Copyright © 2004 by the European Society of Cardiology.
Letter to the Editor
Comments on the European guidelines on cardiovascular disease prevention
First Department of Internal Medicine, University of Athens Medical School, Laiko Hospital, 17 Agiou Thoma St., Athens 115 27, Greece
* Corresponding author. Tel./fax: +30-210-777-1161
E-mail address: aaisopos{at}cc.uoa.gr
E-mail address: dfarm1{at}panafonet.gr
Dear Editor
We have read the European guidelines for the prevention of cardiovascular disease (CVD) published in the September 2003 issue of the European Heart Journal with enthusiasm.1 Evidence-based clinical practice guidelines have become an invaluable tool for clinicians, especially in the field of Cardiovascular Medicine with such a high rate of continuously growing knowledge. Interestingly, the Third Task Force urges the need for the establishment of national strategies for CVD prevention. Moreover, it is encouraging that the guidelines also address the difficulties involved in the behavioral counseling and propose some strategies on how to deal with these difficulties.
The Task Force suggests the use of the SCORE model published earlier by Conroy et al.2 This model has several advantages, as it provides a quick and simple means to calculate the global CVD risk, while it allows the projection of the risk of a certain individual to a higher age as well as the estimation of the effect of risk factor modification on this risk. Furthermore, the SCORE charts offer a graphical and quite comprehensible way to explain the risk factor modification concept to the patients and motivate them to participate actively in the counseling procedure.
However, the SCORE model underwent a considerable criticism by Assmann et al.3 in a recent issue of the Journal. In contrast to what Assmann et al. state in the conclusion of their letter, we believe that a simplified system does not necessarily compromise the provision of individually-tailored guidance. Moreover, despite the fact that some risk factors are more epidemiologically "specific" for the one or the other component of the cardiovascular system, we do agree with the SCORE approach in treating cardiovascular system as a whole entity, as the differentiation among coronary, cerebral and peripheral artery disease is neither feasible nor rational in the context of a preventive strategy. It seems to us that the main weakness of the SCORE model is the omission of several CVD risk factors, including both traditional and recently established ones, as also stressed by Assmann et al.
Apart from the cases with an obviously high total CVD risk, including patients with already established CVD or diabetes and individuals with considerably high cholesterol or blood pressure levels, the guidance proposed by the Task Force in all other individuals is based on the total risk as calculated by the SCORE charts, using a threshold of 5% to define cases in high risk.1 However, individuals with a risk 
5% according to SCORE charts represent only a subgroup of the high risk cases. As a result, the guidance based only on the SCORE model is apparently inappropriate in individuals bearing risk factors that have not been incorporated in the SCORE charts. Therefore, although the SCORE system is quite an appealing tool for an initial risk assessment, treatment decisions and the total CVD prevention strategy should be based on the entire collection of risk factors, which are quite comprehensively presented by the Task Force in their recent report.1
References
- De Backer G, Ambrosioni E, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur. Heart J. 2003;24:1601–1610.
[Free Full Text] - Conroy RM, Pyorala K, Fitzgerald AP et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur. Heart J. 2003;24:987–1003.
[Abstract/Free Full Text] - Assmann G, Cullen P, Hense HW et al. Response to Conroy et al. SCORE Project. Eur. Heart J. 2003;24:2070.
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