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Individual risk assessment in secondary prevention for cardiovascular disease

The role of individual risk assessment in secondary prevention for cardiovascular disease

Better individualised estimates of risk in patients with previous cardiovascular disease will enable more  intensive treatment, motivation and follow-up in identified high-risk individuals.

European guidelines on cardiovascular disease (CVD) prevention in clinical practice state that patients with documented CVD, on average, are at very high-risk of recurrent cardiovascular events and mortality. [1] This, however, does not mean that all patients are alike. In fact, there is substantial variation in the estimated 10-year risk of recurrent vascular events, even if all modifiable risk factors are treated until the treatment target is reached. [2,3]

The SMART risk score estimates individual risk for myocardial infarction, stroke or vascular death in the next 10 years if standard care is provided. The SMART risk score can be used for all individual patients with clinical manifest atherosclerotic vascular disease (ASCVD). [2] These include coronary artery disease, cerebrovascular disease, peripheral artery disease, abdominal aortic aneurysm and polyvascular disease. It is based on common, easy-to-measure, clinical patient characteristics.

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High-risk individuals are more likely to benefit from preventive treatment, such as cholesterol-lowering, blood pressure-lowering or novel drugs. High-risk patients experience a larger absolute risk reduction (ARR) and subsequently have a lower number needed to treat (NNT) from any type of preventive treatment. [4]

Therapeutic resources that one might reserve for high-risk patients could include: lower target values for blood pressure and cholesterol, more intensive follow-up, high-cost therapies (e.g. PCSK9-inhibition) or therapies with a high risk of adverse events (e.g. bleeding risk in dual antiplatelet therapy). [1]

In addition, individual 10-year risk estimations for (recurrent) major cardiovascular events can also be used for patient education. This may provide the patient with more insight in their personal prognosis and, thereby, increase their motivation and positively impact adherence to preventive interventions. 


[1] Piepoli MF, Hoes AW, Agewall S ea.2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2016 Aug 1;37(29):2315-81 (

[2] Dorresteijn JA, Visseren FL, Wassink AM ea. Development and validation of a prediction rule for recurrent vascular events based on a cohort study of patients with arterial disease: the SMART risk score.

Heart. 2013 Jun;99(12):866-72.

[3] Kaasenbrood L, Boekholdt SM, van der Graaf Y ea. Distribution of Estimated 10-Year Risk of Recurrent Vascular Events and Residual Risk in a Secondary Prevention Population. Circulation. 2016 Nov 8;134(19):1419-1429.

[4] Dorresteijn JA, Visseren FL, Ridker PM ea. Estimating treatment effects for individual patients based on the results of randomised clinical trials. BMJ. 2011 Oct 3;343:d5888.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer for good, and Sanofi and Regeneron in the form of educational grants.