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cumulative CV death risks exceeding the 510% level, based on age only, even when other CV risk factor levels are relatively low. Therefore, before initiating treatment in the elderly, clinicians should evaluate patients carefully. The relative strengths of risk factors vary with age and SCORE overestimates risk in older people (that is, those aged >65 years).11 These Guidelines include illustrative charts for older people (see Figures 1 and 2). While older people benefit from smoking cessation, and control of hypertension and hyperlipidaemia (see section 9.3), clinical judgement is required to avoid side effects from overmedication. The additional impact of HDL-C on risk estimation is illustrated in Supplementary Figures 3 and 4; HDL-C can be used to increase the accuracy of the risk evaluation. In these charts, HDL-C is used categorically. The electronic version of SCORE, HeartScore (http://www. heartscore.org/en_GB/), has been modified to take HDL-C into consideration as a continuous variable. Clinicians should be aware that at extremely high values [above 2.3 mmol/L (90 mg/dL)] of HDL-C there appears to be an increased risk of ASCVD, so at such levels HDL-C cannot be used as a risk predictor.

4.1.2 How to use the risk estimation charts Use of the low- or the high-risk SCORE charts will depend on the CVD mortality experience in each country. While any cut-off point is arbitrary and open to debate, in these Guidelines, the cut-off point for calling a country ‘low CVD risk’ is based on WHO data derived from the Global Burden of Disease Study. Countries are categorized as low-risk if their age-adjusted 2016 CVD mortality rate was <150/100 000 (for men and women together) (http://www.who.int/healthinfo/global_burden_disease/esti mates/en/). Countries with a CVD mortality rate of >_150/100 000 or more are considered to be at high-risk. Boxes 1 to 5 summarize the main points regarding the risk estimation charts and their use.

Box 1 How to use the risk estimation charts

To estimate a person’s 10-year risk of CVD death, find the table for his/ her gender, smoking status, and age. Within the table, find the cell nearest to the person’s BP and TC. Risk estimates will need to be adjusted upwards as the person approaches the next age category. Risk is initially assessed on the level of TC and systolic BP before treatment, if known. The longer the treatment and the more effective it is, the greater the reduction in risk, but in general it will not be more than about one-third of the baseline risk. For example, for a person on antihypertensive drug treatment in whom the pre-treatment BP is not known, if the total CV SCORE risk is 6%, then the pre-treatment total CV risk may have been 9%. Low-risk persons should be offered advice to maintain their low-risk status. While no threshold is universally applicable, the intensity of advice should increase with increasing risk. The charts may be used to give some indication of the effects of reducing risk factors, given that there is apparently a time lag before the risk reduces. In general, people who stop smoking halve their cumulative risk over a relatively short period of time. BP = blood pressure; CV = cardiovascular; CVD = cardiovascular disease; SCORE = Systematic Coronary Risk Estimation; TC = total cholesterol. Box 2 Risk estimation charts for different countries

The low-risk charts should be considered for use in Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Netherlands, Norway, Malta, Portugal, Slovenia, Spain, Sweden, Switzerland, and the UK. The high-risk charts should be considered for use in Albania, Algeria, Armenia, Bosnia and Herzegovina, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lebanon, Libya, Lithuania, Montenegro, Morocco, Poland, Romania, Serbia, Slovakia, Tunisia, and Turkey. Some countries have a cardiovascular disease mortality rate >350/100 000, and the high-risk chart may underestimate risk. These are Azerbaijan, Belarus, Bulgaria, Egypt, Georgia, Kazakhstan, Kyrgyzstan, North Macedonia, Republic of Moldova, Russian Federation, Syria, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan. See http://apps.who.int/gho/data/node.home.

Box 3 Qualifiers

The charts can assist in risk assessment and management, but must be interpreted in light of the clinician’s knowledge and experience, and of the patient’s pre-test likelihood of CVD. Risk will be overestimated in countries with decreasing CVD mortality, and underestimated in countries in which mortality is increasing. This is dealt with by recalibration (http://www.heartscore.org/en_GB/). Risk estimates are lower in women than in men. However, risk is only deferred in women; the risk of a 60-year-old woman is similar to that of a 50-year-old man. Ultimately, more women die from CVD than men. Relative risks may be unexpectedly high in young persons, even if absolute risk levels are low. The relative risk chart (Supplementary Figure 1) and the estimated risk age (Supplementary Figure 2) may be helpful in identifying and counselling such persons. CVD = cardiovascular disease.

Box 4 Factors modifying Systematic Coronary Risk Estimation risks

Social deprivation: the origin of many of the causes of CVD. Obesity and central obesity as measured by the body mass index and waist circumference, respectively. Physical inactivity. Psychosocial stress including vital exhaustion. Family history of premature CVD (men: <55 years and women: <60 years). Chronic immune-mediated inflammatory disorder. Major psychiatric disorders. Treatment for human immunodeficiency virus infection. Atrial fibrillation. Left ventricular hypertrophy. Chronic kidney disease. Obstructive sleep apnoea syndrome. Non-alcoholic fatty liver disease. CVD = cardiovascular disease. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026