Framingham Risk Score

The Framingham Risk Score is a gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual. The Framingham Risk Score was first developed based on data obtained from the Framingham Heart Study, to estimate the 10-year risk of developing coronary heart disease.[1] In order to assess the 10-year cardiovascular disease risk, cerebrovascular events, peripheral artery disease and heart failure were subsequently added as disease outcomes for the 2008 Framingham Risk Score, on top of coronary heart disease.[2]

Cardiovascular Risk Scoring systems

The Framingham Risk Score is one of a number of scoring systems used to determine an individual's chances of developing cardiovascular disease. A number of these scoring systems are available online.[3][4] Cardiovascular risk scoring systems give an estimate of the probability that a person will develop cardiovascular disease within a specified amount of time, usually 10 to 30 years.[5] Because they give an indication of the risk of developing cardiovascular disease, they also indicate who is most likely to benefit from prevention. For this reason, cardiovascular risk scores are used to determine who should be offered preventive drugs such as drugs to lower blood pressure and drugs to lower cholesterol levels. For example, nearly 30% of coronary heart disease (CHD) events in both men and women were singularly attributable to blood pressure levels that exceeded high normal (≥130/85), showing that blood pressure management and monitoring is paramount both to cardiovascular health and prediction of outcomes.[6]

Usefulness

Because risk scores such as the Framingham Risk Score give an indication of the likely benefits of prevention, they are useful for both the individual patient and for the clinician in helping decide whether lifestyle modification and preventive medical treatment, and for patient education, by identifying men and women at increased risk for future cardiovascular events.[7] Coronary heart disease (CHD) risk at 10 years in percent can be calculated with the help of the Framingham Risk Score. Individuals with low risk have 10% or less CHD risk at 10 years, with intermediate risk 10-20%, and with high risk 20% or more. However it should be remembered that these categorisations are arbitrary.

A more useful metric is to consider the effects of treatment. If a group of 100 persons all have a 20% ten-year risk of cardiovascular disease it means that we should expect that 20 of these 100 individuals will develop cardiovascular disease (coronary heart disease or stroke) in the next 10 years and eighty of them will not develop cardiovascular disease in the next 10 years. If they were to take a combination of treatments (for example drugs to lower cholesterol levels plus drugs to lower blood pressure) that reduced their risk of cardiovascular disease by half it means that 10 of these 100 individuals should be expected to develop cardiovascular disease in the next 10 years and 90 of them should not be expected to develop cardiovascular disease. If that was the case then 10 of these individuals would have avoided cardiovascular disease by taking treatment for 10 years; 10 would get cardiovascular disease whether or not they took treatment; and 80 would not have got cardiovascular disease whether or not they took treatment.

Issues Raised by Cardiovascular Risk Prediction

It is important to recognize that the strongest predictor of cardiovascular risk in any risk equation is age. Almost all persons aged 70 and over are at >20% ten year cardiovascular risk and almost nobody aged under 40 is at >20% ten year cardiovascular risk. Since those who benefit most from treatment are those at highest risk, this means that treatment of patients with raised blood pressure and raised cholesterol levels in their thirties benefits very few. Whereas treatment of patients with "normal" blood pressure and "normal" cholesterol levels in their seventies benefits many. This casts doubt on the wisdom of categorizing individuals as having high blood pressure or raised cholesterol and treating these individual risk factors without a consideration of both their overall risk of cardiovascular disease and of the probability that they will benefit.

Background

Cardiovascular disease is common in the general population, affecting the majority of adults. It includes: 1) Coronary heart disease (CHD): Myocardial infarction (MI), angina pectoris, heart failure (HF), and coronary death. 2) Cerebrovascular disease, stroke and transient ischemic attack (TIA). 3) Peripheral arterial disease, intermittent claudication and significant limb ischemia. 4) Aortic disease: Aortic atherosclerosis, thoracic aortic aneurysm, and abdominal aortic aneurysm.

An individual’s risk for future cardiovascular events is modifiable, by lifestyle changes and preventive medical treatment. Lifestyle changes can include stopping smoking, healthy diet, regular exercise, etc. Preventive medical treatment can include a statin, mini dose aspirin, treatment for hypertension, etc. It is important to be able to predict the risk of an individual patient, in order to decide when to initiate lifestyle modification and preventive medical treatment.

Multiple risk models for the prediction of cardiovascular risk of individual patients have been developed. One such key risk model is the Framingham Risk Score.

The Framingham Risk Score is based on findings from the Framingham Heart Study.

Validation

The Framingham Risk Score has been validated in the USA, both in men and women, both in European Americans and African Americans.[8] While several studies have claimed to improve on the FRS, there is little evidence for any improved prediction beyond the Framingham risk score [9]

Limitations

There are two limitations.

The Framingham Risk Score predicts only future coronary heart disease (CHD) events, however, it does not predict future total cardiovascular events, meaning that it does not predict risk for stroke, transient ischemic attack (TIA), and heart failure. These also important patient outcomes were included in the 2008 Framingham General Cardiovascular Risk Score.[10] The predicted risk for an individual usually is higher with the 2008 Framingham General Cardiovascular Risk Score than with the 2002 Framingham Risk Score.

The Framingham Risk Score could overestimate (or underestimate) risk in populations other than the US population,[11][12] and within the USA in populations other than European Americans and African Americans, e.g. Hispanic Americans and Native Americans.[13] It is not yet clear if this limitation is real, or appears to be real because of differences in methodology, etc. As a result, other countries may prefer to use another risk score, e.g. SCORE (HeartScore is the interactive version of SCORE - Systematic COronary Risk Evaluation),[14] which has been recommended by the European Society of Cardiology in 2007.[15]

If possible, a cardiology professional should select the risk prediction model which is most appropriate for an individual patient and should remember that this is only an estimate.

Versions

The current version of the Framingham Risk Score was published in 2008. The publishing body is the ATP III, i.e. the «Adult Treatment Panel III», an expert panel of the National Heart, Lung, and Blood Institute, which is part of the National Institutes of Health (NIH), USA.

The prior version was published in 2002 [16]

The original Framingham Risk Score had been published in 1998.[17]

Differences between the versions

The first Framingham Risk Score included age, sex, LDL cholesterol, HDL cholesterol, blood pressure (and also whether the patient is treated or not for his/her hypertension), diabetes, and smoking. It estimated the 10-year risk for coronary heart disease (CHD). It performed well, and correctly predicted 10-year risk for CHD in American men and women of European and African descent.

The updated version was modified to include dyslipidemia, age range, hypertension treatment, smoking, and total cholesterol, and it excluded diabetes, because Type 2 diabetes meanwhile was considered to be a CHD Risk Equivalent, having the same 10-year risk as individuals with prior CHD. Patients with Type 1 diabetes were considered separately with slightly less aggressive goals; while at increased risk, no study had shown them to be at equivalent risk for CHD as those with previously diagnosed coronary disease or Type 2 diabetes.[16]

CHD Risk Equivalent

Some patients without known CHD have risk of cardiovascular events that is comparable to that of patients with established CHD. Cardiology professionals refer to such patients as having a CHD risk equivalent. These patients should be managed as patients with known CHD.

CHD risk equivalents are patients with a 10-year risk for MI or coronary death >20%. CHD risk equivalents are primarily other clinical forms of atherosclerotic disease. The National Cholesterol Education Program NCEP's ATP III guidelines also list diabetes as a CHD risk equivalent since it also has a 10-year risk for CHD around 20%. NCEP ATP III CHD risk equivalents are:

  1. clinical coronary heart disease (CHD)
  2. symptomatic carotid artery disease (CAD)
  3. peripheral arterial disease (PAD)
  4. abdominal aortic aneurysm (AAA)
  5. diabetes mellitus
  6. Chronic Kidney Disease

Analysis of the US population with the Framingham/ATP III criteria

The Framingham/ATP III criteria were used to estimate CHD risk in the USA. Data from 11,611 patients from a very large study, the NHANES III, were used. The patients were 20 to 79 years of age, and had no self reported CHD, stroke, peripheral arterial disease, or diabetes.

The results: 82% of patients had low risk (10% or less CHD risk at 10 years). 16% had intermediate risk (10-20%). 3% had high risk (20% or more).[18]

High risk was most commonly found in patients with advanced age, and was more common in men than women. High risk patients are sometimes become unknown with certain signs and symptoms of cardiac failure

Scoring

Framingham Risk Score for Women

Age: 20–34 years: Minus 7 points. 35–39 years: Minus 3 points. 40–44 years: 0 points. 45–49 years: 3 points. 50–54 years: 6 points. 55–59 years: 8 points. 60–64 years: 10 points. 65–69 years: 12 points. 70–74 years: 14 points. 75–79 years: 16 points.

Total cholesterol, mg/dL: Age 20–39 years: Under 160: 0 points. 160-199: 4 points. 200-239: 8 points. 240-279: 11 points. 280 or higher: 13 points. • Age 40–49 years: Under 160: 0 points. 160-199: 3 points. 200-239: 6 points. 240-279: 8 points. 280 or higher: 10 points. • Age 50–59 years: Under 160: 0 points. 160-199: 2 points. 200-239: 4 points. 240-279: 5 points. 280 or higher: 7 points. • Age 60–69 years: Under 160: 0 points. 160-199: 1 point. 200-239: 2 points. 240-279: 3 points. 280 or higher: 4 points. • Age 70–79 years: Under 160: 0 points. 160-199: 1 point. 200-239: 1 point. 240-279: 2 points. 280 or higher: 2 points.

If cigarette smoker: Age 20–39 years: 9 points. • Age 40–49 years: 7 points. • Age 50–59 years: 4 points. • Age 60–69 years: 2 points. • Age 70–79 years: 1 point.

All non smokers: 0 points.

HDL cholesterol, mg/dL: 60 or higher: Minus 1 point. 50-59: 0 points. 40-49: 1 point. Under 40: 2 points.

Systolic blood pressure, mm Hg: Untreated: Under 120: 0 points. 120-129: 1 point. 130-139: 2 points. 140-159: 3 points. 160 or higher: 4 points. • Treated: Under 120: 0 points. 120-129: 3 points. 130-139: 4 points. 140-159: 5 points. 160 or higher: 6 points.

10-year risk in %: Points total: Under 9 points: <1%. 9-12 points: 1%. 13-14 points: 2%. 15 points: 3%. 16 points: 4%. 17 points: 5%. 18 points: 6%. 19 points: 8%. 20 points: 11%. 21=14%, 22=17%, 23=22%, 24=27%, >25= Over 30%

Framingham Risk Score for Men

Age: 20–34 years: Minus 9 points. 35–39 years: Minus 4 points. 40–44 years: 0 points. 45–49 years: 3 points. 50–54 years: 6 points. 55–59 years: 8 points. 60–64 years: 10 points. 65–69 years: 11 points. 70–74 years: 12 points. 75–79 years: 13 points.

Total cholesterol, mg/dL: Age 20–39 years: Under 160: 0 points. 160-199: 4 points. 200-239: 7 points. 240-279: 9 points. 280 or higher: 11 points. • Age 40–49 years: Under 160: 0 points. 160-199: 3 points. 200-239: 5 points. 240-279: 6 points. 280 or higher: 8 points. • Age 50–59 years: Under 160: 0 points. 160-199: 2 points. 200-239: 3 points. 240-279: 4 points. 280 or higher: 5 points. • Age 60–69 years: Under 160: 0 points. 160-199: 1 point. 200-239: 1 point. 240-279: 2 points. 280 or higher: 3 points. • Age 70–79 years: Under 160: 0 points. 160-199: 0 points. 200-239: 0 points. 240-279: 1 point. 280 or higher: 1 point.

If cigarette smoker: Age 20–39 years: 8 points. • Age 40–49 years: 5 points. • Age 50–59 years: 3 points. • Age 60–69 years: 1 point. • Age 70–79 years: 1 point.

All non smokers: 0 points.

HDL cholesterol, mg/dL: 60 or higher: Minus 1 point. 50-59: 0 points. 40-49: 1 point. Under 40: 2 points.

Systolic blood pressure, mm Hg: Untreated: Under 120: 0 points. 120-129: 0 points. 130-139: 1 point. 140-159: 1 point. 160 or higher: 2 points. • Treated: Under 120: 0 points. 120-129: 1 point. 130-139: 2 points. 140-159: 2 points. 160 or higher: 3 points.

10-year risk in %: Points total: 0 point: <1%. 1-4 points: 1%. 5-6 points: 2%. 7 points: 3%. 8 points: 4%. 9 points: 5%. 10 points: 6%. 11 points: 8%. 12 points: 10%. 13 points: 12%. 14 points: 16%. 15 points: 20%. 16 points: 25%. 17 points or more: Over 30%.[19]

Further risk score profiles based on the Framingham Heart Study

Not only coronary heart disease (CHD) events, but also further risks can be predicted. Risk prediction models for cardiovascular disease outcomes other than CHD events have also been developed by the Framingham Heart Study researchers. Amongst others, a risk score for 10-year risk for atrial fibrillation has been developed.[20][21]

A calculator for 10-year risk for atrial fibrillation is available on the Framingham Heart Study website: http://www.framinghamheartstudy.org/risk-functions/atrial-fibrillation/10-year-risk.php#

See also

References

  1. ↑ P.W., Wilson; D'Agostino, R.B.; Levy, D.; Belanger, A.M.; Silbershatz, H.; Kannel, W.B. (12 May 1998). "Prediction of coronary heart disease using risk factor categories.". Circulation. 97 (18): 1837–1847. doi:10.1161/01.CIR.97.18.1837. PMID 9603539. Retrieved 7 May 2013.
  2. ↑ D'Agostino, R.B.; Vasan, R.S.; Pencina, M.J.; Wolf, P.A.; Cobain, M.; Massaro, J.M.; Kannel, W.B. (22 January 2008). "General cardiovascular risk profile for use in primary care: the Framingham Heart Study". Circulation. 117 (6): 743–753. doi:10.1161/circulationaha.107.699579.
  3. ↑ Collins, Dylan; Lee, Joseph; Bobrovitz, Niklas; Koshiaris, Constantinos; Ward, Alison; Heneghan, Carl (2016-10-14). "Simple and adaptable R implementation of WHO/ISH cardiovascular risk charts for all epidemiological subregions of the world". F1000Research. 5. doi:10.12688/f1000research.9742.1.
  4. ↑ "Cardiovascular Risk Calculator and Chart v3.0". Cvrisk.mvm.ed.ac.uk. 2010-05-19. Retrieved 2013-09-14.
  5. ↑ "Risk Scoring Systems". Framingham Heart Study. Retrieved 7 May 2013.
  6. ↑ Wilson, PW; D'Agostino, RB; Levy, D; Belanger, AM; Silbershatz, H; Kannel, WB (1998). "Prediction of coronary heart disease using risk factor categories.". Circulation. 97 (18): 1837–47. doi:10.1161/01.cir.97.18.1837. PMID 9603539.
  7. ↑ Estimation of cardiovascular risk in an individual patient without known cardiovascular disease. Wilson PWF. In: UpToDate [Textbook of Medicine]. Basow, DS (Ed). Massachusetts Medical Society, and Wolters Kluwer publishers, The Netherlands. 2010.
  8. ↑ Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. D'Agostino RB Sr, Grundy S, Sullivan LM, Wilson P. JAMA. 2001 Jul 11;286(2):180-7.
  9. ↑ Tzoulaki, I.; Liberopoulos, G.; Ioannidis, JP. (Dec 2009). "Assessment of claims of improved prediction beyond the Framingham risk score.". JAMA. 302 (21): 2345–52. doi:10.1001/jama.2009.1757. PMID 19952321.
  10. ↑ D'Agostino RB Sr; Vasan RS; Pencina MJ; Wolf PA; Cobain M; Massaro JM; Kannel WB (Feb 2008). "General cardiovascular risk profile for use in primary care: the Framingham Heart Study". Circulation. 117 (6): 743–53. doi:10.1161/circulationaha.107.699579.
  11. ↑ Brindle P, Emberson J, Lampe F, Walker M, Whincup P, Fahey T, Ebrahim S (Nov 2003). "Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study". BMJ. 327 (7426): 1267. doi:10.1136/bmj.327.7426.1267. PMC 286248Freely accessible. PMID 14644971.
  12. ↑ Liu J; Hong Y; D'Agostino RB Sr; Wu Z; Wang W; Sun J; Wilson PW; Kannel WB; Zhao D (Jun 2004). "Predictive value for the Chinese population of the Framingham CHD risk assessment tool compared with the Chinese Multi-Provincial Cohort Study". JAMA. 291 (21): 2591–9. doi:10.1001/jama.291.21.2591.
  13. ↑ Sacco RL, Khatri M, Rundek T, Xu Q, Gardener H, Boden-Albala B, Di Tullio MR, Homma S, Elkind MS, Paik MC (Dec 2009). "Improving global vascular risk prediction with behavioral and anthropometric factors. The multiethnic NOMAS (Northern Manhattan Cohort Study)". J Am Coll Cardiol. 54 (24): 2303–11. doi:10.1016/j.jacc.2009.07.047.
  14. ↑ Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project European Heart Journal 2003;24:987-1003
  15. ↑ Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, De Bacquer D, Ducimetiere P, Jousilahti P, Keil U, Njolstad I, Oganov RG, Thomsen T, Tunstall-Pedoe H, Tverdal A, Wedel H, Whincup P, Wilhelmsen L, Graham IM (Jun 2003). "Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project". Eur Heart J. 24 (11): 987–1003. doi:10.1016/s0195-668x(03)00114-3.
  16. 1 2 Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002 Dec 17;106(25):3143-421.
  17. ↑ Prediction of coronary heart disease using risk factor categories. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Circulation. 1998 May 12;97(18):1837-47.
  18. ↑ The distribution of 10-Year risk for coronary heart disease among US adults: findings from the National Health and Nutrition Examination Survey III. Ford ES, Giles WH, Mokdad AH. J Am Coll Cardiol. 2004 May 19;43(10):1791-6.
  19. ↑ "NHLBI, Estimate of 10-Year Risk for CHD". Nhlbi.nih.gov. Retrieved 2013-09-14.
  20. ↑ Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study. Schnabel RB, Sullivan LM, Levy D, Pencina MJ, Massaro JM, D'Agostino RB Sr, Newton-Cheh C, Yamamoto JF, Magnani JW, Tadros TM, Kannel WB, Wang TJ, Ellinor PT, Wolf PA, Vasan RS, Benjamin EJ. Lancet. 2009 Feb 28;373(9665):739-45.
  21. ↑ Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D'Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ. Circulation. 2004 Aug 31;110(9):1042-6.
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