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      Framingham Risk Score and Alternatives for Prediction of Coronary Heart Disease in Older Adults

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          Abstract

          Background

          Guidelines for the prevention of coronary heart disease (CHD) recommend use of Framingham-based risk scores that were developed in white middle-aged populations. It remains unclear whether and how CHD risk prediction might be improved among older adults. We aimed to compare the prognostic performance of the Framingham risk score (FRS), directly and after recalibration, with refit functions derived from the present cohort, as well as to assess the utility of adding other routinely available risk parameters to FRS.

          Methods

          Among 2193 black and white older adults (mean age, 73.5 years) without pre-existing cardiovascular disease from the Health ABC cohort, we examined adjudicated CHD events, defined as incident myocardial infarction, CHD death, and hospitalization for angina or coronary revascularization.

          Results

          During 8-year follow-up, 351 participants experienced CHD events. The FRS poorly discriminated between persons who experienced CHD events vs. not (C-index: 0.577 in women; 0.583 in men) and underestimated absolute risk prediction by 51% in women and 8% in men. Recalibration of the FRS improved absolute risk prediction, particulary for women. For both genders, refitting these functions substantially improved absolute risk prediction, with similar discrimination to the FRS. Results did not differ between whites and blacks. The addition of lifestyle variables, waist circumference and creatinine did not improve risk prediction beyond risk factors of the FRS.

          Conclusions

          The FRS underestimates CHD risk in older adults, particularly in women, although traditional risk factors remain the best predictors of CHD. Re-estimated risk functions using these factors improve accurate estimation of absolute risk.

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          Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score.

          Paul Ridker, Julie Buring, Nader Rifai … (2007)
          Despite improved understanding of atherothrombosis, cardiovascular prediction algorithms for women have largely relied on traditional risk factors. To develop and validate cardiovascular risk algorithms for women based on a large panel of traditional and novel risk factors. Thirty-five factors were assessed among 24 558 initially healthy US women 45 years or older who were followed up for a median of 10.2 years (through March 2004) for incident cardiovascular events (an adjudicated composite of myocardial infarction, ischemic stroke, coronary revascularization, and cardiovascular death). We used data among a random two thirds (derivation cohort, n = 16 400) to develop new risk algorithms that were then tested to compare observed and predicted outcomes in the remaining one third of women (validation cohort, n = 8158). Minimization of the Bayes Information Criterion was used in the derivation cohort to develop the best-fitting parsimonious prediction models. In the validation cohort, we compared predicted vs actual 10-year cardiovascular event rates when the new algorithms were compared with models based on covariates included in the Adult Treatment Panel III risk score. In the derivation cohort, a best-fitting model (model A) and a clinically simplified model (model B, the Reynolds Risk Score) had lower Bayes Information Criterion scores than models based on covariates used in Adult Treatment Panel III. In the validation cohort, all measures of fit, discrimination, and calibration were improved when either model A or B was used. For example, among participants without diabetes with estimated 10-year risks according to the Adult Treatment Panel III of 5% to less than 10% (n = 603) or 10% to less than 20% (n = 156), model A reclassified 379 (50%) into higher- or lower-risk categories that in each instance more accurately matched actual event rates. Similar effects were achieved for clinically simplified model B limited to age, systolic blood pressure, hemoglobin A(1c) if diabetic, smoking, total and high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, and parental history of myocardial infarction before age 60 years. Neither new algorithm provided substantive information about women at very low risk based on the published Adult Treatment Panel III score. We developed, validated, and demonstrated highly improved accuracy of 2 clinical algorithms for global cardiovascular risk prediction that reclassified 40% to 50% of women at intermediate risk into higher- or lower-risk categories.
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            Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation.

            R B D'Agostino, S Grundy, L M Sullivan … (2001)
            The Framingham Heart Study produced sex-specific coronary heart disease (CHD) prediction functions for assessing risk of developing incident CHD in a white middle-class population. Concern exists regarding whether these functions can be generalized to other populations. To test the validity and transportability of the Framingham CHD prediction functions per a National Heart, Lung, and Blood Institute workshop organized for this purpose. Sex-specific CHD functions were derived from Framingham data for prediction of coronary death and myocardial infarction. These functions were applied to 6 prospectively studied, ethnically diverse cohorts (n = 23 424), including whites, blacks, Native Americans, Japanese American men, and Hispanic men: the Atherosclerosis Risk in Communities Study (1987-1988), Physicians' Health Study (1982), Honolulu Heart Program (1980-1982), Puerto Rico Heart Health Program (1965-1968), Strong Heart Study (1989-1991), and Cardiovascular Health Study (1989-1990). The performance, or ability to accurately predict CHD risk, of the Framingham functions compared with the performance of risk functions developed specifically from the individual cohorts' data. Comparisons included evaluation of the equality of relative risks for standard CHD risk factors, discrimination, and calibration. For white men and women and for black men and women the Framingham functions performed reasonably well for prediction of CHD events within 5 years of follow-up. Among Japanese American and Hispanic men and Native American women, the Framingham functions systematically overestimated the risk of 5-year CHD events. After recalibration, taking into account different prevalences of risk factors and underlying rates of developing CHD, the Framingham functions worked well in these populations. The sex-specific Framingham CHD prediction functions perform well among whites and blacks in different settings and can be applied to other ethnic groups after recalibration for differing prevalences of risk factors and underlying rates of CHD events.
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              Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals.

              Philip Greenland, Laurie LaBree, Stanley Azen … (2004)
              Guidelines advise that all adults undergo coronary heart disease (CHD) risk assessment to guide preventive treatment intensity. Although the Framingham Risk Score (FRS) is often recommended for this, it has been suggested that risk assessment may be improved by additional tests such as coronary artery calcium scoring (CACS). To determine whether CACS assessment combined with FRS in asymptomatic adults provides prognostic information superior to either method alone and whether the combined approach can more accurately guide primary preventive strategies in patients with CHD risk factors. Prospective observational population-based study, of 1461 asymptomatic adults with coronary risk factors. Participants with at least 1 coronary risk factor (>45 years) underwent computed tomography (CT) examination, were screened between 1990-1992, were contacted yearly for up to 8.5 years after CT scan, and were assessed for CHD. This analysis included 1312 participants with CACS results; excluded were 269 participants with diabetes and 14 participants with either missing data or had a coronary event before CACS was performed. Nonfatal myocardial infarction (MI) or CHD death. During a median of 7.0 years of follow-up, 84 patients experienced MI or CHD death; 70 patients died of any cause. There were 291 (28%) participants with an FRS of more than 20% and 221 (21%) with a CACS of more than 300. Compared with an FRS of less than 10%, an FRS of more than 20% predicted the risk of MI or CHD death (hazard ratio [HR], 14.3; 95% confidence interval [CI]; 2.0-104; P =.009). Compared with a CACS of zero, a CACS of more than 300 was predictive (HR, 3.9; 95% CI, 2.1-7.3; P<.001). Across categories of FRS, CACS was predictive of risk among patients with an FRS higher than 10% (P<.001) but not with an FRS less than 10%. These data support the hypothesis that high CACS can modify predicted risk obtained from FRS alone, especially among patients in the intermediate-risk category in whom clinical decision making is most uncertain.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 28 March 2012
                Volume: 7
                Issue: 3
                Electronic Location Identifier: e34287
                Affiliations
                [1 ]Department of General Internal Medicine, Inselspital, University of Bern, Bern, Switzerland
                [2 ]Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
                [3 ]University Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
                [4 ]Cardiology Division, Emory University, Atlanta, Georgia, United States of America
                [5 ]Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
                [6 ]Intramural Research Program, National Institute on Aging, Baltimore, Maryland, United States of America
                [7 ]Department of Preventive Medicine, University of Tennessee College of Medicine, Memphis, Tennessee, United States of America
                [8 ]Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
                [9 ]Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia, United States of America
                [10 ]Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
                FuWai hospital, Chinese Academy of Medical Sciences, China
                Author notes

                Conceived and designed the experiments: NR. Performed the experiments: NR IL EV. Analyzed the data: NR IL EV. Contributed reagents/materials/analysis tools: AN DB. Wrote the paper: NR. Critical revision of the manuscript: NR IL DA JB EV ES SS AN PW MP DB. Interpretation of data: NR IL DA JB EV ES SS AN PW MP DB.

                Article
                Publisher ID: PONE-D-12-01242
                DOI: 10.1371/journal.pone.0034287
                PMC ID: 3314613
                PubMed ID: 22470551
                SO-VID: 61da2efd-0cb2-49c8-a98e-fcab00e94790
                Copyright © Rodondi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 8 January 2012
                Date accepted : 26 February 2012
                Page count
                Pages: 8
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Cardiovascular
                Subject: Epidemiology
                Subject: Geriatrics
                Subject: Public Health
                Subject: Women's Health

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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