE less than 1% and free of qualifiers Source: European Guidelines on CVD Prevention in Clinical Practice (Version 2012)
© European Society of Cardiology - DOI: 10.1093/eurheartj/EHS092
 E uropean SCORE C harts
Relative Risk
HOW DO I ASSESS RISK? Note that a low total cardiovascular risk in a young person may conceal a
The «Priorities» section indicates that certain subject declare themselves to be at very high or high risk without requiring the use a chart such as SCORE (Systematic COronary high relative risk; this may be explained to the person by using the relative
Risk Evaluation), which is designed for use in apparently healthy individuals. These are those with known CVD, type 2 diabetes or type 1 diabetes with target organ damage risk chart. As the person ages, a high relative risk will translate into a high total
and those with moderate to severe CKD (all very high risk), and those with markedly elevated single risk factors (high risk). Such individuals require immediate attention to risk. More intensive lifestyle advice will be needed in such persons.
all risk factors. For others, the SCORELow
chartsrisk
may be used to assign them to the appropriate risk category. This chart refers to relative risk, not percentage risk, so that a person in the top
Countries Chart right corner is at 12 times higher risk than a person in the bottom left corner.
Women Men Women
Women Men Another approach to explaining risk to younger persons is to use cardiovascular
LOW RISK COUNTRIES non-smoker Smoker Age non-smoker Smoker HIGH RISK COUNTRIES Non-smoker
non-smoker Smoker
Age non-smoker Smoker risk age.
180 4 5 6 6 7 9 9 11 12 14 8 9 10 12 14 15 17 20 23 26 180
180 7 78 9 10 12
89 13 15 17 19 22 14 16 19 22 26 26 30 35 41 47 non-Smoker Smoker

Pressure (mmHg)
160 3 3 4 4 5 6 6 7 8 10 5 6 7 8 10 10 12 14 16 19 160
160 5 55 6 7 8
56 9 10 12 13 16 9 11 13 15 16 18 21 25 29 34
For example, in the high risk chart, a 40 year

Systolic Blood
180 3 3 4 5 6 6 7 8 10 12
140 2 2 2 3 3 4 4 5 6 7 65 4 4 5 6 7 7 8 9 11 13 140
140 3 33 4 5 6
34 6 7 8 9 11 65 6 8 9 11 13 13 15 17 20 24

© ESC 2012
160 2 3 3 4 4 4 5 6 7 8
120 1 1 2 2 2 3 3 3 4 4 2 3 3 4 5 5 5 6 8 9 120
120 2 22 3 3 4
23 4 5 5 6 7 4 5 6 7 9 9 10 12 14 17 old male hypertensive smoker has a risk of 140 1 2 2 2 3 3 3 4 5 6

180 3 3 3 4 4 5 5 6 7 8 5 6 7 8 9 10 11 13 15 18 180 4 44 45
180 5 6 7 8 9 10 11 13 9 11 13 15 18 18 21 24 28 33 4%, which is the same as a 65 year old with 120 1 1 1 2 2 2 2 3 3 4
4 5 6 7 8 4 5 6 7 8
160 2
140 1
2 2 2 3 3 4 4 5 9
60
3 4 5 5 6 7 8 9 11 13 160 3 33 333 4
160
140 2 22 22
140 2 3
5
3
5 6 7 8
3 4 5 5 6
9
60
6
4
7
5
9 10 12
6 7 9
12 14 17 20 24
8 10 12 14 17
no risk factors, so that his risk age is 65. This
1 1 2 2 2 2 3 3 4 2 3 3 4 4 5 5 6 7 9 150 200 250 300
120 1 1 1 1 1 1 2 2 2 3 2 2 2 3 3 3 4 4 5 6 120 1 11 12
120 2 2 2 2 3 3 4 4 3 3 4 5 6 6 7 8 10 12 can be reduced by reducing his risk factors. Cholesterol (mmol/L)
mg/dL

180 1 1 2 2 2 3 3 3 4 4 3 4 4 5 6 6 7 8 10 12 180 2 22 23
180 3 3 4 4 5 5 6 7 6 7 8 10 12 12 13 16 19 22
SCORE 160 1 1 1 1 1 2 2 2 3 3 2 2 3 3 4 4 5 6 7 8 SCORE 160 1 12 22
160 2 2 3 3 3 4 4 5 4 5 6 7 8 8 9 11 13 16 Risk estimation using SCORE: Qualifiers
140 1 1 1 1 1 1 1 1 2 2 55 1 2 2 2 3 3 3 4 5 6 140 1 11 11
140 1 1 2 2 2 2 3 3 55 3 3 4 5 6 5 6 8 9 11
15% and over 15% and over
10% - 14%
120 0 0 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 3 3 4 10% - 14%
120 1 11 11
120 1 1 1 1 1 2 2 2 2 2 3 3 4 4 4 5 6 8 • The charts should be used in the light of the clinician’s knowledge and
Systolic blood pressure (mmHg)

pressure (mmHg)
5% -
3% -
9%
4% 180 1 1 1 1 1 1 1 2 2 2 2 2 3 3 4 4 4 5 6 7
5% -
3% -
9%
4% 180 1 11 11
180 1 2 2 2 2 3 3 4 4 4 5 6 7 7 8 10 12 14 judgement, especially with regard to local conditions.
2% 160 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 3 3 4 5 2% 160 1 11 11
160 1 1 1 1 2 2 2 3 2 3 3 4 5 5 6 7 8 10
• As with all risk estimation systems, risk will be over-estimated in countries

blood pressure
1% 140 0 0 0 0 0 1 1 1 1 1 50 1 1 1 1 2 2 2 2 3 3 1% 140 0 01 11
140 1 1 1 1 1 1 1 2 50 2 2 2 3 3 3 4 5 6 7
< 1% 120 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 2 2 2 < 1% 120 0 00 01
120 1 1 1 1 1 1 1 1 1 1 2 2 2 2 3 3 4 5 with a falling CVD mortality rate, and under estimated if it is rising.
• At any given age, risk appears lower for women than men. However,

Systolic blood
180 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 2 2 180 0 00 00
180 0 0 0 0 0 0 1 1 1 1 1 2 2 2 2 3 3 4

2012ESC
10-year risk of 10-year risk of
160 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 160 0 00 00
160 0 0 0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 3
inspection of the charts shows that their risk is merely deferred by 10 years,

© ESC 2012
Systolic
2007
fatal CVD in 140 0 0 0 0 0 0 0 0 0 0 40 0 0 0 0 0 0 1 1 1 1 fatal CVD in 140 0 00 00
140 0 0 0 0 0 0 0 0 40 0 1 1 1 1 1 1 1 2 2
with a 60 year old woman resembling a 50 year old man in terms of risk.

©©ESC
120 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 120 0 00 00
120 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1
populations at populations at

low CVD Risk

4 5 6 7 8 4 5 6 7 8 4
Cholesterol (mmol/L)
5 6 7 8 4 5 6 7 8
high CVD Risk
4 45 56
6 77 88 4 5 6 7 8 4 5 6
Cholesterol (mmol/L)
7 8 4 5 6 7 8
• Risk may be higher than indicated in the chart in:
150 200 250 300
mg/dL
150 200 250 300
mg/dL - Sedentary or obese subjects, especially those with central obesity
- Those with a strong family history of premature CVD
How do I use the SCORE charts to assess CVD risk in asymptomatic persons? - Socially deprived individuals and those from some ethnic minorities
1. Use the low risk charts in Andorra, Austria, Belgium*, Cyprus, Denmark, Finland, France, Germany, Greece*, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, - Individuals with diabetes- the SCORE charts should only be used in
Monaco, The Netherlands*, Norway, Portugal, San Marino, Slovenia, Spain*, Sweden*, Switzerland and United Kingdom. those with type 1 diabetes without target-organ damage; other
Use the high risk charts in other European countries. Of these, some are at very high risk and the charts may underestimate risk in these. These include Armenia, diabetic subjects are already at very high risk.
Azerbaijan, Belarus, Bulgaria, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Macedonia FYR, Moldova, Russia, Ukraine and Uzbekistan. - Those with low HDL cholesterol* or increased triglyceride, fibrinogen,
Updated, re-calibrated charts are now available for Belgium, Germany, Greece, The Netherlands, Spain, Sweden and Poland.
* opoB, Lp(a) levels and perhaps increased high-sensitivity CRP.
2. Find the cell nearest to the person’s age, cholesterol and BP values, bearing in mind that risk will be higher as the person approaches the next age, cholesterol - Asymptomatic subjects with evidence of pre-clinical atherosclerosis,
or BP category. for example plaque on ultrasonography.
3. Check the qualifiers - Those with moderate to severe chronic kidney disease
4. Establish the total 10 year risk for fatal CVD. (GFR <60 mL/min/1.73 m2)
*Note that HDL cholesterol impacts on risk in both sexes, at all ages, and at all level of risk. This effect can be estimatedusing
Online CVD Risk Assessment the electronic version of SCORE, HeartScore, which has been updated to include HDL cholesterol level.
Visit www.heartScore.org