Dear reinaldo,

Attached please find four publications which cover the answer to your question. In addition the following publication might be helpful as well:

BMC Public Health. 2013 Jun 5;13:539. doi: 10.1186/1471-2458-13-539.

Assessment of total cardiovascular risk using WHO/ISH risk prediction charts in three low and middle income countries in Asia.

Otgontuya D1, Oum S, Buckley BS, Bonita R.

Author information

Abstract

BACKGROUND:

Recent research has used cardiovascular risk scores intended to estimate "total cardiovascular disease (CVD) risk" in individuals to assess the distribution of risk within populations. The research suggested that the adoption of the total risk approach, in comparison to treatment decisions being based on the level of a single risk factor, could lead to reductions in expenditure on preventive cardiovascular drug treatment in low- and middle-income countries. So that the patient benefit associated with savings is highlighted.

METHODS:

This study used data from national STEPS surveys (STEPwise Approach to Surveillance) conducted between 2005 and 2010 in Cambodia, Malaysia and Mongolia of men and women aged 40-64 years. The study compared the differences and implications of various approaches to risk estimation at a population level using the World Health Organization/International Society of Hypertension (WHO/ISH) risk score charts. To aid interpretation and adjustment of scores and inform treatment in individuals, the charts are accompanied by practice notes about risk factors not included in the risk score calculations. Total risk was calculated amongst the populations using the charts alone and also adjusted according to these notes. Prevalence of traditional single risk factors was also calculated.

RESULTS:

The prevalence of WHO/ISH "high CVD risk" (≥20% chance of developing a cardiovascular event over 10 years) of 6%, 2.3% and 1.3% in Mongolia, Malaysia and Cambodia, respectively, is in line with recent research when charts alone are used. However, these proportions rise to 33.3%, 20.8% and 10.4%, respectively when individuals with blood pressure > = 160/100 mm/Hg and/or hypertension medication are attributed to "high risk". Of those at "moderate risk" (10- < 20% chance of developing a cardio vascular event over 10 years), 100%, 94.3% and 30.1%, respectively are affected by at least one risk-increasing factor. Of all individuals, 44.6%, 29.0% and 15.0% are affected by hypertension as a single risk factor (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg or medication).

CONCLUSIONS:

Used on a population level, cardiovascular risk scores may offer useful insights that can assist health service delivery planning. An approach based on overall risk without adjustment of specific risk factors however, may underestimate treatment needs.At the individual level, the total risk approach offers important clinical benefits. However, countries need to develop appropriate clinical guidelines and operational guidance for detection and management of CVD risk using total CVD-risk approach at different levels of health system. Operational research is needed to assess implementation issues.

http://www.ncbi.nlm.nih.gov/pubmed/23734670

Hoping this will be helpful,

Rafik

Individual variation is also worth considering.

Pat

ABSTRACT: The burden of atherosclerosis has led to treatment prioritization on high-risk individuals without established cardiovascular disease based on risk estimates. We investigated the effects of biological variation in risk factors on risk estimate accuracy and whether current primary prevention screening (risk assessment) models correctly categorize patients. A population of 10 000 'perfect' individuals with 100 stimulants affected by biological and analytical variation for systolic blood pressure, total cholesterol, high-density lipoprotein-cholesterol was mathematically modelled. Coronary heart disease (CHD) risks were calculated using the Framingham study algorithm and the mathematical properties of the screening system were evaluated. At internationally recommended 10-year CHD risk treatment threshold levels of 15, 20 and 30%, the 95% confidence intervals were +/- 5.1, +/- 6.0 and +/- 6.9% for single-point (singlicate), +/- 3.6, +/- 4.2 and +/- 4.9% for duplicate and +/- 2.8, +/- 3.3 and +/- 3.9% for triplicate estimates respectively (i.e. for singlicate 15% risk, 95% confidence interval is 9.9-20.1%). Consequently, using the 30% risk threshold from the National Service Framework (NSF) for CHD with singlicate estimation, 30% of patients who should receive treatment would be denied it and 20% would receive treatment unnecessarily. Multiple measurements improve precision but cannot absolutely define risk. Blood pressure should be measured to the greatest accuracy possible and not rounded prior to averaging. This study suggests biological variation in cardiovascular risk factors has profound consequences on calculated risk for therapeutic decision-making. Current guidelines recommending multiple measurements are usually ignored. Triplicate measurement is required to allow risk to be identified and clinical judgement has to be exercised in interpretation of the results.Journal of Cardiovascular Risk 09/2002; 9(4):183-90. DOI:10.1177/174182670200900402

Dear PArick

Can you please send me a full article 

thanks

Hi As a lower middle income country Sri Lanka at primary care level has adopted in principle the WHO Multiple Risk Factor approach and PENN approach using the SEAR B charts whilst awaiting the country specific guidelines. This has been based on the available evidence and cost effectiveness.  References http://www.who.int/bulletin/volumes/89/4/10-082370/en/ by Roger Ndindjock, Jude Gedeon, Shanthi Mendis, Fred Paccaud & Pascal Bovet et al and      Porfi rio Nordet  Shanthi Mendis , Alfredo Dueñas , Reinaldo de la Noval , Nurys Armas et al  Total Cardiovascular Risk Assessment and Management Using

Two Prediction Tools, with and without Blood Cholesterol  MEDICC Review, October 2013, Vol 15, No 4