Practical use of the Framingham risk score in primary prevention: Canadian perspective

To review the 2009 Canadian Cardiovascular Society guidelines and provide practical recommendations for physicians.

Initial review of the references provided with the guidelines led to a search of the PubMed, ACP Journal Club, and Cochrane databases using the key words primary prevention and statin for English language clinical trials, randomized controlled trials, meta-analyses, and reviews conducted with human participants. References from appropriate retrieved articles were also reviewed.

The guidelines outline low-density lipoprotein cholesterol (LDL-C) thresholds and targets to inform optimal use of statins in the primary prevention of cardiovascular disease (CVD). Family history of CVD and levels of high-sensitivity C-reactive protein (hsCRP) are risk modifiers in calculating the risk score with the new recommendations. An electronic calculator has been developed to facilitate increased uptake of these guidelines. Large numbers of asymptomatic people, particularly the elderly, will become eligible for statin therapy according to these new guidelines. Poor uptake by physicians and patients might result from the need for repeated testing of hsCRP and LDL-C levels in people who do not perceive themselves to be ill. Controversy persists concerning the role of hsCRP in the reclassification of CVD risk, and the concept of treating LDL-C to target has never been tested as an independent variable in a randomized trial. As two-thirds of the LDL-C lowering achieved by a statin occurs at the initial dose, it might be possible to achieve considerable CVD risk reduction for those at risk by treating initially with a mid-dose statin without LDL-C follow-up.

A simplified approach might appeal to patients or physicians who find current guidelines too complex, cumbersome, or costly. Success in getting high-risk patients to take statins is key to achieving improved CVD mortality reduction.