OBJECTIVES: Many clinical practice guidelines recommend that providers and patients base their treatment decisions regarding coronary heart disease (CHD) prevention on the assessment of underlying risk. The need to predict the risk of an event in CHD is of importance when modelling the cost-effectiveness of lipid-modification therapies where the outcome is determined by the risk of a CHD event and the change in risk due to the intervention. Risk score equations have been derived from cohort studies or randomised trials and usually estimate the risk of having a CHD event over 5 to 10 years. The Framingham risk score (FRS) is the most famous and used risk calculator and its many adaptations are used to predict the risk for very different populations. In this study we investigate FRS’s development into a global tool to estimate CHD events, focussing on its use in health economic modelling to demonstrate the efficacy of lipid modifying therapies in European populations.   METHODS: A systematic search was undertaken in Embase to identify European health economic studies using FRS. The studies where assessed for information about the implementation of the FRS and any results of the validation of the predicted risk. RESULTS: There exist several studies employing the FRS to evaluate the cost-effectiveness of interventions for CHD. However, the Framingham cohort differs from many groups to which it has been applied. There have been several attempts to recalibrate FRS to better its performance toward European populations with varying success. CONCLUSIONS: The Framingham risk score is still used in a European setting, even if it is often criticised to misrepresent the CHD risk. There are alternative risk functions, developed in order to better accommodate the risk of specific European populations. However, the use of FRS seems to still be a valid option for a Global or pan-European perspective.