Framingham Risk Score Calculator Pdf To Excel

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Framingham Risk Score
Purposeestimate 10 year cardiovascular risk

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]

The single most cited scientific article from Framingham is published describing the “ Framingham risk score” —an equation. For calculating your 10-year risk of heart disease. 26 This article has been cited 150 more times than the average paper in the same. There are several distinct Framingham risk models. MDCalc uses the 'Hard' coronary Framingham outcomes model, which is intended for use in non-diabetic patients age 30-79 years with no prior history of coronary heart disease or intermittent claudication, as it is the most widely applicable to patients without previous cardiac events.

Cardiovascular Risk Scoring systems[edit]

Mar 07, 2018 Framingham Risk Score Calculator Pdf To Excel Average ratng: 6,6/10 7215 votes Framingham Risk Score is the estimation of 10-year cvd (cardiovascular disease) risk of a person. It was developed by the Framingham Heart Study to assess the hard coronary heart disease outcome.

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.[1]

Usefulness[edit]

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.[6]

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.

Despite their widespread popularity, randomized trials assessing the impact of using cardiovascular disease risk scores show limited impact on patient outcomes. Although there is good evidence that targeting individuals with high total CVD risk is the most efficient way to reduce CVD-related morbidity and mortality, to date trials assessing the usefulness of risk scores at helping clinicians target high risk patients show limited benefit.[7]

Issues Raised by Cardiovascular Risk Prediction[edit]

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[edit]

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[edit]

The Framingham Risk Score has been validated in the US, 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[edit]

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.[2] 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,[10][11] and within the US in populations other than European Americans and African Americans, e.g. Hispanic Americans and Native Americans.[12] 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),[13] which has been recommended by the European Society of Cardiology in 2007.[14]

Pdf

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[edit]

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 [15]

The original Framingham Risk Score had been published in 1998.[1]

Differences between the versions[edit]

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.[15]

CHD Risk Equivalent[edit]

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)

Analysis of the US population with the Framingham/ATP III criteria[edit]

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).[16]

High risk was most commonly found in patients with advanced age, and was more common in men than women.[medical citation needed]

Scoring[edit]

Framingham Risk Score for Women[edit]

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[edit]

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.

Calculator

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%.[17]

Further risk score profiles based on the Framingham Heart Study[edit]

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.[18][19]

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

See also[edit]

  • Framingham Risk Score Calculator for Coronary Heart Disease - Cholesterol in mg/dL
  • Framingham Coronary Heart Disease Risk Score - Cholesterol in mg/dL or mmol/L

References[edit]

  1. ^ abcWilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (May 1998). 'Prediction of coronary heart disease using risk factor categories'. Circulation. 97 (18): 1837–47. doi:10.1161/01.cir.97.18.1837. PMID9603539.
  2. ^ abD'Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB (22 January 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. PMID18212285.
  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: 2522. 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. ^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.
  7. ^Collins, Dylan Raymond James; Tompson, Alice; Onakpoya, Igho; Roberts, Nia; Ward, Alison; Heneghan, Carl (2017). 'Global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews'. BMJ Open. 7 (3): e013650. doi:10.1136/bmjopen-2016-013650. PMC5372072. PMID28341688.
  8. ^D'Agostino RB, Grundy S, Sullivan LM, Wilson P (July 2001). 'Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation'. JAMA. 286 (2): 180–7. doi:10.1001/jama.286.2.180. PMID11448281.
  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. PMID19952321.
  10. ^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. PMC286248. PMID14644971.
  11. ^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. PMID15173150.
  12. ^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. PMC2812026. PMID19958966.
  13. ^Conroy R (2003). 'Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project'. European Heart Journal. 24 (11): 987–1003. doi:10.1016/s0195-668x(03)00114-3.
  14. ^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.
  15. ^ ab'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. 106 (25): 3143–421. December 2002. doi:10.1161/circ.106.25.3143. PMID12485966.
  16. ^Ford ES, Giles WH, Mokdad AH (May 2004). 'The distribution of 10-Year risk for coronary heart disease among US adults: findings from the National Health and Nutrition Examination Survey III'. J. Am. Coll. Cardiol. 43 (10): 1791–6. doi:10.1016/j.jacc.2003.11.061. PMID15145101.
  17. ^'NHLBI, Estimate of 10-Year Risk for CHD'. National Heart, Lung, and Blood Institute (NHLBI). Retrieved 2013-09-14.
  18. ^Schnabel RB, Sullivan LM, Levy D, Pencina MJ, Massaro JM, D'Agostino RB, Newton-Cheh C, Yamamoto JF, Magnani JW, Tadros TM, Kannel WB, Wang TJ, Ellinor PT, Wolf PA, Vasan RS, Benjamin EJ (February 2009). 'Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study'. Lancet. 373 (9665): 739–45. doi:10.1016/S0140-6736(09)60443-8. PMC2764235. PMID19249635.
  19. ^Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D'Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ (August 2004). 'Lifetime risk for development of atrial fibrillation: the Framingham Heart Study'. Circulation. 110 (9): 1042–6. doi:10.1161/01.CIR.0000140263.20897.42. PMID15313941.
Retrieved from 'https://en.wikipedia.org/w/index.php?title=Framingham_Risk_Score&oldid=993711865'

The Framingham risk score (FRS)

  • American (National Cholesterol Education Program) and European guidelines uses the FRS to classify people for primary prevention. Those with score <10% are classified as low risk, 10-20% as moderately high risk and >20% as high risk.
  • People with established CVD (cardiovascular disease) or diabetes are already at high risk of CVD events and are targeted for maximum aggressive therapy with an LDL goal of <100 mg/dl, with an optional goal of LDL<70 mg/dl in very high risk patients.1 Those who have high triglycerides should also meet the non-HDL-C goal which is set at 30 mg/dl higher than the LDL goal.
  • The FRS is derived from the landmark Framingham Heart Study (FHS) that has provided valuable insights into CAD (coronary artery disease) risk prediction. The FRSis based on the clinical experience and coronary events of 5,209 men and women (aged 28-62 years) followed since 1948 and have guided the delivery of preventive cardiology for half a century.2
  • Launched in 1948, blood pressure readings for each subject were taken at two year intervals for a period of 14 years and the findings dispelled several myths that existed then and shared by some even today.3One such myth was “ The greatest danger to a man with blood pressure lies in its discovery because some fool may try to treat it.”4The first key finding from the study was that both systolic blood pressure (SBP) and diastolic blood pressure (DBP) are key markers of cardiovascular risk, especially stroke, heart failure, and heart attacks.3
  • Weighted scores are assigned to 6 easily measurable constructs─ total cholesterol (TC), HDL-C, systolic blood pressure, treatment of hypertension, smoking status, age and gender.5

Table125A. Differences in Estimated 10year CAD risk among White, Asian Indian and Chinese based on Framingham Risk Score5-7

Risk Factors

WhitemaleWhite femaleIndianmaleIndianfemaleChinese maleChinesefemale
Age -50yrsTotal cholesterol-225mg/dl

HDL-35mg/dl

Blood Pressure – 130/80

Smoking- 1 pack/d

16%

11%

32%

22%

3%

2%

Overestimation and Underestimation of the Risk

  • D’Agostino et al 8 applied FRS calculations to 6 prospectively studied, ethnically diverse populations within the US. It was discovered that the FHS performed well for whites and blacks. Among Japanese American and Hispanic men and Native American women, the FRS systematically overestimated the risk. After recalibration, taking into account different prevalence of risk factors and underlying rates of developing CAD, the authors were able to construct more accurate models for those subgroups whose risk was overestimated by the conventional method. 8
  • The prediction of absolute risk was not very accurate when a model derived from one study was applied to a different study or population.9 The FRS has been shown to substantially overestimate the risk, when applied to northern Europeans (including UK, Belfast) with high risk of CAD and particularly in southern Europeans with low risk of CAD. 10-13 Over 50% of the variance in CAD death rates in 25 years was accounted for by the difference in mean serum cholesterol.14 The overestimation was as high as 2-fold among Spaniards and 4-fold among Chinese, but the accuracy could be improved by recalibration.12
  • The FRS systematically overestimated the absolute CAD risk in the Chinese Multi-provincial Cohort Study (CMCS). This cohort consisted of 30,121 adults aged 35-65 years at baseline and was followed for 12 years. The 10-year CAD rate of the CMCS cohort was one-fifth that of the Framingham cohort.
  • For example, in the 10th risk decile, the predicted rate of CAD death in men was 20% CMCS vs. an actual rate of 3%. The proportion of Chinese people with 10-year risk exceeding 10% was 9.9% by FRS estimate but only 0.35 by the CMCS functions. 6 The recalibration of the FRS using the mean values of risk factors and mean CAD incidence rates of the CMCS cohort substantially improved the performance of the FRS functions in the CMCS cohort. 6 Nevertheless, application of recalibrated FRS models again significantly overestimated the CAD risk in both men (by approximately 97%) and women (by approximately 228%).
  • Stroke is much more prevalent than CAD in China; thus, any risk prediction model only for CAD may not be appropriate in application. In another study involving 9903 Chinese followed for 17 years, of the 371 CVD events, 266 were ischemic strokes and 105 were coronary events.15
  • Recently a simplified point score model has been developed and tested for estimating the 10-year integrated cardiovascular risk (Ischemic stroke and heart attack) in Chinese, in whom stroke is the predominant form of CVD. This model uses age, systolic blood pressure, smoking, total cholesterol, diabetes and BMI (body mass index).15 Since overestimation of the risk in Chinese population could result in over treatment, the Framingham risk function cannot be used without calibration.
  • In sharp contrast to the Chinese the FRS underestimate the risk of CAD among Indians by 200%.7 See Underestimation of risk among Asian Indians.

Framingham Risk Factor Calculator

  • Recalibrating the Framingham equations to the event rate and the prevalence of the risk among Spaniards and Chinese have been shown to improve the prediction of the risk. After calibration, the FRS function became an effective method of estimating the risk .8 The FRS-based coronary risk chart overestimates absolute coronary risk in populations characterized by a lower incidence of CAD events and should be used with caution.

Limitations of the FRS

  • The FRS is recommended only for patients with > 2 risk factors and is not accurate in patients with extreme end of a particular risk factor such as heavy smoking or very high cholesterol level.
  • FRS uses TC (instead of LDL-C) and does not include risk factor modification interventions, except for hypertension. It does not include family history or south Asian ethnicity both of which are known to confer 2-fold risk of future CAD 16, 17 It also does not include other identified risk factors such as overall and abdominal obesity, physical inactivity, metabolic syndrome, high lipoprotein(a), high triglycerides, non-HDL-C, apolipoprotein B, C-reactive protein, fibrinogen, left ventricular hypertrophy, estimated glomerular filtration rates etc.
  • The FRS includes only CAD events but excludes other vascular events such as stroke, which are more common than heart attack in Asian populations. The scoring was developed by studying a predominantly white and middle class population and particularly useful in the elderly but not be accurate for young and people of other ethnic origin. 18, 19
  • The young subjects in FHS were not only underrepresented but had very few events, which led to its heavy emphasis on age and is unsuitable for predicting premature CAD (defined as 55 years and younger in men and 65 years and younger in women). In a study of 220 patients with premature heart attack (mean age 50, 25% women), almost 70% were classified as low risk by FRS and only 25% met criteria to qualify for medication prior to the heart attack. For women in this population, only 18% met criteria for treatment.20
  • People with metabolic syndrome have recently been found to have a 53% higher mortality than is found in people without diabetes or metabolic syndrome. The metabolic syndrome and its components help predict the risk independent of Framingham risk score in people with in diabetics and nondiabetics alike.
  • 10-year risk and lifetime risk: A major limitation of FRS is that it estimates the risk of developing CAD within only a 10-yr period. Among young individuals, there is marked disparity between 10-year risk and lifetime risk in the FHS. For example, a 50-year old man in the lowest risk tertile had a 10-year risk of only 4% but a life time risk of 50%. Ford et al have recently estimated that only 3% of the US population would be classified as CAD risk equivalents and therefore qualify for intensive lipid therapy.21 Thus, FRS may not identify subjects with low short-term but high lifetime risk for CAD 22
  • These data underscore the need for continued vigilance in those who have been found to be at low short-term risk. Likewise it may underestimate the risk in populations highly prone for premature CAD.

Sources

1. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. Jul 13 2004;110(2):227-239.

2. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. May 12 1998;97(18):1837-1847.

3. Turnbull F., Pascal Kengne A, MacMahon S. Blood pressure and cardiovascular disease: tracing the steps from Framingham. Prog Cardiovasc Dis. Jul-Aug 2010;53(1):39-44.

Framingham Risk Score Calculator Pdf To Excel Spreadsheet

4. Moser M. Historical perspectives on the management of hypertension. J Clin Hypertens (Greenwich). Aug 2006;8(8 Suppl 2):15-20; quiz 39.

5. NCEP III. Third Report of the National Cholesterol Education Program(NCEP) Adult Treatment Panel III: National Institute of Health; September2002, 2002. 02-5215.

6. Liu JL, Hong Y, D’Agostino RB, Sr., et al. Predictive value for the Chinese population of the Framingham CHD risk assessment tool compared with the Chinese Multi-Provincial Cohort Study. Jama. Jun 2 2004;291(21):2591-2599.

7. Enas EA, Singh V, Munjal YP, et al. Recommendations of the second Indo-U.S. health summit on prevention and control of cardiovascular disease among Asian Indians. Indian Heart J. May-Jun 2009;61(3):265-274.

8. D’Agostino RB Sr, Grundy S, Sullivan LM, Wilson P. Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. Jama. 2001;286(2):180-187.

9. Prediction of mortality from coronary heart disease among diverse populations: is there a common predictive function? Heart. Sep 2002;88(3):222-228.

10. Brindle P, Emberson J, Lampe F, et al. Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study. Bmj. Nov 29 2003;327(7426):1267.

11. Empana JP, Ducimetiere P, Arveiler D, et al. Are the Framingham and PROCAM coronary heart disease risk functions applicable to different European populations? The PRIME Study. Eur Heart J. Nov 2003;24(21):1903-1911.

12. Marrugat J, D’Agostino R, Sullivan L, et al. An adaptation of the Framingham coronary heart disease risk function to European Mediterranean areas. J Epidemiol Community Health. Aug 2003;57(8):634-638.

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