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ASSIGN

ASSIGN. Paul Ryan, Clinical Director, North Glasgow CHCP. Risk Scoring. Risk scoring Likelihood of having an event in next 10 years Not exact - underestimates for some and over estimates for others In fact most cardiac events occur in lower risk groups. Risk Scoring.

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ASSIGN

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  1. ASSIGN Paul Ryan, Clinical Director, North Glasgow CHCP

  2. Risk Scoring • Risk scoring • Likelihood of having an event in next 10 years • Not exact - underestimates for some and over estimates for others • In fact most cardiac events occur in lower risk groups

  3. Risk Scoring • Original studies (eg Framingham) measured Coronary Heart Risk - CHD • Newer studies (JBS 2 and ASSIGN) measure Cardiovascular Risk - CVD • CVD Risk is sum of cardiovascular and stroke risk • 15% CHD = 20% CVD

  4. Risk Scoring • The risk is composite of several risk factors ( age, sex, systolic BP, smoking, cholesterol) and is expressed as probability (% chance) of that person developing event within next ten years • Gives threshold for when drug therapy should be instigated but that threshold is assigned arbitrarily since risk is a continuously distributed variable – there is no one point where risk really “takes off”

  5. Risk Scoring • For primary prevention i.e. those who have not developed CVD already • Aid to Clinical Management • Not replace Clinical Judgement • May still have to treat individual risk factors in isolation if they are substantial enough (see guidelines) BP consistently >180 and/or 110, familial hypercholesterolemia.

  6. Framingham • Based on old studies in USA • Does not include family history • Does not include deprivation • Underreporting in certain socio economic groups • Underreporting in older women • Measured CHD risk

  7. Risk Scoring • Framingham scores significantly under predicted CHD risk in Scottish Male population ( Paisley and Renfrew) • Also underestimated risk in lower socio economic groups (Paisley/Renfrew fairly deprived)

  8. JBS 2 • Based on Framingham Scores • Gives Cardiovascular Risk • Proxy for deprivation by adding 10 years ( JBS2 + 10) • CVD risk includes risk of stroke and equals CHD risk x 4/3

  9. ASSIGN • ASsessing cardiovascular risk using Scottish Intercollegiate Guidelines Network guidelines to ASSIGN preventative treatment

  10. ASSIGN • Results tested on Scottish Heart Health Cohort Extended ( SHHEC) - 6,419 men - 6,618 women aged 30-74 in 25 local government districts in Scotland between 1984 and 1995 i.e. local

  11. ASSIGN • Age • Sex • Smoking • Family History • Systolic BP • Cholesterol • HDL • SIMD

  12. ASSIGN • New Features • Family History • SIMD (Scottish Index of Multiple Deprivation) • http://assign-score.com

  13. Family History • Parents developed CVD before 60 • Siblings developed CVD before 60 • Grandparents, aunts, uncles, first cousins developed CVD before 60 (need 2)

  14. SIMD • Scottish Index of Multiple Deprivation • Relative Indicator of Deprivation based on datazones 1 – 6,505 • Based on 37 Indicators across 7 domains to provide weighted score • SIMD scores range from 0.54 to 87.60

  15. SIMD Domains • Current Income 28% • Employment 28% • Health 14% • Education 14% • Geographic Access 9% • Crime 5% • Housing 2%

  16. SIMD • G22 5HD Allander St, Possilpark • SIMD 73.4 • G62 8PN Allander Road, Milngavie • SIMD 9.81 • (Range in Scotland 0.54 – 87.60)

  17. ASSIGN Scores Male 50 smoker SBP150 Chol 6, HDL1,FH G22 5HD (Possil) 32% G62 8PN (Milngavie) 22% Fem 60, smoker SBP 140, Chol 6 HDL1,FH G22 5HN (Possil) 49% G62 8PN (Milngavie) 31%

  18. Effect of ASSIGN CVD Risk FRAM 30 ASS30 ASS20 • Affluent men 7% 3% 10% • Deprived men 10% 9% 24% • Affluent women 0% 0% 2% • Deprived women 4% 7% 30%

  19. ASSIGN • ASSIGN 20 would commit 1 in 3 asymptomatic individuals aged 40 to drug treatment, with its attendant medical and social costs

  20. ASSIGN • Being Evaluated by Keep Well i.e. YOU • This means we are looking at effect of using ASSIGN as against JBS2 and JBS2+10 • How many and which patients move into and out of high risk groups (depending on where we decide “high risk” lies)

  21. ASSIGN • This means we are asking that you use all three scores where they are available • We know many are missing and that makes evaluation difficult

  22. Previous Guidelines Primary Prevention • Cholesterol 30% CHD = 40% CVD • BP 15% CHD = 20% CVD • Antiplatelet 30% CHD = 40% CVD • JBS2 20% CVD • SIGN 97 20% CVD

  23. New Guidelines • UNIFIED TARGET • TREAT at 30 % CVD RISK

  24. NEW PATIENTS • Calculate JBS2, JBS2 + 10 and ASSIGN • Treat according to ASSIGN 30

  25. TAKE HOME MESSAGES • Use 30% CVD risk • Record JBS2, JBS2 + 10 and ASSIGN for 1st appointment • 1st appointment ( new cases) use ASSIGN 30

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