Cardiovascular Risk Prediction in Africa: Why Global Tools Fail and What We Must Do.

Cardiovascular disease is emerging as a leading cause of death in Africa, yet clinicians use risk prediction tools developed primarily in high-income countries that systematically misclassify risk in African populations. When the Framingham score, SCORE, ASCVD equations, or WHO/ISH charts are applied directly to African cohorts, they produce dramatically discordant results, sometimes varying fourfold in risk estimates within the same population. This occurs because African populations face fundamentally different CVD epidemiology: HIV and tuberculosis function as key CVD risk factors, lipid profiles follow different patterns than European/American cohorts, and disease onset occurs at younger ages during epidemiological transition. We argue that global internists have a professional responsibility to acknowledge this tool limitation and advocate for recalibrated, African-specific risk prediction. Achievable solutions exist: rapid regional recalibration using existing WHO cohorts, integration of digital health technologies, and targeted biobank research. Without action, Africa's rising CVD burden will be met with inappropriate risk stratification, ineffective prevention, and widening health inequities.