Correspondence: P ä ivi Korhonen, MD PhD, Central Satakunta Health Federation of Municipalities, Jokikatu 3, 29200 Harjavalta, Finland.
Tel: ? 358-40-7653257. Fax: ? 358-2-6741180. E-mail: paivi.e.korhonen@fi mnet.fi
(Received 16 March 2011 ; accepted 11 February 2012 )
Assessment of cardiovascular risk in primary health care
P Ä IVI KORHONEN 1,2 , RISTO VESALAINEN 3,4 , PERTTI AARNIO 5 ,
HANNU KAUTIAINEN 6,7 , SALME J Ä RVENP Ä Ä 8 & ILKKA KANTOLA 3
1Central Satakunta Health Federation of Municipalities, Harjavalta, Finland, 2Institute of Clinical Medicine, Family Medicine,
University of Turku, Turku, Finland, 3Department of Medicine, University of Turku, Turku, Finland, 4Pulssi Medical Center,
Turku, Finland, 5Department of Surgery, Satakunta Hospital District, Pori, Finland, 6Department of Family Practice, Central
Finland Central Hospital, Jyväskylä, Finland, 7Unit of Primary Health Care, Kuopio University Hospital, Kuopio, Finland, and
8Medcare Foundation, Äänekoski, Finland
Objective. This study aimed at investigating whether cardiovascular risk factors and their impact on total risk estimation dif-
fer between men and women. Design. Cross-sectional cohort study. Subjects . Finnish cardiovascular risk subjects (n ? 904)
without established cardiovascular disease, renal disease, or known diabetes. Main outcome measures. Ankle-brachial index
(ABI), estimated glomerular fi ltration rate (eGFR), oral glucose tolerance test, and total cardiovascular risk using SCORE
risk charts. Results . According to the SCORE risk charts, 27.0% (95% CI 23.1 – 31.2) of the women and 63.1% (95% CI
58.3 – 67.7) of the men (p ? 0.001) were classifi ed as high-risk subjects. Of the women classifi ed as low-risk subjects
according to SCORE, 25% had either subclinical peripheral arterial disease or renal insuffi ciency. Conclusions . The SCORE
system does not take into account cardiovascular risk factors typical in women, and thus underestimates their total cardiovascu-
lar risk. Measurement of ABI and eGFR in primary care might improve cardiovascular risk assessment. especially in women.
Key Words: Ankle-brachial index , cardiovascular risk estimation , gender difference , glucose disorders , renal function
Cardiovascular disease (CVD) is the main cause of
death in Europe and accounts for 54% of deaths in
women and 43% of deaths in men . With the age-
ing of the European population and with elderly
women outnumbering elderly men, the gender gap
in CVD mortality continues to widen.
The SCORE (Systematic COronary Risk Evalu-
ation) risk charts , which are recommended to
estimate the risk of dying of CVD over the next
decade, show this gender gap clearly: a 60-year-old
woman has an almost identical risk to a 50-year-old
man. Therefore, it is recommended that in women
total CVD risk should be estimated to 70 years
instead of 60 years, both the absolute risk and rela-
tive risk should be estimated, and risk factors that
are particularly important for women, i.e. diabetes
and obesity, should be taken into account .
Primary prevention efforts of CVD are less sim-
ple to implement than secondary prevention efforts,
where an array of evidence-based therapies is avail-
able. In primary prevention, high-risk strategies focus
on the detection and treatment of individuals identi-
fi ed as being at unacceptably high risk of CVD .
The key question to be resolved is how to best defi ne
high risk; to use total CVD risk-estimating tools like
SCORE, to assess additional risk factors like renal
function and glucose homeostasis, or to use indica-
tors of asymptomatic atherosclerosis like measure-
ment of ankle-brachial index (ABI). We applied these
methods, which are easily available to a general prac-
titioner (GP), to compare CVD risk estimation
between male and female subjects. Our study sub-
jects were selected from the general population by
using a two-stage screening method, in order to cre-
ate a cohort of subjects who form a typical dilemma
Scandinavian Journal of Primary Health Care, 2012; 30: 101–106
ISSN 0281-3432 print/ISSN 1502-7724 online © 2012 Informa Healthcare
102 P. Korhonen et al.
for a GP: Which patients should receive intensive
primary prevention therapy?
Material and methods
The study population was drawn from the Harmonica
Project, a population survey designed to evaluate
cardiovascular risk factors in people aged 45 to 70 years
living in two communities, Harjavalta and Kokem ä ki,
in south-western Finland. A two-stage screening strat-
egy was used: a risk factor survey was mailed to 6013
inhabitants, and of the 4450 (74%) subjects willing to
participate in the project, those having at least one
cardiovascular risk factor (n ? 2752) were invited to
an enrolment examination performed by a trained
nurse. High-risk subjects (n ? 1928) with hyperten-
sion, metabolic syndrome as defi ned by the Interna-
tional Diabetes Federation criteria , impaired
glucose homeostasis as defi ned by the WHO criteria
, body mass index ? 30 kg/m 2, or a 10-year risk of
cardiovascular disease death of 5% or more according
to the SCORE system  were further examined by a
physician. In Harjavalta, ankle-brachial index (ABI)
was measured in 972 of 1076 (90%) non-claudicant
risk subjects who did not have established CVD, renal
disease, or previously known diabetes. A detailed
description of the enrolment and examination methods
has been published earlier . In this paper, we analyse
the test results of 904 study subjects who had valid
measurements of ABI, OGTT, and renal function.
Estimation of renal function, subclinical arterial disease,
and glucose homeostasis
Renal function was measured with plasma creatinine
level (enzymatic method, Olympus ® AU640, Japan)
and estimated glomerular fi ltration rate (eGFR) cal-
culated by the modifi ed four-variable MDRD Study
equation  175 x (P Cr /88.4) ?1.154 x (Age) ?0.203 x
(0.742 if female) x (1.21 if black), where P Cr ? plasma
creatinine in μ mol/l, and age is expressed in years.
Race was not applicable in our study because all
patients were white. Because the MDRD formula is
based on data from patients with advanced renal fail-
ure, the results may not be valid in subjects with
normal or near normal glomerular fi ltration rates.
Therefore we report only eGFR levels ? 60 mL/
min/1.73 m 2 as renal dysfunction.
ABI was determined from blood pressure mea-
surements in the arms and ankles with the patient
supine. Systolic blood pressure (SBP) in the brachial
artery was measured in both arms using a blood
pressure cuff and Doppler instrument (UltraTec ®
PD1v with a vascular probe of 5 MHz, United King-
dom) in the antecubital fossa. SBP at the left and
right dorsalis pedis arteries, and if not found at the
left and right posterior tibial arteries, was then mea-
sured with Doppler detection with a blood pressure
cuff applied to the ankle just proximal to the malleoli.
ABI was the lower ankle systolic blood pressure
divided by the higher brachial systolic blood pres-
sure. Using the lower of the ankle pressures has been
shown to identify a higher number of patients with
increased risk of future cardiovascular events than
using the higher ankle pressure in calculating ABI
. ABI value ? 1.00 was used to indicate subclinical
peripheral arterial disease.
OGTT was performed by measuring a fasting
plasma glucose and a two-hour plasma glucose after
ingestion of a glucose load of 75 g anhydrous glucose
dissolved in water. Glucose values were measured
from capillary whole blood with HemoCue ® Glucose
201 ? system ( Ä ngelholm, Sweden).
All of the participants provided written informed
consent for the project and subsequent medical
research. The study protocol and consent forms were
reviewed and approved by the ethics committee of
Satakunta Hospital District.
The data are presented as the means with standard
deviations (SD) or as counts with percentages. Sta-
tistical comparison between genders in was made by
t-test, Mann – Whitney test, or chi-squared test. Con-
fi dence interval for the ratio between genders was
estimated using bias-corrected bootstrapping. In order
to make comparisons with SCORE values, ABI
values and eGFR values were divided into sex-specifi c
More women than men die from cardiovascular
disease in Europe, but the non-conventional
risk factors in women may remain undiagnosed
In a cohort of middle-aged cardiovascular
risk subjects in primary care, 27% of the
women and 63% of the men (p ? 0.001)
were classifi ed as high-risk subjects according
to the SCORE risk charts.
Of the women classifi ed as low-risk subjects
according to SCORE, 25% had either sub-
clinical peripheral arterial disease or renal
Measurement of ABI and eGFR in pri-
mary care might improve cardiovascular risk
assessment, especially in women.
Assessment of cardiovascular risk in primary health care 103
tertiles: ABI women: 0.65 – 1.03, 1.04 – 1.12, 1.13 – 1.39;
ABI men: 0.60 – 1.04, 1.05 – 1.14, 1.15 – 1.39; eGFR
women: 35 – 70, 70 – 81, 82 – 172; eGFR men: 48 – 77,
78 – 90, 90 – 197.
We evaluated 481 women and 423 men aged 45 to
70 years (mean age 59 ? 7 years) with hypertension,
metabolic syndrome, newly detected glucose disor-
ders, BMI of at least 30 kg/m 2 , or SCORE risk of at
least 5%. None of the study subjects had clinical
cardiovascular or renal disease or known diabetes.
Table I shows the demographic and clinical char-
acteristics of the study subjects according to gender.
With regard to the cardiovascular risk factors entered
into the SCORE model, men smoked more often
than women, but women had higher total cholesterol
values. Of the cardiovascular risk factors not included
in the SCORE model, women tended to have higher
body mass index, higher fasting and two-hour glu-
cose values, as well as lower eGFR than men.
According to SCORE risk charts, 130/481 (27.0%
[95% CI 23.1 – 31.2]) of the women and 267/423
(63.1% [95% CI 58.3 – 67.7]) of the men (p ? 0.001)
were classifi ed as high-risk subjects (SCORE ? 5%)
when extrapolated to 60 years. Ratio between male
and female in SCORE value was 1.90 (95% CI 1.64 –
2.20), p ? 0.001. When the risks of women and men
were extrapolated to 70 years using SCORE risk
charts, 412/481 (85.7% [95% CI 82.2 – 88.7]) and
423/423 (100.0% [95% CI 99.1 – 100)] had SCORE
? 5%, respectively.
SCORE values were signifi cantly higher in men
across all tertiles of ABI and eGFR (Figures 1A and
B), and across all stages of glucose homeostasis
(Figure 1C). When the risks of the diabetic subjects
were multiplied by four in women and by two in men
as recommended by the SCORE project group ,
10-year risk of cardiovascular death was comparable
According to the MDRD formula, the crude
prevalence of renal insuffi ciency defi ned as eGFR
? 60 mL/min/1.73 m 2 was 51/481 (10.6% [95% CI
8.0 – 13.7]) in women and 16/423 (3.8% [95% CI
2.2 – 16.1]) in men (p ? 0.001). Of the patients with
renal insuffi ciency, 30/51 (58.8%) female and 3/16
(18.6%) male subjects had SCORE ? 5% when extrap-
olated to 60 years.
Of the 51 female patients with eGFR ? 60 mL/
min/1.73 m 2 , only three (5.9%) had elevated plasma
creatinine concentration, i.e. ? 107 μ mol/L as defi ned
by European guidelines . Respectively, nine male
patients of the 16 (56.3%) with renal insuffi ciency
had plasma creatinine ? 115 μ mol/L.
Table I. Characteristics of the subjects according to gender.
Female n ? 481 Male n ? 423 P-value
Age, years, mean (SD)
Body mass index, kg/m 2 , mean (SD)
Waist circumference, cm, mean (SD)
Current smokers, n (%)
Blood pressure, mmHg, mean (SD)
Ankle-brachial index, mean (SD)
eGFR, mL/min/1.73 m 2 , mean (SD)
SCORE, %, mean (SD)
Total cholesterol, mmol/L, mean (SD)
LDL cholesterol, mmol/L, mean (SD)
HDL cholesterol, mmol/L, mean (SD)
Triglycerides, mmol/L, mean (SD)
Fasting glucose, mmol/L, mean (SD)
Two-hour glucose, mmol/L, mean (SD)
Current medication, (%):
Note: eGFR ? estimated glomerular fi ltration rate; SCORE ? Systematic COronary Risk Evaluation;
LDL ? low-density cholesterol; HDL ? high-density cholesterol.
104 P. Korhonen et al.
The prevalence of subclinical peripheral arterial
disease defi ned as ABI ? 1.00 was 96/481 (20.0%
[95% CI 16.5 – 23.8]) in women and 75/423 (17.8%
[95% CI 14.2 – 21.7]) in men (p ? 0.393). Of the 96
women with low ABI, 57 (59.4%) had SCORE ? 5%
when extrapolated to 60 years. The corresponding
fi gures in men were 7/75 (9.3%).
Of the glucose disorders, the prevalence of
impaired glucose tolerance (IGT) was 89/481 (18.5%
[95% CI 15.1 – 22.3]) in women and 67/423 (15.8%
[95% CI 12.5 – 19.7]) in men (p ? 0.29), and the
prevalence of previously undetected type 2 diabetes
was 28/481 (5.8% [95% CI 3.9 – 8.3]) in women and
22/423 (5.2% [95% CI 3.3 – 7.8]) in men (p ? 0.68).
Of the subjects with IGT, 58/156 (37.2%) had
SCORE ? 5% when extrapolated to 60 years, and
54/58 (93.1%) of them were women.
Our results from a cohort of 904 cardiovascular risk
subjects show that the SCORE system does not take
into account typical cardiovascular risk factors in
women. Of the major risk factors incorporated in the
SCORE system, only total cholesterol values were
higher in women than in men, but the difference is
explained by the higher high-density lipoprotein cho-
lesterol concentration in women. The lack of major
risk factors may at least partly explain the results of
the Euro Heart Survey , indicating that women
with stable coronary heart disease are less likely to
be referred to testing for ischaemia, less likely to be
referred for revascularization, and less likely to receive
secondary preventive therapies. At the same time, the
non-conventional risk factors may remain undiag-
nosed or ignored, leading to the high cardiovascular
mortality rates in women.
The causes of cardiovascular risk factors may
alter between genders; for example sedentary lifestyle
and smoking are associated with left ventricular dia-
stolic dysfunction only in women . It has also
been suggested that clinical manifestations of CVD
in women may be different from those commonly
observed in males . In our study, measurement of
ABI revealed subclinical peripheral arterial disease
(PAD) in every fi fth of the study subjects – evenly in
women and in men. This is in concordance with
other studies showing that the prevalence of PAD
does not vary with gender [12,13]. Recent meta-
analysis of 16 cohort studies, in which participants
aged 47 to 78 years were derived from a general
population, showed that in women with ABI 0.91 –
1.00 the hazard ratio for cardiovascular mortality was
1.84 (95% CI 1.53 – 2.22) and in men 1.68 (95% CI
1.40 – 2.00) compared with reference ABI 1.11 – 1.20
. In our study, out of 351 female subjects classi-
fi ed into the low-risk category according to the
SCORE system, measurement of ABI reclassifi ed 57
(16%) into the high-risk category needing intensive
lifestyle counselling, possibly preventive medication,
and certainly indicating follow-up. In contrast to the
other cardiovascular diseases, PAD is easily detectable
with determination of ABI. ABI level ? 0.90 is 95%
sensitive in detecting angiogram-positive PAD and
almost 100% specifi c in identifying apparently healthy
individuals . Variability of ABI measurement is
comparable with that of routine blood pressure .
PAD is rarely an isolated disease of the lower limb
Tertiles of ABI
Tertiles of eGFR
Stages of glucose homeostasis
Norm IFGIGT T2D
Figure 1. SCORE values across tertiles of ABI (A), eGFR (B), and stages of glucose homeostasis (C). Note: SCORE ? Systematic
COronary Risk Evaluation; ABI ? ankle-brachial index; eGFR ? estimated glomerular fi ltration rate; IFG ? impaired fasting glucose;
IGT ? impaired glucose tolerance; T2D ? type 2 diabetes.
Assessment of cardiovascular risk in primary health care 105
arteries; patients with PAD frequently also have
coronary heart disease or cerebrovascular disease
[17 – 19]. These facts also strengthen the role of ABI
in cardiovascular risk estimation in primary care.
In our study, the prevalence of chronic kidney
disease defi ned as eGFR ? 60 mL/min/1.73 m 2
according to the MDRD formula was three times
higher in women than in men. Chronic kidney dis-
ease is an independent risk factor for cardiovascular
diseases; individuals with GFR ? 60 ml/min/1.73 m 2
have an approximate 16% increase, and individuals
with GFR ? 30 ml/min/1.73 m 2 , a 30% increase in
cardiovascular mortality . If we would had esti-
mated renal function on the basis of plasma creati-
nine alone, we would have missed 80% of the patients
with renal insuffi ciency.
In contrast to ABI ? 1.00 and eGFR ? 60 mL/
min/1.73 m 2 , there is no compelling evidence to sug-
gest that cardiovascular risk associated with IGT is
substantial . Thus, the chief advantage of con-
ducting an oral glucose tolerance test is to identify
people with undiagnosed type 2 diabetes, who
encompassed only 5% of our study population.
European guidelines recommend that SCORE
risk should be extrapolated to a higher degree in
women than in men, i.e. 70 years instead of 60 years
. Having performed this in our study cohort of
women at risk of CVD, 86% of the women without
previously known CVD or diabetes or renal disease
would have been labelled as high-risk patients
(SCORE risk ? 5%) needing intensive risk man-
agement. The same phenomenon was observed in
Norway; nearly all women aged 65 years and older
were classifi ed as at “ high risk ” . In Sweden, the
SCORE guidelines were applied to a large popula-
tion-based cohort, and resulted in substantial over-
estimation of the expected number of deaths from
CVD . The sensitivity of the SCORE risk chart
in predicting cardiovascular mortality in Finnish
men and women has been shown to be 64% and
24%, respectively . High sensitivity means that
the majority of the screened population might get a
positive test result.
In conclusion, our results suggest that the SCORE
risk chart does not take into account typical cardio-
vascular risk factors in women. Given the simplicity
and suitability of ABI and eGFR measurements to
daily clinical practice, and their potential ability to
recognize high-risk individuals – especially women –
more systematic use of these measurements in the
general practice seems justifi ed.
The work was supported by the University of Turku,
Declaration of interest
The authors report no confl ict of interest. The
authors alone are responsible for the content and
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